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Catheter-Directed Therapy in Acute Pulmonary Embolism with Right Ventricular Dysfunction: A Promising Modality to Provide Early Hemodynamic Recovery.

Dilektasli AG, Demirdogen Cetinoglu E, Acet NA, Erdogan C, Ursavas A, Ozkaya G, Coskun F, Karadag M, Ege E - Med. Sci. Monit. (2016)

Bottom Line: The primary outcomes were mortality, clinical success, and complications.Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure.In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Medicine, Uludag University Faculty of Medicine, Bursa, Turkey.

ABSTRACT
BACKGROUND Catheter-directed therapy (CDT) for pulmonary embolism (PE) is considered as an alternative to systemic thrombolysis (ST) in patients with hemodynamically unstable acute PE who are considered at high bleeding risk for ST. We aimed to evaluate the efficacy and safety of CDT in the management of acute PE with right ventricular dysfunction (RVD). The primary outcomes were mortality, clinical success, and complications. Secondary outcomes were change in hemodynamic parameters in the first 24 hours following the procedure. MATERIAL AND METHODS Medical records of consecutive patients diagnosed as having acute massive or submassive PE with accompanying RVD treated by immediate CDT at our institution from January 2007 to January 2014 were reviewed. Patient characteristics, mortality, achievement of clinical success, and minor and major bleeding complications were analyzed in the overall study group, as well as massive vs. submassive PE subgroups. Change in hemodynamic parameters in the second, eighth, and 24th hours after the CDT procedure were also analyzed. RESULTS The study included 15 consecutive patients (M/F=10/5) with a mean age of 54.2 ± 16.6 years who underwent immediate CDT. Nine of the patients had submassive PE, and 6 had massive PE. In-hospital mortality rate was 13.3% (95% CI, 0.04-0.38). One major, but not life-threatening, bleeding episode was evident in the whole group. Hemodynamic parameters were stabilized and clinical success was achieved in 14/15 (93.3%; 95% CI, 70.2-98.8) of the patients in the first 24 hours. Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure. CONCLUSIONS CDT is a promising treatment option for patients with acute PE with RVD with no fatal bleeding complication. In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

No MeSH data available.


Related in: MedlinePlus

(A) Pulmonary angiography showing filling defect of the right main and low left lobar pulmonary arteries. (B) Thrombus aspiration was performed with a guide catheter which was inserted through a long introducer sheath. (C, D) Final angiograms after catheter aspiration and local alteplase administration.
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f1-medscimonit-22-1265: (A) Pulmonary angiography showing filling defect of the right main and low left lobar pulmonary arteries. (B) Thrombus aspiration was performed with a guide catheter which was inserted through a long introducer sheath. (C, D) Final angiograms after catheter aspiration and local alteplase administration.

Mentions: Under local anesthesia, a 5F sheath was inserted through the right common femoral vein with ultrasound guidance. 5F pigtail (Cook, Bloomington, USA) or angled (Picard) catheters guided with a 0.035-inch hydrophilic guide wire (Terumo, Tokyo, Japan) were used to catheterize the main pulmonary artery trunk. After measuring the PAP, pulmonary angiography was performed to identify the thrombus (Figure 1A). Then, the F sheath was exchanged via hydrophilic guide wire to an 8F/10F introducer sheath (Flexor Sheath, Cook Medical, Bloomington, USA). The introducer sheath positioned in the main or one of the right or left pulmonary artery. Sidearm of the sheath was connected to a heparinized saline flush (4000 IU heparin/1000 cc normal saline), infused at 15 cc/h. Before aspiration, 5 mg alteplase diluted in 20 cc saline injected slowly into the thrombus. The total alteplase dose varied depending on the interventionist’s discretion and the patient’s condition. Afterward, a guide catheter (100 cm-6F-Envoy, or 8F MPA-1Vista Brite Tip Cordis) was used for thrombus aspiration. A 20-mL syringe with a luer-lock connector was used to apply suction while moving the guide catheter slowly back and forth over several centimeters within the clot (Figure 1B). After several passes, control low-dose contrast injections were performed. If total or partial recanalization was achieved, we switched to another obstructed segment. The procedure was considered clinically successful when the subsegmental branches became visible behind recanalized pulmonary artery segments with an improvement in hemodynamic parameters without major complications (such as a perforation of the pulmonary vascular or cardiac structures, tamponade, or death) [9,14]. Pulmonary angiography was performed routinely before and 24 hours after the procedure (Figure 1C, 1D).


