Perioperative Management and Outcomes after Endovascular Mechanical Thrombectomy in Patients with Submassive (Intermediate-Risk) Pulmonary Embolism: A Retrospective Observational Cohort Study
Abstract
:1. Introduction
2. Methods
3. Results
3.1. Patient Characteristics
3.2. Echocardiographic Data
3.3. Mechanical Thrombectomy Device-Related Data
4. Discussion
4.1. Predicting Mortality
4.2. Comparing Mortality Outcomes
4.3. ICU and Hospital LOS
5. Limitations
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Raskob, G.E.; Angchaisuksiri, P.; Blanco, A.N.; Buller, H.; Gallus, A.; Hunt, B.J.; Hylek, E.M.; Kakkar, A.; Konstantinides, S.V.; McCumber, M.; et al. Thrombosis: A major contributor to global disease burden. Arter. Thromb. Vasc. Biol. 2014, 34, 2363–2371. [Google Scholar] [CrossRef] [PubMed]
- Porres-Aguilar, M.; Rosovsky, R.P.; Rivera-Lebron, B.N.; Kaatz, S.; Mukherjee, D.; Anaya-Ayala, J.E.; Jimenez, D.; Jerjes-Sánchez, C. Pulmonary embolism response teams: Changing the paradigm in the care for acute pulmonary embolism. J. Thromb. Haemost. 2022, 20, 2457–2464. [Google Scholar] [CrossRef] [PubMed]
- Keller, K.; Hobohm, L.; Ebner, M.; Kresoja, K.-P.; Münzel, T.; Konstantinides, S.V.; Lankeit, M. Trends in thrombolytic treatment and outcomes of acute pulmonary embolism in Germany. Eur. Heart J. 2020, 41, 522–529. [Google Scholar] [CrossRef] [PubMed]
- Lehnert, P.; Lange, T.; Møller, C.H.; Olsen, P.S.; Carlsen, J. Acute Pulmonary Embolism in a National Danish Cohort: Increasing Incidence and Decreasing Mortality. Thromb. Haemost. 2018, 118, 539–546. [Google Scholar] [CrossRef] [PubMed]
- Sindet-Pedersen, C.; El-Chouli, M.; Nouhravesh, N.; Lamberts, M.; Christensen, D.M.; Kümler, T.; Lock, M.; Grove, E.L.; Holt, A.; Schou, M.; et al. High risk of rehospitalization within one year following a pulmonary embolism-Insights from the Danish nationwide registries from 2000–2020. Eur. Heart J.-Qual. Care Clin. Outcomes 2023, 10, 256–264. [Google Scholar] [CrossRef] [PubMed]
- Jaff, M.R.; McMurtry, M.S.; Archer, S.L.; Cushman, M.; Goldenberg, N.; Goldhaber, S.Z.; Jenkins, J.S.; Kline, J.A.; Michaels, A.D.; Thistlethwaite, P.; et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American Heart Association. Circulation 2011, 123, 1788–1830, Erratum in: Circulation 2012, 126, e104. [Google Scholar] [CrossRef] [PubMed]
- Konstantinides, S.V.; Meyer, G.; Becattini, C.; Bueno, H.; Geersing, G.J.; Harjola, V.-P.; Huisman, M.V.; Humbert, M.; Jennings, C.S.; Jiménez, D.; et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur. Heart J. 2020, 41, 543–603. [Google Scholar] [CrossRef] [PubMed]
- Mudrakola, H.V.; Caples, S.M.; Hyde, R.J.; McBane, R.D., II; Ahmad, S.R. Inpatient Management of Pulmonary Embolism: Clinical Characteristics and Mortality in a High-Volume Tertiary Care Center. J. Thromb. Thrombolysis 2022, 54, 145–152. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Meyer, G.; Vicaut, E.; Danays, T.; Agnelli, G.; Becattini, C.; Beyer-Westendorf, J.; Bluhmki, E.; Bouvaist, H.; Brenner, B.; Couturaud, F.; et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N. Engl. J. Med. 2014, 370, 1402–1411. [Google Scholar] [CrossRef] [PubMed]
- Sharifi, M.; Bay, C.; Skrocki, L.; Rahimi, F.; Mehdipour, M.; MOPETT Investigators. Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). Am. J. Cardiol. 2013, 111, 273–277. [Google Scholar] [CrossRef] [PubMed]
