Utilization of catheter‐directed thrombolysis in pulmonary embolism and outcome difference between systemic thrombolysis and catheter‐directed thrombolysis

Abstract

Objective: The aim of the study was to assess the utilization of catheter-directed thrombolysis (CDT) and its comparative effectiveness against systemic thrombolysis in acute pulmonary embolism (PE). Background: Contemporary real world data regarding utilization and outcomes comparing systemic thrombolysis with CDT for PE is sparse. Methods: We queried the Nationwide Inpatient Sample from 2010 to 2012 using the ICD-9-CM diagnosis code 415.11, 415.13, and 415.19 for acute PE. We used propensity score analysis to compare outcomes between systemic thrombolysis and CDT. Primary outcome was in-hospital mortality. Secondary outcome was combined in-hospital mortality and intracranial hemorrhage (ICH). Results: Out of 110,731 patients hospitalized with PE, we identified 1,521 patients treated with thrombolysis, of which 1,169 patients received systemic thrombolysis and 352 patients received CDT. After propensitymatched comparison, primary and secondary outcomes were significantly lower in the CDT group compared to systemic thrombolysis (21.81% vs. 13.36%, OR 0.55, 95% CI Additional Supporting Information may be found in the online version of this article. 86:1219-1227 (2015) 0.36-0.85, P value 5 0.007) and (22.89% vs. 13.36%, OR 0.52, 95% CI 0.34-0.80, P value 5 0.003), respectively. The median length of stay [7 days, interquartile range (IQR) (5-9 days) vs. 7 days, IQR (5-10 days), P 5 0.17] was not significant between the two groups. The CDT group had higher cost of hospitalization [$17,218, IQR ($12,906) vs. $23,799, IQR ($17,338), P < 0.001]. Multivariate analysis identified increasing age, saddle PE, cardiopulmonary arrest, and Medicaid insurance as independent predictors of in-hospital mortality. Conclusions: CDT was associated with lower in-hospital mortality and combined in-hospital mortality and ICH. V C 2015 Wiley Periodicals, Inc. Catheterization and Cardiovascular Interventions

Systemic thrombolysis increases hemorrhagic stroke risk without survival benefit compared with catheter-directed intervention for the treatment of acute pulmonary embolism

“…A recent study by Patel and colleagues 15 using NIS data found that CDI provided a significant benefit for in-hospital mortality compared to ST, with nearly a 40% relative risk reduction and significant decrease in odds (CDI: 13.36%; ST: 21.81%; OR 0.55, 95% CI [0.36–0.85]; P=.007). Our methodology differed from theirs in terms of patient selection, resulting in a larger amount of patients in our study and reflecting a higher sensitivity of identification of acute PE.…”

A pulmonary embolism response team’s initial 20 month experience treating 87 patients with submassive and massive pulmonary embolism

“…The literature shows that LOS following PE ranges from 5 to 11 days. [13][14][15][16][17] If a PERT participates in the care of a patient for the duration of the hospitalization (which was not true for the WCMC PERT), then it can give discharge recommendations and potentially impact LOS. However, a PERT may also impact LOS based on how it manages severe PE.…”

Catheter-Based Approaches for the Treatment of Acute Pulmonary Embolism

“…8 The reasons for this decrease may relate to the continued concern regarding devastating bleeding complications, particularly ICH, as well as the results of recent studies suggesting relative safety and efficacy of CBT. 5 Unfortunately, as effective as systemic thrombolysis can be, the incidence of major bleeding and ICH is clearly higher than with anticoagulation alone. 9,10 This persisting obstacle together with advances in surgical techniques and catheter technology has prompted alternate treatment options, including lower dose systemic fibrinolysis, surgical embolectomy, and a number of catheter-based approaches.…”

“…A recent analysis of the National Inpatient Sample database indicates that utilization of CBT has increased since 2010. 5 It was shown, based on a propensity-matched analysis of a cohort of 352 inpatients with PE who underwent CBT compared with 352 inpatients who had systemic thromboly-sis, that the inhospital mortality rate was approximately 10% which was significantly lower than the rates for systemic thrombolysis ($20%). There were very low rates of intracranial hemorrhage (ICH) (0.28%) and no ICH after 2010.…”

“…This was, however, at the expense of higher rates of acute renal failure requiring hemodialysis and higher cost. 5 The gradually decreasing major bleeding rates may reflect increasing experience and use of lower doses of thrombolytic agents with newer catheter-based devices. Despite increased utilization of CBT, there are limited data which are mainly from small uncontrolled series and cohort studies.…”