Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism

doi:10.1378/chest.129.4.1043

Chest

Volume 129, Issue 4, April 2006, Pages 1043-1050

https://doi.org/10.1378/chest.129.4.1043 Get rights and content

Background

The management of patients with acute massive pulmonary embolism (PE) who do not respond to fibrinolytic therapy remains unclear. We aimed to compare rescue surgical embolectomy and repeat thrombolysis in patients who did not respond to thrombolysis.

Methods

We conducted a prospective single-center registry of PE patients who underwent thrombolytic therapy. Lack of response to thrombolysis within the first 36 h was prospectively defined as both persistent clinical instability and residual echocardiographic right ventricular dysfunction. Patients underwent surgical embolectomy or repeat thrombolysis, at the discretion of the attending physician. The clinical end point was a combined end point including recurrent PE, bleeding complications, or PE-related death, which was defined as death from recurrent PE or cardiogenic shock. Long-term adverse outcomes included death, recurrent thromboembolic events, and congestive heart failure.

Results

From January 1995 to January 2005, 488 PE patients underwent thrombolysis, of whom 40 (8.2%) did not respond to thrombolysis. Fourteen patients were treated by rescue surgical embolectomy, and 26 were treated by repeat thrombolysis. There was no significant difference in baseline characteristics between the two groups. The in-hospital course was uneventful in 11 of the surgically treated patients (79%) and in 8 patients (31%) treated by repeat thrombolysis (p = 0.004). There was a trend for higher mortality in the medical group than in the surgical group (10 vs 1 deaths, respectively; p = 0.07). There were significantly more recurrent PEs (fatal and nonfatal) in the repeat-thrombolysis group (35% vs 0%, respectively; p = 0.015). While no significant difference was observed in number of major bleeding events, all bleeding events in the repeat-thrombolysis group were fatal. The rate of uneventful long-term evolution was the same in the two groups.

Conclusion

Rescue surgical embolectomy led to a better in-hospital course when compared with repeat thrombolysis in patients with massive PE who have not responded to thrombolysis. The transfer of patients who have not responded to thrombolysis to tertiary cardiac surgery centers could be considered as an alternative option.

Section snippets

Selection of Patients

The study population was derived from a single-center registry of patients with confirmed massive and submassive PEs who had undergone thrombolytic treatment between January 1995 and January 2005. All patients gave their informed written consent for inclusion in the registry, and the protocol was approved by the local ethics committee.

Patients with proven recent PE (symptom onset, < 15 days) and no contraindication to thrombolytic therapy were included in the registry if they met at least one

Results

From January 1995 to January 2005, 1,876 consecutive patients were referred to the cardiology department with confirmed PE, of whom 488 (26%) were treated with thrombolytic therapy. At 24 to 36 h, thrombolysis was considered to be unsuccessful in 40 (8.2%) patients, of whom 37 had both persistent clinical instability and echocardiographic findings of RV dysfunction, and 3 patients experienced early echocardiographic deterioration following initial thrombolysis. Two eligible patients were

Discussion

To date, no study has ever assessed the management of failed thrombolysis in the setting of acute massive PE. Our study, based on a single-center prospective registry, is the first study to report the immediate clinical course as well as the long-term outcome of acute PE patients who had undergone either rescue embolectomy or repeat thrombolysis after not responding to initial thrombolysis. Patients who were unresponsive to thrombolysis were prospectively defined as patients with both

Conclusions

Lack of response to thrombolysis, which was defined as persistent RV dysfunction and hemodynamic instability, can be expected in about 8% of patients who experience massive PE. Rescue surgical embolectomy led to a better in-hospital course when compared with repeat thrombolysis in such patients. An uneventful in-hospital evolution was significantly higher in the surgical group, due to a lower in-hospital mortality rate, less frequent episodes of major bleeding, and recurrent PE. Based on our