- Mathew, D.; Seelam, S.; Bumrah, K.; Sherif, A.; Shrestha, U. Systemic thrombolysis with newer thrombolytics vs anticoagulation in acute intermediate risk pulmonary embolism: A systematic review and meta-analysis. BMC Cardiovasc. Disord. 2023, 23, 482. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Pruszczyk, P.; Klok, F.K.; Kucher, N.; Roik, M.; Meneveau, N.; Sharp, A.S.; Nielsen-Kudsk, J.N.-K.; Obradović, S.; Barco, S.; Giannini, F.; et al. Percutaneous treatment options for acute pulmonary embolism: A clinical consensus statement by the ESC Working Group on Pulmonary Circulation and Right Ventricular Function and the European Association of Percutaneous Cardiovascular Interventions. EuroIntervention 2022, 18, e623–e638. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Gonsalves, C.F.; Gibson, C.M.; Stortecky, S.; Alvarez, R.A.; Beam, D.M.; Horowitz, J.M.; Silver, M.J.; Toma, C.; Rundback, J.H.; Rosenberg, S.P.; et al. Randomized controlled trial of mechanical thrombectomy vs. catheter-directed thrombolysis for acute hemodynamically stable pulmonary embolism: Rationale and design of the PEERLESS study. Am. Heart J. 2023, 266, 128–137. [Google Scholar] [CrossRef] [PubMed]
- Klok, F.A.; Piazza, G.; Sharp, A.S.; Ainle, F.N.; Jaff, M.R.; Chauhan, N.; Patel, B.; Barco, S.; Goldhaber, S.Z.; Kucher, N.; et al. Ultrasound-facilitated, catheter-directed thrombolysis vs anticoagulation alone for acute intermediate-high-risk pulmonary embolism: Rationale and design of the HI-PEITHO study. Am. Heart J. 2022, 251, 43–53. [Google Scholar] [CrossRef] [PubMed]
- Toma, C.; Jaber, W.A.; Weinberg, M.D.; Bunte, M.C.; Khandhar, S.; Stegman, B.; Gondi, S.; Chambers, J.; Amin, R.; Leung, D.A.; et al. Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism. EuroIntervention 2023, 18, 1201–1212. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Brunton, N.; McBane, R.; Casanegra, A.I.; Houghton, D.E.; Balanescu, D.V.; Ahmad, S.; Caples, S.; Motiei, A.; Henkin, S. Risk Stratification and Management of Intermediate-Risk Acute Pulmonary Embolism. J. Clin. Med. 2024, 13, 257. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Meinel, F.G.; Nance, J.W.; Schoepf, U.J.; Hoffmann, V.S.; Thierfelder, K.M.; Costello, P.; Goldhaber, S.Z.; Bamberg, F. Predictive Value of Computed Tomography in Acute Pulmonary Embolism: Systematic Review and Meta-analysis. Am. J. Med. 2015, 128, 747–759.e2. [Google Scholar] [CrossRef] [PubMed]
- Pruszczyk, P.; Goliszek, S.; Lichodziejewska, B.; Kostrubiec, M.; Ciurzyński, M.; Kurnicka, K.; Dzikowska-Diduch, O.; Palczewski, P.; Wyzgal, A. Prognostic value of echocardiography in normotensive patients with acute pulmonary embolism. JACC Cardiovasc. Imaging 2014, 7, 553–560. [Google Scholar] [CrossRef] [PubMed]
- Khemasuwan, D.; Yingchoncharoen, T.; Tunsupon, P.; Kusunose, K.; Moghekar, A.; Klein, A.; Tonelli, A.R. Right ventricular echocardiographic parameters are associated with mortality after acute pulmonary embolism. J. Am. Soc. Echocardiogr. 2015, 28, 355–362. [Google Scholar] [CrossRef] [PubMed]
- Lobo, J.L.; Holley, A.; Tapson, V.; Moores, L.; Oribe, M.; Barrón, M.; Otero, R.; Nauffal, D.; Valle, R.; Monreal, M.; et al. Prognostic significance of tricuspid annular displacement in normotensive patients with acute symptomatic pulmonary embolism. J. Thromb. Haemost. 2014, 12, 1020–1027. [Google Scholar] [CrossRef] [PubMed]
- Becattini, C.; Vedovati, M.C.; Agnelli, G. Prognostic value of troponins in acute pulmonary embolism: A meta-analysis. Circulation 2007, 116, 427–433. [Google Scholar] [CrossRef] [PubMed]
