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Pulmonary Arteries: Revascularization (PE Thrombolysis)
Christopher Bailey, MD; Clifford R. Weiss, MD, FSIR
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          • Outcomes

            TERMINOLOGY

            • Abbreviations

              • Pulmonary embolism (PE)
            • Definitions

              • Massive PE
                • Acute PE with sustained hypotension (systolic BP < 90 mm Hg or decrease from baseline of 40 mm Hg for > 15 min or pulseless or persistent bradycardia < 40 bpm)
                • Mortality > 50% at 90 days
                • 5% of patients present with massive PEs
              • Submassive PE
                • Acute PE without hypotension
                • Mortality estimated: 16-22% at 90 days
                • Signs of right ventricular (RV) dysfunction or myocardial necrosis
                • 40% of patients present with submassive PE
              • Low-risk PE
                • Acute PE and absence of clinical markers that define massive or submassive
                • Mortality estimated 15% at 90 days
                • 55% of patients present with low-risk PE
            • Overview

              • Incidence of PE in United States ~ 900,000 per year
              • Deep vein thrombosis (DVT) most common cause of PE
              • PE and DVT results in up to 100,000 deaths per year in United States
            • Symptoms of PE

              • Chest pain
              • Dyspnea
              • Diaphoresis
              • Palpitations
              • Syncope
              • Cough
              • Hemoptysis
              • Lower extremity swelling
            • Diagnostic Approach

              • Wells score should be calculated to risk stratify patients with suspected PE if patient stable
              • D-dimer: Fibrin degradation product
                • Used in moderate or low pretest probability of PE to further stratify patients
                • D-dimer > 500 µg/L warrants further work-up
                • D-dimer may be falsely elevated in other conditions (pregnancy, rheumatologic conditions, malignancy, and liver disease)
              • CT pulmonary angiography (CTPA) definitive imaging modality for diagnosis of PE
              • Ventilation/perfusion scan can be obtained if patient cannot receive intravenous contrast due to allergy or preexisting condition
            • Treatment of Low-Risk PE and Submassive PE

              • Mainstay of treatment is anticoagulation
              • Anticoagulants can be administered parenterally, orally, or subcutaneously
              • Most commonly used parenteral anticoagulant is unfractionated heparin; however, it is only used in short-term as "bridge" to oral or subcutaneous long-term option
              • Long-term options include warfarin (vitamin K antagonist), novel oral anticoagulants (NOACs) such as rivaroxaban, apixaban, dabigatran, or low molecular weight heparin
              • Oral anticoagulant options include warfarin and NOACs
                • Warfarin therapy most cost effective but requires regular interval monitoring of patient’s international normalized ratio (INR)
                • NOACs do not require therapeutic monitoring
              • Patient's renal function, comorbidities, and preference should be taken into account when selecting anticoagulation regimen
              • In cases of massive and some submassive PEs, systemic doses of thrombolytic drugs such as tissue plasminogen activator (systemic thrombolysis) or invasive therapies required for treatment
            • Catheter-Directed Therapies

              • Can be performed rapidly in hemodynamically unstable patients with multiple comorbidities
              • Becoming standard of care for treatment of massive and submassive PE
              • Multiple endovascular therapies have been developed to break up up clot directly at point of occlusion
                • Mechanical thrombus disruption
                  • Suction
                  • Fragmentation
                • Catheter-directed thrombolysis
                  • Pharmacologic techniques result in lower doses of thrombolytics when compared to systemic thrombolysis
                  • Lower risk of bleeding events since thrombolytic directly delivered into pulmonary arteries (PAs)
                  • Currently, literature is mixed whether US-assisted catheter directed thrombolysis is more efficacious than standard catheter-directed thrombolysis
                    • US-assisted catheter-directed thrombolysis (pharmacomechanical technique) in both massive and submassive PE has shown significant reduction in RV/left ventricular diameter ratio, mean PA peak systolic pressure, and PA angiographic obstruction over 48 hours
              • Combination of mechanical disruption to expose more surface area of thrombus and direct thrombolytic infusion is currently thought to be most efficacious technique
            • Signs of RV Dysfunction

              • Imaging
                • Right ventricle displaced toward left ventricle (ratio > 0.9 on CT or echo)
                • RV dilatation
                • Contrast reflux into IVC or hepatic veins
              • EKG: RV strain; ischemic strain
              • Laboratory: Elevated troponin or proBNP