Catheter-Directed Therapy in Acute Pulmonary Embolism with Right Ventricular Dysfunction: A Promising Modality to Provide Early Hemodynamic Recovery.

Dilektasli AG, Demirdogen Cetinoglu E, Acet NA, Erdogan C, Ursavas A, Ozkaya G, Coskun F, Karadag M, Ege E - Med. Sci. Monit. (2016)

(A) Pulmonary angiography showing filling defect of the right main and low left lobar pulmonary arteries. (B) Thrombus aspiration was performed with a guide catheter which was inserted through a long introducer sheath. (C, D) Final angiograms after catheter aspiration and local alteplase administration.
© Copyright Policy
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC4835153&req=5

f1-medscimonit-22-1265: (A) Pulmonary angiography showing filling defect of the right main and low left lobar pulmonary arteries. (B) Thrombus aspiration was performed with a guide catheter which was inserted through a long introducer sheath. (C, D) Final angiograms after catheter aspiration and local alteplase administration.
Mentions: Under local anesthesia, a 5F sheath was inserted through the right common femoral vein with ultrasound guidance. 5F pigtail (Cook, Bloomington, USA) or angled (Picard) catheters guided with a 0.035-inch hydrophilic guide wire (Terumo, Tokyo, Japan) were used to catheterize the main pulmonary artery trunk. After measuring the PAP, pulmonary angiography was performed to identify the thrombus (Figure 1A). Then, the F sheath was exchanged via hydrophilic guide wire to an 8F/10F introducer sheath (Flexor Sheath, Cook Medical, Bloomington, USA). The introducer sheath positioned in the main or one of the right or left pulmonary artery. Sidearm of the sheath was connected to a heparinized saline flush (4000 IU heparin/1000 cc normal saline), infused at 15 cc/h. Before aspiration, 5 mg alteplase diluted in 20 cc saline injected slowly into the thrombus. The total alteplase dose varied depending on the interventionist’s discretion and the patient’s condition. Afterward, a guide catheter (100 cm-6F-Envoy, or 8F MPA-1Vista Brite Tip Cordis) was used for thrombus aspiration. A 20-mL syringe with a luer-lock connector was used to apply suction while moving the guide catheter slowly back and forth over several centimeters within the clot (Figure 1B). After several passes, control low-dose contrast injections were performed. If total or partial recanalization was achieved, we switched to another obstructed segment. The procedure was considered clinically successful when the subsegmental branches became visible behind recanalized pulmonary artery segments with an improvement in hemodynamic parameters without major complications (such as a perforation of the pulmonary vascular or cardiac structures, tamponade, or death) [9,14]. Pulmonary angiography was performed routinely before and 24 hours after the procedure (Figure 1C, 1D).

Bottom Line: The primary outcomes were mortality, clinical success, and complications.Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure.In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Medicine, Uludag University Faculty of Medicine, Bursa, Turkey.

ABSTRACT
BACKGROUND Catheter-directed therapy (CDT) for pulmonary embolism (PE) is considered as an alternative to systemic thrombolysis (ST) in patients with hemodynamically unstable acute PE who are considered at high bleeding risk for ST. We aimed to evaluate the efficacy and safety of CDT in the management of acute PE with right ventricular dysfunction (RVD). The primary outcomes were mortality, clinical success, and complications. Secondary outcomes were change in hemodynamic parameters in the first 24 hours following the procedure. MATERIAL AND METHODS Medical records of consecutive patients diagnosed as having acute massive or submassive PE with accompanying RVD treated by immediate CDT at our institution from January 2007 to January 2014 were reviewed. Patient characteristics, mortality, achievement of clinical success, and minor and major bleeding complications were analyzed in the overall study group, as well as massive vs. submassive PE subgroups. Change in hemodynamic parameters in the second, eighth, and 24th hours after the CDT procedure were also analyzed. RESULTS The study included 15 consecutive patients (M/F=10/5) with a mean age of 54.2 ± 16.6 years who underwent immediate CDT. Nine of the patients had submassive PE, and 6 had massive PE. In-hospital mortality rate was 13.3% (95% CI, 0.04-0.38). One major, but not life-threatening, bleeding episode was evident in the whole group. Hemodynamic parameters were stabilized and clinical success was achieved in 14/15 (93.3%; 95% CI, 70.2-98.8) of the patients in the first 24 hours. Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure. CONCLUSIONS CDT is a promising treatment option for patients with acute PE with RVD with no fatal bleeding complication. In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

No MeSH data available.


Related in: MedlinePlus