- Lankeit, M.; Friesen, D.; Aschoff, J.; Dellas, C.; Hasenfuß, G.; Katus, H.; Konstantinides, S.; Giannitsis, E. Highly sensitive troponin T assay in normotensive patients with acute pulmonary embolism. Eur. Heart J. 2010, 31, 1836–1844. [Google Scholar] [CrossRef] [PubMed]
- Klok, F.A.; Mos, I.C.M.; Huisman, M.V. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: A systematic review and meta-analysis. Am. J. Respir. Crit. Care Med. 2008, 178, 425–430. [Google Scholar] [CrossRef] [PubMed]
- Tu, T.; Toma, C.; Tapson, V.F.; Adams, C.; Jaber, W.A.; Silver, M.; Khandhar, S.; Amin, R.; Weinberg, M.; Engelhardt, T.; et al. A Prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism: The FLARE Study. JACC Cardiovasc. Interv. 2019, 12, 859–869. [Google Scholar] [CrossRef] [PubMed]
- Sista, A.K.; Horowitz, J.M.; Tapson, V.F.; Rosenberg, M.; Elder, M.D.; Schiro, B.J.; Dohad, S.; Amoroso, N.E.; Dexter, D.J.; Loh, C.T.; et al. Indigo Aspiration System for Treatment of Pulmonary Embolism: Results of the EXTRACT-PE Trial. JACC Cardiovasc. Interv. 2021, 14, 319–329. [Google Scholar] [CrossRef] [PubMed]
- Ismayl, M.; Balakrishna, A.M.; Aboeata, A.; Gupta, T.; Young, M.N.; Altin, S.E.; Aronow, H.D.; Goldsweig, A.M. Meta-Analysis Comparing Catheter-Directed Thrombolysis Versus Systemic Anticoagulation Alone for Submassive Pulmonary Embolism. Am. J. Cardiol. 2022, 178, 154–162. [Google Scholar] [CrossRef] [PubMed]
- Buckley, J.R.; Wible, B.C. In-Hospital Mortality and Related Outcomes for Elevated Risk Acute Pulmonary Embolism Treated With Mechanical Thrombectomy Versus Routine Care. J. Intensiv. Care Med. 2022, 37, 877–882. [Google Scholar] [CrossRef] [PubMed]
- Khorana, A.A.; Francis, C.W.; Culakova, E.; Kuderer, N.M.; Lyman, G.H. Frequency, risk factors, and trends for venous thromboembolism among hospitalized cancer patients. Cancer 2007, 110, 2339–2346. [Google Scholar] [CrossRef] [PubMed]
- Khazi, Z.M.; Pierce, J.; Azizaddini, S.; Davis, R.; Bhat, A.P. Mechanical thrombectomy is associated with shorter length of hospital stay and lower readmission rates compared with conservative therapy for acute submassive pulmonary embolism: A propensity-matched analysis. Diagn. Interv. Radiol. 2023, 29, 794–799. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Welker, C.; Huang, J.; Elmadhoun, O.; Esmaeilzadeh, S.; Mookadam, F.; Ramakrishna, H. Morbidity Following Pulmonary Embolism Hospitalization- Contributing Factors and Outcomes. J. Cardiothorac. Vasc. Anesthesia 2024, 38, 1239–1243. [Google Scholar] [CrossRef] [PubMed]
Patient | Age | Sex | BMI | Concurrent DVT | h/o PE | h/o DVT | Surgery within 2 weeks of PE | Contraindication to Thrombolytics | Active Cancer | RV Dysfunction on ECHO or CT | PESI Score |
---|---|---|---|---|---|---|---|---|---|---|---|
1 | 45 | female | 42.8 | yes | no | no | no | no | no | yes | 116 |
2 | 80 | female | 20.3 | yes | no | no | no | no | no | yes | 180 |
3 | 34 | male | 34.3 | yes | no | no | no | no | no | no | 44 |
4 | 88 | female | 26.9 | yes | no | no | no | yes | no | yes | 147 |
5 | 68 | male | 23.1 | no | no | no | no | no | no | no | 88 |
6 | 71 | male | 33.5 | no | no | no | yes | yes | no | yes | 181 |
7 | 65 | female | 29.4 | yes | no | no | yes | yes | no | yes | 105 |
8 | 68 | male | 34 | yes | no | no | no | no | no | yes | 168 |
9 | 63 | male | 28.9 | yes | no | no | no | no | yes | yes | 123 |
10 | 83 | female | 28 | yes | no | no | no | yes | yes | yes | 143 |
11 | 73 | female | 26.5 | yes | no | no | no | yes | yes | yes | 153 |
12 | 74 | male | 27.9 | yes | yes | no | no | no | yes | yes | 134 |
13 | 75 | female | 39.8 | no | no | no | no | yes | no | yes | 115 |
