Ultrasound-accelerated thrombolysis (USAT) versus standard catheter-directed thrombolysis (CDT) for treatment of pulmonary embolism: A retrospective analysis

Abstract

Ultrasound-accelerated thrombolysis (USAT) is advocated in pulmonary embolism (PE) based on the hypothesis that adjunctive ultrasound provides superior clinical efficacy compared to standard catheter-directed thrombolysis (CDT). This retrospective study was designed to compare outcomes between the two modalities. We analyzed patients with computed tomography-diagnosed PE at our institution treated with either USAT or standard CDT. Efficacy parameters assessed included invasive pulmonary artery systolic pressure (PASP; pre-and 24 hours post-treatment), non-invasive right-to-left ventricle (RV/LV) ratio (pre-and post-treatment), and general clinical outcomes (length-of-stay, significant bleeding, and mortality). We analyzed 98 cases (62 USAT and 36 CDT), in whom massive PE was diagnosed in 7%, intermediate/high risk in 81%, and intermediate/low risk in 12%. Overall, 92% had bilateral clot and 40% saddle embolus. At 24 hours, PASP decreased similarly in both groups (CDT Δ14.7 mmHg, USAT Δ10.8 mmHg; p = 0.14). Posttreatment, CDT showed similar improvement in the RV/LV ratio (CDT Δ0.58 vs USAT Δ0.45; p = 0.07), despite the baseline ratio being greater in the CDT group, indicating more severe RV strain (1.56 ± 0.36 vs 1.40 ± 0.29; p = 0.01). Intensive care unit and hospital length-of-stays were similar in both groups. A trend toward lesser significant bleeding rates in the CDT group (8.3% vs 12.9%, p = 0.74) as well as improved survival-to-discharge (97.2% vs 91.9%, p = 0.66) was observed. Compared to USAT, standard CDT achieves similar beneficial effects on hemodynamics, RV/LV ratios, and clinical outcomes. These observations suggest that salutary clinical results may be achieved without the need for very expensive devices.

Catheter-Directed Thrombolysis With Ultrasound Assistance for Acute Pulmonary Embolism

“…This well-done study is complementary to others revealing no short-term clinical outcomes differences in patients when CDT-US is used. Specifically, previous research has failed to find differences in in-hospital surrogate imaging outcomes, 8,9 and the current study 10 failed to find differences in in-hospital bleeding, ICH, and mortality outcomes. As Beyer et al 10 note, more studies, ideally randomized, are needed prior to more widespread use of CDT-US over CDT, particularly in this era of value-based care given that the former therapy carries substantially increased costs to the institution.…”

“…Studies comparing the two approaches to date have been single-center, retrospective, and modest in scope, with a focus on surrogate imaging outcomes related to echocardiographic comparisons of right ventricular function and pulmonary artery pressure changes. 8,9 It is in this context that, in this issue of CHEST, that Beyer et al 10 creatively utilized the 2016 National Readmissions Database (NRD) to examine nationwide, real-world utilization of systemic thrombolysis, CDT, and CDT-US, as well as to compare outcomes between CDT and CDT-US. The NRD is part of the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project all-payer family of databases.…”

Analysis of pulmonary embolism patients treated with EkoSonicTM endovascular system

“…[19] In a recent retrospective study of PE, USAT and CDT were compared and PAP reduction, RV/ LV ratio, ICU stay, and bleeding rates were similar. [20] In the Paced Electrocardiogram Requiring Fast Emergent Coronary Therapy (PERFECT) study, PAP changes were similar in patients who underwent USAT and CDT for massive and submassive PE, but there was no significant comparison in the improvement of RVD. [21] In a retrospective study of 63 patients, no significant difference was found between USAT and CDT in terms of all clinical and hemodynamic parameters, mortality, and procedural complications at threemonth and one-year follow-up.…”

The Role of EkoSonic Endovascular System or EKOS® in Pulmonary Embolism

“…This study was able to demonstrate that there were similar improvements in hemodynamics and length of ICU and hospital stays in both treatment groups. They also observed lesser bleeding complications and survival-to-discharge in patients receiving CDT [22]. One single center retrospective study done reviewed 60 patients between 2010 and 2016.…”

“…Some studies done in the past few years, however, have shown similar results when comparing ultrasound CDT with standard CDT [21][22][23]. A retrospective study done compared patients with submassive and massive PE receiving either CDT or ultrasound CDT.…”