            PREPROCEDURE

            • Indications

              • Contraindications

                • Getting Started

                  PROCEDURE

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things To Do

                        OUTCOMES

                        • Complications

                          • Expected Outcomes

                            Selected References

                            1. Behravesh S et al: Pathogenesis of thromboembolism and endovascular management. Thrombosis. 2017:3039713, 2017
                            2. Goktay AY et al: Endovascular treatment of thrombosis and embolism. Adv Exp Med Biol. 906:195-213, 2017
                            3. Lou BH et al: A meta-analysis of efficacy and safety of catheter-directed interventions in submassive pulmonary embolism. Eur Rev Med Pharmacol Sci. 21(1):184-198, 2017
                            4. Bajaj NS et al: Catheter-directed treatment for acute pulmonary embolism: Systematic review and single-arm meta-analyses. Int J Cardiol. 225:128-139, 2016
                            5. Biteker M et al: Thrombolysis in pulmonary embolism: full-dose, low-dose, or catheter-directed thrombolysis? Am J Emerg Med. 34(8):1720-1, 2016
                            6. Dilektasli AG et al: Catheter-directed therapy in acute pulmonary embolism with right ventricular dysfunction: a promising modality to provide early hemodynamic recovery. Med Sci Monit. 22:1265-73, 2016
                            7. Kaymaz C et al: Ultrasound-assisted catheter-directed thrombolysis in high-risk and intermediate-high-risk pulmonary embolism: results from a single-center cohort. Angiology. ePub, 2016
                            8. Liang NL et al: Comparative outcomes of ultrasound-assisted thrombolysis and standard catheter-directed thrombolysis in the treatment of acute pulmonary embolism. Vasc Endovascular Surg. 50(6):405-10, 2016
                            9. Monteleone PP et al: Multidisciplinary pulmonary embolism response teams and systems. Cardiovasc Diagn Ther. 6(6):662-667, 2016
                            10. Sadiq I et al: Risk factors for major bleeding in the SEATTLE II trial. Vasc Med. 1358863X16676355, 2016
                            11. Sag S et al: Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis. J Thromb Thrombolysis. 42(3):322-8, 2016
                            12. Sharifi M: Systemic Full dose, half dose, and catheter directed thrombolysis for pulmonary embolism. When to use and how to choose? Curr Treat Options Cardiovasc Med. 18(5):31, 2016
                            13. Tafur AJ et al: Catheter-directed treatment of pulmonary embolism: a systematic review and meta-analysis of modern literature. Clin Appl Thromb Hemost. 20(11):1431-40, 2016
                            14. Teleb M et al: Ultrasound-assisted catheter-directed thrombolysis: a novel and promising endovascular therapeutic modality for intermediate-risk pulmonary embolism. Angiology. ePub, 2016
                            15. Teman NR et al: Massive pulmonary embolism treated with catheter therapy and extracorporeal membrane oxygenation. Heart Surg Forum. 19(6):E303-E305, 2016
                            16. Kuo WT et al: Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT): initial results from a prospective multicenter registry. Chest. 148(3):667-73, 2015
                            17. Nykamp M et al: Safety and efficacy of ultrasound-accelerated catheter-directed lytic therapy in acute pulmonary embolism with and without hemodynamic instability. J Vasc Surg Venous Lymphat Disord. 3(3):251-7, 2015
                            18. Piazza G et al: A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II study. JACC Cardiovasc Interv. 8(10):1382-92, 2015
                            19. Kucher N et al: Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 129(4):479-86, 2014
                            20. Kuo WT: Endovascular therapy for acute pulmonary embolism. J Vasc Interv Radiol. 23(2):167-79.e4; quiz 179, 2012
                            21. Sobieszczyk P: Catheter-assisted pulmonary embolectomy. Circulation. 126(15):1917-22, 2012
                            22. Kandarpa K et al. Handbook of Interventional Radiologic Procedures. Philadelphia, PA: Lippincott, Williams & Wilkins, 2011
                            23. Agnelli G et al: Acute pulmonary embolism. N Engl J Med. 363(3):266-74, 2010
                            24. Kuo WT et al: Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol. 20(11):1431-40, 2009
                            25. Weiss CR et al: CT pulmonary angiography is the first-line imaging test for acute pulmonary embolism: a survey of US clinicians. Acad Radiol. 13(4):434-46, 2006
                            26. Sacks D et al: Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol. 14(9 Pt 2):S199-202, 2003
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Terminology

                              • Preprocedure

                                • Procedure

                                  • Post Procedure

                                    • Outcomes

                                      TERMINOLOGY

                                      • Abbreviations

                                        • Pulmonary embolism (PE)
                                      • Definitions

                                        • Massive PE
                                          • Acute PE with sustained hypotension (systolic BP < 90 mm Hg or decrease from baseline of 40 mm Hg for > 15 min or pulseless or persistent bradycardia < 40 bpm)
                                          • Mortality > 50% at 90 days
                                          • 5% of patients present with massive PEs
                                        • Submassive PE
                                          • Acute PE without hypotension
                                          • Mortality estimated: 16-22% at 90 days
                                          • Signs of right ventricular (RV) dysfunction or myocardial necrosis
                                          • 40% of patients present with submassive PE
                                        • Low-risk PE
                                          • Acute PE and absence of clinical markers that define massive or submassive
                                          • Mortality estimated 15% at 90 days
                                          • 55% of patients present with low-risk PE
                                      • Overview

                                        • Incidence of PE in United States ~ 900,000 per year
                                        • Deep vein thrombosis (DVT) most common cause of PE
                                        • PE and DVT results in up to 100,000 deaths per year in United States
                                      • Symptoms of PE

                                        • Chest pain
                                        • Dyspnea
                                        • Diaphoresis
                                        • Palpitations
                                        • Syncope
                                        • Cough
                                        • Hemoptysis
                                        • Lower extremity swelling
                                      • Diagnostic Approach

                                        • Wells score should be calculated to risk stratify patients with suspected PE if patient stable
                                        • D-dimer: Fibrin degradation product
                                          • Used in moderate or low pretest probability of PE to further stratify patients
                                          • D-dimer > 500 µg/L warrants further work-up
                                          • D-dimer may be falsely elevated in other conditions (pregnancy, rheumatologic conditions, malignancy, and liver disease)
                                        • CT pulmonary angiography (CTPA) definitive imaging modality for diagnosis of PE
                                        • Ventilation/perfusion scan can be obtained if patient cannot receive intravenous contrast due to allergy or preexisting condition
                                      • Treatment of Low-Risk PE and Submassive PE

                                        • Mainstay of treatment is anticoagulation
                                        • Anticoagulants can be administered parenterally, orally, or subcutaneously
                                        • Most commonly used parenteral anticoagulant is unfractionated heparin; however, it is only used in short-term as "bridge" to oral or subcutaneous long-term option
                                        • Long-term options include warfarin (vitamin K antagonist), novel oral anticoagulants (NOACs) such as rivaroxaban, apixaban, dabigatran, or low molecular weight heparin
                                        • Oral anticoagulant options include warfarin and NOACs
                                          • Warfarin therapy most cost effective but requires regular interval monitoring of patient’s international normalized ratio (INR)
                                          • NOACs do not require therapeutic monitoring
                                        • Patient's renal function, comorbidities, and preference should be taken into account when selecting anticoagulation regimen
                                        • In cases of massive and some submassive PEs, systemic doses of thrombolytic drugs such as tissue plasminogen activator (systemic thrombolysis) or invasive therapies required for treatment
                                      • Catheter-Directed Therapies

                                        • Can be performed rapidly in hemodynamically unstable patients with multiple comorbidities
                                        • Becoming standard of care for treatment of massive and submassive PE
                                        • Multiple endovascular therapies have been developed to break up up clot directly at point of occlusion
                                          • Mechanical thrombus disruption
                                            • Suction
                                            • Fragmentation
                                          • Catheter-directed thrombolysis
                                            • Pharmacologic techniques result in lower doses of thrombolytics when compared to systemic thrombolysis
                                            • Lower risk of bleeding events since thrombolytic directly delivered into pulmonary arteries (PAs)
                                            • Currently, literature is mixed whether US-assisted catheter directed thrombolysis is more efficacious than standard catheter-directed thrombolysis
                                              • US-assisted catheter-directed thrombolysis (pharmacomechanical technique) in both massive and submassive PE has shown significant reduction in RV/left ventricular diameter ratio, mean PA peak systolic pressure, and PA angiographic obstruction over 48 hours
                                        • Combination of mechanical disruption to expose more surface area of thrombus and direct thrombolytic infusion is currently thought to be most efficacious technique
                                      • Signs of RV Dysfunction

                                        • Imaging
                                          • Right ventricle displaced toward left ventricle (ratio > 0.9 on CT or echo)
                                          • RV dilatation
                                          • Contrast reflux into IVC or hepatic veins
                                        • EKG: RV strain; ischemic strain
                                        • Laboratory: Elevated troponin or proBNP