14 | 30 | male | 30.6 | yes | no | no | yes | yes | yes | yes | 90 |
15 | 63 | male | 32.1 | yes | no | no | yes | yes | no | yes | 163 |
16 | 69 | male | 26.5 | yes | no | no | no | yes | no | yes | 129 |
17 | 74 | male | 29.3 | yes | yes | no | yes | no | no | yes | 134 |
18 | 61 | female | 41.2 | not reported | no | no | no | no | no | yes | 231 |
19 | 60 | female | 42.3 | no | yes | yes | no | yes | no | yes | 61 |
20 | 68 | female | 38.6 | no | yes | yes | no | no | no | yes | 81 |
21 | 64 | female | 19.4 | yes | no | no | no | no | no | yes | 94 |
22 | 72 | male | 38.6 | not reported | no | no | no | yes | no | yes | 122 |
Patient | Troponin level (ng/L) | BNP level (pg/mL) | Initial presenting systolic BP (mmHg) | Location of PE | Pre MT mPAP (mmHg) | Post MT mPAP (mmHg) | Death within 30 days | Length of stay (days) | Recurrent PE in 30 days | Readmission within 30 days | |
1 | 19 | 528 | 131 | right main | 37 | 25 | no | 4 | yes | no | |
2 | 248 | 304 | 114 | saddle, right and left main | 26 | 17 | no | 4 | no | no | |
3 | 6 | 317 | 143 | bilateral main | 22 | 15 | no | 10 | no | no | |
4 | 210 | 538 | 141 | saddle with occlusive right main | 21 | 15 | no | 10 | no | no | |
5 | 11 | 970 | 104 | left main | 33 | 33 | no | 8 | no | no | |
6 | 44 | not reported | 124 | saddle, right and left main | 24 | 19 | no | 11 | no | no | |
7 | 92 | not reported | 135 | bilateral segmental in all 3 branches of right lung | 34 | 28 | no | 7 | no | no | |
8 | 59 | not reported | 89 | saddle and bilateral segmental branches | 28 | 23 | no | 3 | no | no | |
9 | 120 | 5458 | 145 | saddle and bilateral segmental branches | 29 | 20 | no | 6 | no | yes | |
10 | 44 | 8074 | 134 | right main and left segmental | not reported | not reported | no | 4 | no | no | |
11 | 32 | 1047 | 118 | saddle and bilateral segmental branches | 19 | not reported | yes | 10 | no | no | |
12 | 86 | 5532 | 114 | bilateral main PA and segmental | not reported | not reported | no | 3 | no | no | |
13 | 55 | 7749 | 147 | bilateral segmental branches | not reported | not reported | no | 7 | no | yes | |
14 | 16 | 225 | 88 | bilateral segmental branches | not reported | not reported | no | 7 | yes | yes | |
15 | 86 | not reported | 109 | right main and bilateral segmental branches | 26 | not reported | no | 21 | no | no | |
16 | 53 | 692 | 98 | saddle and bilateral segmental branches | not reported | not reported | no | 7 | no | no | |
17 | 313 | 953 | 97 | bilateral main PA and segmental | 35 | not reported | no | 5 | no | no | |
18 | 114 | 2974 | 107 | saddle and bilateral segmental branches | 46 | not reported | yes | 1 | no | no | |
19 | 10 | 296 | 156 | distal right main | 25 | 25 | no | 5 | no | no | |
20 | 22 | not reported | 120 | bilateral main and lobar branches | 27 | 17 | no | 11 | no | no | |
21 | 53 | 15,437 | 105 | left main and segmental branches | 50 | 37 | no | 5 | no | no | |
22 | 59 | 1900 | 128 | bilateral distal main, lobar, and segmental branches | not reported | not reported | no | 3 | no | no |
Characteristic | Number of Patients | Mean | Standard Deviation | Standard Error | 95% Confidence Interval |
---|---|---|---|---|---|
PESI score | 22 | 127.4 | 43.1 | 9.2 | 108.2 |
Troponin level (ng/L) | 22 | 79.6 | 80.6 | 17.2 | 43.9 |
BNP level (pg/mL) | 17 | 3117.3 | 4149.6 | 1006.4 | 983.8 |
Initial presenting systolic BP | 22 | 120.3 | 19.6 | 4.2 | 111.6 |
Pre-thrombectomy mean PAP (mmHg) | 16 | 30.1 | 8.7 | 2.2 | 25.5 |
Post-thrombectomy mean PAP (mmHg) | 12 | 22.8 | 7.1 | 2.0 | 18.3 |
RV/LV ratio pre-thrombectomy | 11 | 1.3 | 0.4 | 0.1 | 1.0 |