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High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE.
This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations.
High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions.
Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
Management of high and intermediate-high risk pulmonary embolism: A position paper of the Interventional Cardiology Working Group of the Italian Society of Cardiology
2024, International Journal of Cardiology
Pulmonary embolism (PE) is a potentially life-threatening condition that remains a major global health concern. Noteworthy, patients with high- and intermediate-high-risk PE pose unique challenges because they often display clinical and hemodynamic instability, thus requiring rapid intervention to mitigate the risk of clinical deterioration and death. Importantly, recovery from PE is associated with long-term complications such as recurrences, bleeding with oral anticoagulant treatment, pulmonary hypertension, and psychological distress.
Several novel strategies to improve risk factor characterization and management of patients with PE have recently been introduced. Accordingly, this position paper of the Working Group of Interventional Cardiology of the Italian Society of Cardiology deals with the landscape of high- and intermediate-high risk PE, with a focus on bridging the gap between the evolving standards of care and the current clinical practice. Specifically, the growing importance of catheter-directed therapies as part of the therapeutic armamentarium is highlighted. These interventions have been shown to be effective strategies in unstable patients since they offer, as compared with thrombolysis, faster and more effective restoration of hemodynamic stability with a consistent reduction in the risk of bleeding. Evolving standards of care underscore the need for continuous re-assessment of patient risk stratification. To this end, a multidisciplinary approach is paramount in refining selection criteria to deliver the most effective treatment to patients with unstable hemodynamics. In conclusion, the current management of unstable patients with PE should prioritize tailored treatment in a patient-oriented approach in which transcatheter therapies play a central role.
Catheter-directed therapy for acute pulmonary embolism: results of a multicenter national registry
2024, Revista Espanola de Cardiologia
El emergente tratamiento por catéter (TPC) de la embolia pulmonar (EP) aguda combina técnicas heterogéneas. El objetivo del estudio es describir la práctica clínica contemporánea y los resultados relacionados con la TPC en un registro de ámbito nacional.
Registro multicéntrico iniciado por investigador, destinado a incluir a pacientes con EP aguda consecutivos y en riesgo intermedio-alto (IAR) o alto riesgo (AR) elegibles para TPC. El resultado primario del estudio fue la muerte por cualquier causa en el hospital.
Se incluyó en total a 253 pacientes, 93 (36,8%) con EP-AR y 160 (63,2%) con EP-IAR, de una media de edad de 62,3 ± 15,1. Se realizó trombolisis local al 70,8% de los pacientes, trombectomía aspirativa al 51,8% y ambas al 23,3%. Sin embargo, la trombectomía por aspiración fue más frecuente en la cohorte de EP-AR (el 80,6 frente al 35%; p < 0,001). Solo 51 pacientes (20,2%) se sometieron a TPC con dispositivos específicos de EP. El éxito de la TPC fue del 90,9% (el 98,1% de los casos de EP-IAR frente al 78,5% de los de EP-AR; p < 0,001). La mortalidad hospitalaria fue del 15,5%, muy concentrada en los casos de EP-AR (37,6%) y significativamente menor entre los de EP-IAR (2,5%; p < 0,001). La mortalidad a largo plazo (24 meses) fue del 40,2 en EP-AR frente al 8,2% en EP-IAR (p < 0,001).
A pesar del elevado éxito de la TPC, la mortalidad hospitalaria por EP-AR sigue siendo alta (37,6%) respeto a la muy baja mortalidad de la EP-IAR (2,5%).
Catheter-directed therapy (CDT) for acute pulmonary embolism (PE) is an emerging therapy that combines heterogeneous techniques. The aim of the study was to provide a nationwide contemporary snapshot of clinical practice and CDT-related outcomes.
This Investigator-initiated multicenter registry aimed to include consecutive patients with intermediate-high risk (IHR) or high-risk (HR), acute PE eligible for CDT. The primary outcome of the study was in-hospital all-cause death.
