Is it safe to perform percutaneous treatment in acute pulmonary thrombosis?

Courtesy of Dr. Carlos Fava

Massive and submassive pulmonary embolism (PE) has traditionally been treated with anticoagulation and catheter direct thrombolysis (CDT), but the safety and efficacy of this treatment has not been yet properly assessed.

The study analyzed 137 patients presenting acute PE massive or submassive. All patients received CTD associated to heparin by direct infusion or ultrasound assisted catheter. Infusion time was left to operators’ criteria.

Age was 59, half were men, 26% had a history of thromboembolism, 24% were diabetic, 82% had right ventricle compromise, and 12% had massive PE.

82% of cases presented bilateral PE, other 14% presented right pulmonary thrombosis, and the remaining 4% presented left pulmonary thrombosis. Thrombolysis was often ultrasound assisted (84%).

After thrombolysis, PASP decreased 19±15 mmHg and vena cava filters were implanted in 45% of patients.

5 patients died (all with massive PE). 13 patients presented major bleeding or vascular lesions; 4 presented bleeding (2 intracranial and 2 gastrointestinal), while other 6 required transfusions. There were no differences in thrombolysis technique.

Factors associated to complications were elderly age, massive PE and vena cava filter implantation.

In addition, a meta-analyzis of 16 studies with 860 patients presenting PE undergoing CDT (including this study) was carried out. Mean age was 60 (54-61), half of patients were men, and 21.6% presented massive PE.

After thrombolysis, PE decreased 15 mmHg. Major bleeding or vascular complications rate was 4.65%, intracranial bleeding was 0.35% and mortality was 3.4% (12.9% in massive PE and 0.74% in submassive).

Conclusion

Catheter direct thrombolysis is associated to low complications rate. Randomized studies should be carried out to assess its efficacy relative to anticoagulation alone.

Commentary

This analyzis –with a large number of patients− disregards the fact that it is possible to treat PE percutaneously, not just by injecting thrombolytics, but also by safely extracting thrombi.

Perhaps a stronger commitment to this condition might improve outcomes and help develop better devices or techniques.

Courtesy of Dr. Carlos Fava

Original Title: Safety of Catheter-Direct Thrombolysis for Massive and Submassive Pulmonary Embolism: Results for Massive and Submassive Pulmonary Embolism.

Reference: Tyler Blommer, et al. Catheterization and Cardiovasacular Intervention 2017:89:754-760.

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