Pre-thrombectomy TAPSE | 11 | 14.7 | 4.7 | 1.4 | 11.6 |
Age | 22 | 65.8 | 14.1 | 3.0 | 59.6 |
BMI | 22 | 31.5 | 6.8 | 1.5 | 28.5 |
Patient | RV/LV Ratio Pre-Thrombectomy | Pre-Thrombectomy TAPSE (mm) | Pre-Thrombectomy RVSP on ECHO (mmHg) | Pre-Thrombectomy RV to PA Coupling (TAPSE/RVSP Ratio in mm/mmHg) |
---|---|---|---|---|
1 | not reported | not reported | not reported | not reported |
2 | 2 | 12 | 40 | 0.3 |
3 | 0.88 | 23 | 26 | 0.88 |
4 | 1.1 | 10 | 49 | 0.2 |
5 | not reported | not reported | not reported | not reported |
6 | 1.8 | not reported | 47 | not reported |
7 | 1.3 | 16 | 50 | 0.32 |
8 | not reported | not reported | not reported | not reported |
9 | not reported | 14 | 36 | 0.39 |
10 | not reported | not reported | 44 | not reported |
11 | 1.06 | 24 | 52 | 0.46 |
12 | 1.17 | 11 | 15 | 0.73 |
13 | not reported | not reported | 76 | not reported |
14 | 0.73 | not reported | not reported | not reported |
15 | not reported | not reported | 53 | not reported |
16 | 1.4 | 13 | 29 | 0.45 |
17 | not reported | 11 | 23 | 0.48 |
18 | not reported | not reported | not reported | not reported |
19 | not reported | not reported | 44 | not reported |
20 | 1.09 | 13 | 59 | 0.22 |
21 | 1.3 | 15 | 59 | 0.25 |
22 | not reported | not reported | not reported | not reported |
Patient | Able to Remove Clot during Procedure | Device-Related Death | Major Bleeding | Major Adverse Event in First 48 h after Procedure |
---|---|---|---|---|
1 | yes | no | no | no |
2 | yes | no | no | no |
3 | yes | no | no | no |
4 | yes | no | no | no |
5 | no | no | no | no |
6 | yes | no | no | no |
7 | no | no | no | no |
8 | yes | no | no | Yes, there was a perforation of the left pulmonary artery with the guidewire causing hemoptysis without any need for transfusion or intubation. |
9 | yes | no | no | no |
10 | yes | no | no | no |
11 | yes | no | no | no |
12 | yes | no | no | no |
13 | yes | no | no | no |
14 | yes | no | no | no |
15 | yes | no | no | no |
16 | yes | no | no | no |
17 | yes | no | no | no |
18 | no | no | no | Yes, during the procedure, the patient had a respiratory arrest with hypoxemia requiring intubation and then developed PEA arrest without achieving ROSC. The proceduralist was unable to remove any thrombus during the procedure. |
19 | yes | no | no | no |
20 | yes | no | no | no |
21 | no | no | no | no |
22 | yes | no | no | no |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Merren, M.P.; Padkins, M.R.; Cajigas, H.R.; Neidert, N.B.; Abcejo, A.S.; Elmadhoun, O. Perioperative Management and Outcomes after Endovascular Mechanical Thrombectomy in Patients with Submassive (Intermediate-Risk) Pulmonary Embolism: A Retrospective Observational Cohort Study. Healthcare 2024, 12, 1714. https://doi.org/10.3390/healthcare12171714
Merren MP, Padkins MR, Cajigas HR, Neidert NB, Abcejo AS, Elmadhoun O. Perioperative Management and Outcomes after Endovascular Mechanical Thrombectomy in Patients with Submassive (Intermediate-Risk) Pulmonary Embolism: A Retrospective Observational Cohort Study. Healthcare. 2024; 12(17):1714. https://doi.org/10.3390/healthcare12171714
Chicago/Turabian StyleMerren, Michael P., Mitchell R. Padkins, Hector R. Cajigas, Newton B. Neidert, Arnoley S. Abcejo, and Omar Elmadhoun. 2024. "Perioperative Management and Outcomes after Endovascular Mechanical Thrombectomy in Patients with Submassive (Intermediate-Risk) Pulmonary Embolism: A Retrospective Observational Cohort Study" Healthcare 12, no. 17: 1714. https://doi.org/10.3390/healthcare12171714