Author + information
- Tyler Bloomer1,
- Pete Fong1,
- Michael McDaniel2,
- Breck Sandvall1,
- Henry Liberman2,
- Chandan Devireddy2 and
- Wissam Jaber2
There has been a recent surge in the use of catheter-directed thrombolytic therapy (CDT) in patients with high risk pulmonary embolism (PE). While recent trials have shown low complication rates, the safety and outcomes of CDT during routine use in the community is not well elucidated.
A total of 137 patients with high-risk PE (hypotensive [massive] or normotensive with right ventricular strain [submassive]) at 2 academic centers undergoing CDT from December 2012 until April 2016 were entered into a prospective database. The decision for CDT was made by a multidisciplinary PE response team. In hospital complications and outcomes were recorded.
All submassive patients survived (see table). Major complications included: 2 intracranial bleeds, 2 hematomas requiring evacuation, 2 access site complications requiring surgery, 2 pseudoaneurysms treated successfully with thrombin injection, 6 hematomas requiring transfusion, and 2 self-limiting GI bleeds requiring transfusion. Factors associated with complications were advanced age (p<0.01), massive PE presentation (p=0.02), and IVC filter placement (p<0.01), but not total thrombolytic dose administered.
|Baseline Characteristics (N=137), median (range) or (N %)||Age (years)||59 (24-91)||Procedure and Outcomes||Pulmonary arterial side treated||Bilateral 82%|
Right only 14%
Left only 4%
|Male||69 (50%)||Perfusion catheter used||Ultrasound-assisted 84%|
Plain infusion catheter 16%
|African-American||55 (40%)||Total tPA dose (mg)||17 (2-48)|
|Body mass index (kg/m2)||32 (19-59)||Baseline pulmonary artery systolic pressure (mmHg)||55 (21-89)|
|Prior venous thromboembolic disease||36 (26%)||Post-CDT pulmonary artery systolic pressure (mmHg)||39 (16-72); p<0.001 compared to baseline|
|Systolic blood pressure on presentation (mmHg)||129 (50-187)||Total major complications (intracranial bleed, bleeding requiring transfusion or surgery, or drop in Hgb>5gm/dL)||16 (12%)|
|Heart rate on presentation (bpm)||105 (62-153)||Death||5 (3.6%) - All massive|
|Peak troponin at presentation (ng/mL)||0.26 (0.01-4.62)||Patients requiring RBC transfusion||8 (5.8%)|
|Qualitative RV enlargement, dysfunction by echo||None 5%|
|Intracranial bleed||2 (1.4%)|
|Massive PE||16 (12%)||IVC filter placed||63 (45%)|
CDT, while effective at acutely reducing pulmonary arterial pressures and possibly safer than systemic thrombolytics, is associated with serious bleeding complications and should be reserved for patients who are at a significantly elevated risk.
ENDOVASCULAR: Peripheral Vascular Disease and Intervention