                                      PREPROCEDURE

                                      • Indications

                                        • Contraindications

                                          • Getting Started

                                            PROCEDURE

                                            • Procedure Steps

                                              • Alternative Procedures/Therapies

                                                POST PROCEDURE

                                                • Things To Do

                                                  OUTCOMES

                                                  • Complications

                                                    • Expected Outcomes

                                                      Selected References

                                                      1. Behravesh S et al: Pathogenesis of thromboembolism and endovascular management. Thrombosis. 2017:3039713, 2017
                                                      2. Goktay AY et al: Endovascular treatment of thrombosis and embolism. Adv Exp Med Biol. 906:195-213, 2017
                                                      3. Lou BH et al: A meta-analysis of efficacy and safety of catheter-directed interventions in submassive pulmonary embolism. Eur Rev Med Pharmacol Sci. 21(1):184-198, 2017
                                                      4. Bajaj NS et al: Catheter-directed treatment for acute pulmonary embolism: Systematic review and single-arm meta-analyses. Int J Cardiol. 225:128-139, 2016
                                                      5. Biteker M et al: Thrombolysis in pulmonary embolism: full-dose, low-dose, or catheter-directed thrombolysis? Am J Emerg Med. 34(8):1720-1, 2016
                                                      6. Dilektasli AG et al: Catheter-directed therapy in acute pulmonary embolism with right ventricular dysfunction: a promising modality to provide early hemodynamic recovery. Med Sci Monit. 22:1265-73, 2016
                                                      7. Kaymaz C et al: Ultrasound-assisted catheter-directed thrombolysis in high-risk and intermediate-high-risk pulmonary embolism: results from a single-center cohort. Angiology. ePub, 2016
                                                      8. Liang NL et al: Comparative outcomes of ultrasound-assisted thrombolysis and standard catheter-directed thrombolysis in the treatment of acute pulmonary embolism. Vasc Endovascular Surg. 50(6):405-10, 2016
                                                      9. Monteleone PP et al: Multidisciplinary pulmonary embolism response teams and systems. Cardiovasc Diagn Ther. 6(6):662-667, 2016
                                                      10. Sadiq I et al: Risk factors for major bleeding in the SEATTLE II trial. Vasc Med. 1358863X16676355, 2016
                                                      11. Sag S et al: Catheter-directed ultrasound-accelerated thrombolysis may be life-saving in patients with massive pulmonary embolism after failed systemic thrombolysis. J Thromb Thrombolysis. 42(3):322-8, 2016
                                                      12. Sharifi M: Systemic Full dose, half dose, and catheter directed thrombolysis for pulmonary embolism. When to use and how to choose? Curr Treat Options Cardiovasc Med. 18(5):31, 2016
                                                      13. Tafur AJ et al: Catheter-directed treatment of pulmonary embolism: a systematic review and meta-analysis of modern literature. Clin Appl Thromb Hemost. 20(11):1431-40, 2016
                                                      14. Teleb M et al: Ultrasound-assisted catheter-directed thrombolysis: a novel and promising endovascular therapeutic modality for intermediate-risk pulmonary embolism. Angiology. ePub, 2016
                                                      15. Teman NR et al: Massive pulmonary embolism treated with catheter therapy and extracorporeal membrane oxygenation. Heart Surg Forum. 19(6):E303-E305, 2016
                                                      16. Kuo WT et al: Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT): initial results from a prospective multicenter registry. Chest. 148(3):667-73, 2015
                                                      17. Nykamp M et al: Safety and efficacy of ultrasound-accelerated catheter-directed lytic therapy in acute pulmonary embolism with and without hemodynamic instability. J Vasc Surg Venous Lymphat Disord. 3(3):251-7, 2015
                                                      18. Piazza G et al: A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II study. JACC Cardiovasc Interv. 8(10):1382-92, 2015
                                                      19. Kucher N et al: Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 129(4):479-86, 2014
                                                      20. Kuo WT: Endovascular therapy for acute pulmonary embolism. J Vasc Interv Radiol. 23(2):167-79.e4; quiz 179, 2012
                                                      21. Sobieszczyk P: Catheter-assisted pulmonary embolectomy. Circulation. 126(15):1917-22, 2012
                                                      22. Kandarpa K et al. Handbook of Interventional Radiologic Procedures. Philadelphia, PA: Lippincott, Williams & Wilkins, 2011
                                                      23. Agnelli G et al: Acute pulmonary embolism. N Engl J Med. 363(3):266-74, 2010
                                                      24. Kuo WT et al: Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol. 20(11):1431-40, 2009
                                                      25. Weiss CR et al: CT pulmonary angiography is the first-line imaging test for acute pulmonary embolism: a survey of US clinicians. Acad Radiol. 13(4):434-46, 2006
                                                      26. Sacks D et al: Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol. 14(9 Pt 2):S199-202, 2003