A total of 253 patients were included, of whom 93 (36.8%) had HR-PE, and 160 (63.2%) had IHR-PE with a mean age of 62.3 ± 15.1 years. Local thrombolysis was performed in 70.8% and aspiration thrombectomy in 51.8%, with 23.3% of patients receiving both. However, aspiration thrombectomy was favored in the HR-PE cohort (80.6% vs 35%; P < .001). Only 51 patients (20.2%) underwent CDT with specific PE devices. The success rate for CDT was 90.9% (98.1% of IHR-PE patients vs 78.5% of HR-PE patients, P < .001). In-hospital mortality was 15.5%, and was highly concentrated in the HR-PE patients (37.6%) and significantly lower in IHR-PE patients (2.5%), P < .001. Long-term (24-month) mortality was 40.2% in HR-PE patients vs 8.2% in IHR-PE patients (P < .001).
Despite the high success rate for CDT, in-hospital mortality in HR-PE is still high (37.6%) compared with very low IHR-PE mortality (2.5%).
The timing of death in acute pulmonary embolism patients regarding the mortality risk stratification at admission to the hospital
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The management of patients with acute pulmonary embolism (aPE) depends on the severity of aPE. The timing of death in various aPE risk subgroups is only partially known.
1618 patients with an objectively established aPE diagnosis with computed tomography pulmonary angiography enrolled in the regional PE registry were included in the study. According to ESC criteria, patients were stratified at admission to the hospital in four risk strata. The timing of PE-related and non-PE-related deaths was analyzed regarding mortality risk.
PE-related, and non-PE-related hospital death rates were 1.1 % and 1.5 % in low, 1.1 % and 4.8 % in intermediate-low, 8.1 % and 5.9 % in intermediate-high, and 27.7 % and 6.9 % in high-risk groups, respectively. The median time of PE-related and non-PE-related death across the PE mortality risk were: 4 (1.7–7.5) and 7.0 (4–14.7) days in low, 1.5 (1.0–9.5) and 11.5 (2.0–21.0) days in intermediate-low, 4.0 (2.0–9.0) and 9.0 (5.7–18.2) days in intermediate-high, 2.0 (1.0–4.75) and 7.0 (3.0–21.2) days in high-risk subgroups. 48.2 % and 17.1 % of patients who died in the high and intermediate-high risks died during the first hospital day. After the 6th hospitalization day, PE-related deaths were recorded in 43.9 % of deaths from intermediate-high and 17.9 % from high-risk subgroups.
PE-related mortality is prominent on the first hospitalization day in high and intermediate-high-risk PE. A substantial proportion of intermediate-high and high-risk patient's PE deaths occurred after the first 6 days of hospitalization.
Open Surgical Treatment of Acute and Chronic Pulmonary Embolism
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Venous vascular diseases are an important clinical entity estimated to affect several million people worldwide. Deep vein thrombosis (DVT) is a common venous disease with a population variable prevalence of 122 to 160 persons per 100,000 per year, whereas pulmonary embolism (PE) affects up to 60 to 70 per 100 000 and carries much higher mortality. Chronic venous diseases, which cause symptoms like leg swelling, heaviness, pain, and discomfort, are most prevalent in the elderly and significantly impact their quality of life. Some estimate that chronic vascular diseases account for up to 2% of healthcare budgets in Western countries. Treating venous vascular disease includes using systemic anticoagulation and interventional therapies in some patient subsets. In this comprehensive review, we discuss endovascular treatment modalities in the management of venous vascular diseases.

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Chest

Original ResearchManagement of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism

Background

Methods

Results

Conclusion

Section snippets

Selection of Patients

Results

Discussion

Conclusions

Am Heart J

Chest

Lancet

Ann Thorac Surg

Lancet

J Thorac Cardiovasc Surg

Lancet

Chest

Am J Cardiol

J Am Coll Cardiol

In-hospital and long-term outcome after sub-massive and massive pulmonary embolism submitted to thrombolytic therapy

Eur Heart J

Original Research
Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism