Venous thromboembolism represents one of the main causes of cardiovascular death. Pulmonary embolism (PE) can vary from asymptomatic to manifesting with shock and sudden death, with a wide clinical spectrum. Patient followup is crucial, seeing as survival PE patients usually experience residual symptoms at long term, such as dyspnea or functional capacity deterioration.
For decades, the standard treatment has been anticoagulation, reserving thrombolysis for hemodynamically unstable patients. However, given the chronic consequences of PE, both treated and untreated, the use of catheter-based therapies (CBTs), or mechanical thrombectomy, has increased, aiming at rapid reperfusion.
Intermediate risk patients have seen benefits when treated with CBTs in terms of subrogated outcomes, such as RV/LV ratio and reduced mean pulmonary artery pressure. However, evidence on hard end points such as inhospital mortality and readmission at 30 and 90 days is limited.
This was a retrospective analysis of the National Readmissions Database (NRD), using as inclusion criteria PE with cor pulmonale, acute MI type 2, or right cardiac failure without shock or cardiorespiratory arrest. Primary end point was in-hospital mortality, while secondary end points included gastrointestinal and intracranial in-hospital bleeding, post-procedural bleeding and need for transfusion.
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Of 402,799 registered PE admissions, 3.7% were considered high risk, and 13.9% of these were treated with CBTs (51.1% CBTs only, 37% only MT and 11.8% both). Patients undergoing CBTs were younger, had lower cardio respiratory arrest rates, and higher prevalence of deep vein thrombosis vs patients not receiving percutaneous intervention.
After adjusting with inverse treatment probability analysis (IPTW), it was seen that patients treated with CBTs had lower inhospital mortality (45% vs 49.7%, P<0.001; OR 0.83, CI95% 0.80-0.87), lower risk of digestive bleeding (6.9% vs 7.7%%, P<0.006; OR 0.88, CI95% 0.81-0.96), but higher risk of intracranial bleeding (3.1% vs 2.7%, P=0.016; OR 1.18, CI95% 1.06-1.19), post procedure (OR 1.12) and need for hemoderivatives (OR 1.16).
When looking at new hospitalizations, the group treated with CBTs presented lower all cause at 90 day reintervention rates, especially related to VTE and right ventricular failure.
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A sensitivity analysis was carried out including intermediate risk patients treated in centers with endovascular therapies available for PE, with reduced inhospital mortality (OR 0.79, 95% CI 0.72–0.88) and reinterventions at 90 days (HR 0.74, 95% CI 0.71–0.78), especially for bleeding (HR 0.60, 95% CI 0.50–0.73) and VTE disease (HR 0.64, 95% CI 0.54–0.75)
Conclusions
In conclusion, data from this database suggest the CBTs in intermediate-high risk patients might reduce inhospital mortality and rehospitalization risk related to vein thromboembolic disease and right cardiac failure. However, we should not overlook the fact that this is a retrospective analysis and we need to confirm these finding with randomized studies for stronger evidence on these devices.
Dr. Omar Tupayachi.
Member of the Editorial Board of SOLACI.org.
Original Title: Catheter-based therapy for high-risk or intermediate-risk pulmonary embolism: death and re-hospitalization.
Reference: Leiva O, Alviar C, Khandhar S, Parikh SA, Toma C, Postelnicu R, Horowitz J, Mukherjee V, Greco A, Bangalore S. Catheter-based therapy for high-risk or intermediate-risk pulmonary embolism: death and re-hospitalization. Eur Heart J. 2024 Apr 4:ehae184. doi: 10.1093/eurheartj/ehae184. Epub ahead of print. PMID: 38573048.
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