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Patients with life threatening pulmonary emboli (PE) have traditionally been treated with anticoagulation alone, yet emerging data suggests more aggressive therapy may improve outcomes. The purpose of this research was to compare surgical pulmonary embolectomy (SPE) and catheter-directed thrombolysis (CDL) for acute, life-threatening PE.
A single center retrospective review was conducted on patients who underwent SPE or CDL. Patients with chronic thromboembolic disease were excluded from analysis. Statistical analyses utilizing t-tests, chi-square, and mixed effects models were completed. Pre and post procedural echocardiographic data were collected.
126 patients suffered a life-threatening PE during the study period (60 SPE (47.6%), 66 CDL 52.4%). 10 SPE patients (24.4%) and 10 (15.2%) CDL patients had massive PE’s marked by pre-procedural hypotension. Six (10.0%) SPE patients and 4 (6.0%) CLD patients suffered a pre-procedure cardiac arrest. 74% of SPE vs 52% of CDL patients were male (p= 0.01), otherwise there were no significant differences in baseline demographics. In-hospital mortality was 3.3% (2) for SPE, and 3.0% (2) for CDL (p=.99). SPE patients were more likely to require prolonged ventilation (15.0% vs 1.5%, p=0.01). There were no significant differences in other major complications. At baseline 61.5% (16/26) of SPE patients and 54.5% (30/55) of CDL patients had >moderate right ventricular dysfunction (p=0.51). Other baseline echo characteristics were not significantly different. Mean echo follow up was 14 months. Both treatment groups showed marked improvement in echocardiographic markers of right ventricular function from baseline at mid-term follow-up (Table 1).
|Catheter Directed Lysis||N=66||N=24||P value|
|Pre-Procedure||Midterm (Up to 3 years)|
|≥Moderate right ventricular dysfunction, n(%)||32 (48.4%)||0 (0%)||NA|
|Tricuspid valve velocity, mean (95%CI)||3.1 (2.8, 3.4)||2.5 (2.2, 2.8)||0.03|
|Right ventricular systolic pressure, mean (95%CI)||51.6 (46.6, 57.0)||26.5 (22.7, 31.0)||<.0001|
|Surgery Pulmonary Embolectomy||N=41||N=16|
|≥Moderate right ventricular dysfunction, n(%)||26 (63.4%)||0 (0%)||NA|
|Tricuspid valve velocity, mean (95%CI)||2.8 (2.5, 3.2)||2.34 (1.95, 2.79)||0.33|
|Right ventricular systolic pressure, mean (95%CI)||45.3 (39.2, 52.3)||32.4 (25.9, 40.5)||0.07|
Both SPE and CDL can be applied with low morbidity and mortality in the appropriate patient. Further research is needed to delineate which patients would benefit most from either SPE or CDL.
CORONARY: Thrombus / Thrombectomy and Embolic Protection