Gerber Pulmonary Embolism

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Gerber Pulmonary Embolism

  1. 1. Contemporary Management of Pulmonary Embolism Lowell I. Gerber M.D. Associate Professor of Medicine KCOM
  2. 2. PULMONARY EMBOLISM <ul><li>Estimated 650,000 cases annually in the US </li></ul><ul><li>Third most common cause of death in US </li></ul><ul><ul><li>50,000 to 200,000 deaths per year </li></ul></ul><ul><li>15% of all in-hospital deaths </li></ul><ul><li>Difficult to diagnose </li></ul><ul><li>Approx. 10% of patients in whom diagnosis is established die within first 60 minutes </li></ul>
  3. 3. MASSIVE PULMONARY EMBOLISM <ul><li>Estimated 10+% of all PE </li></ul><ul><li>3-7X increased mortality over non-massive PE </li></ul><ul><ul><li>UPET 36% vs 5% </li></ul></ul><ul><ul><li>ICOPER 58% vs 15% </li></ul></ul><ul><ul><li>MAPPET 31% </li></ul></ul>
  4. 4. PULMONARY EMBOLISM PATHOLOGY
  5. 5. PULMONARY EMBOLISM PATHOPHYSIOLOGY
  6. 6. THE SPECTRUM OF PULMONARY EMBOLISM Right Ventricular Dysfunction Hemodynamic Instability Stable Hemodynamics and Cardiac Function
  7. 7. CLINICAL RISK FACTORS FOR VTE <ul><li>AGE > 40 </li></ul><ul><li>MAJOR SURGERY OR TRAUMA </li></ul><ul><li>IMMOBILIZATION </li></ul><ul><li>VENOUS STASIS </li></ul><ul><li>OBESITY </li></ul><ul><li>DIABETES </li></ul><ul><li>FRACTURE </li></ul><ul><li>VARICOSE VEINS </li></ul><ul><li>CHF , MI, CVA </li></ul><ul><li>PRIORHX VTE HIP </li></ul><ul><li>PREGNANCY / POSTPARTUM </li></ul><ul><li>CONTRACEPTIVES </li></ul><ul><li>CANCER </li></ul><ul><li>ANTIPHOSPHOLIPID AB SYNDROME </li></ul>
  8. 8. HERITABLE RISK FACTORS FOR VTE <ul><li>FACTOR V LEIDEN MUTATION </li></ul><ul><li>HYPERHOMOCYSTEINEMIA </li></ul><ul><li>PROTEIN C DEFICIENCY </li></ul><ul><li>RESISTANCE TO ACTIVATED PROTEIN C </li></ul><ul><li>PROTEIN S DEFICIENCY </li></ul><ul><li>ANTITHROMBIN III DEFICIENCY </li></ul>
  9. 9. HERITABLE RISK FACTORS FOR VTE <ul><li>PROTHROMBIN MUTATION G20210A </li></ul><ul><li>HEPARIN COFACTOR II </li></ul><ul><li>DYSFIBRINOGENEMIA </li></ul><ul><li>DYSPLASMINOGENEMIA </li></ul>
  10. 10. RISK STRATIFICATION VARIABLE HAZARD RATIO (95% CI) Age >70 years 1.6 (1.1-2.3) COPD 1.8 (1.2-2.7) Systolic blood pressure <90mmHg 2.9 (1.7-5.0) Right ventricular hypokinesis 2.0 (1.3-2.9) Congestive Heart Failure 2.4 (1.5-3.7) Cancer 2.3 (1.5-3.5) Respiratory rate <20/min 2.0 (1.2-3.2) Goldhaber, et al. Lancet. 353:1386-89; 24 Apr 1999
  11. 11. RISK STRATIFICATION Using a Clinical Decision Rule <ul><li>Clinical signs and symptoms of DVT 3.0 </li></ul><ul><li>Alternative diagnosis less likely than PE 3.0 </li></ul><ul><li>Heart rate >100/min 1.5 </li></ul><ul><li>Immobilization (>3days) or surgery in 4wks 1.5 </li></ul><ul><li>Previous PE or DVT 1.5 </li></ul><ul><li>Hemoptysis 1.0 </li></ul><ul><li>Malignancy (Rxing or Rxed in last 6 mos) 1.0 </li></ul><ul><li>>4 pts: Clinical probability of PE is likely </li></ul><ul><li>4 or less pts: Clinical probability of PE is unlikely </li></ul>Wells, et al Thromb Haemost 2000;83:416-420
  12. 12. MORTALITY PE/DVT IN ELDERLY INHOSPITAL 1 YEAR 21% / 3% 39% / 21% Kniffin et al. Arch Intern Med . 1994 Apr 25
  13. 13. CLINICAL PROFILE PE STEIN, P.D. ET AL. CHEST 100:598, 1991 SYMPTOMS FREQUENCY (%) DYSPNEA 73 PLEURITIC PAIN 66 COUGH 37 LEG SWELLING / PAIN 28 / 26 SIGNS FREQUENCY (%) TACHYPNEA (>20/MIN) 70 RALES 51 TACHYCARDIA 30 S4 / INCREASED S2 24 / 23
  14. 14. CXR PULMONARY VASCULATURE ENLARGED RIGHT DESCENDING PULMONARY ARTERY WEDGE-SHAPED INFILTRATE OFTEN NORMAL
  15. 15. ELECTROCARDIOGRAM PULMONARY EMBOLISM T-wave inversion in leads III, aVF, or in leads V1-V4 QS in leads III and aVF Incomplete or complete right bundle branch block QRS axis > 90 or indeterminate axis Transition zone shift to V5
  16. 16. ELECTROCARDIOGRAM PULMONARY EMBOLISM <ul><li>S1,Q3,T3 most specific </li></ul><ul><li>Normal or Sinus Tachycardia most frequent </li></ul>
  17. 17. LABORATORY TESTING D-DIMER ELISA <ul><li>Sensitive but nonspecific test for PE </li></ul><ul><li>High negative predictive value when concentrations <500ng/ml </li></ul><ul><li>Omit if high clinical suspicion or patient with systemic illness </li></ul>Goldhaber, et al. JAMA. 1993. 270:2819-2822 Bounameaux, et al. Thromb Haemost. 1994; 71; 1-6
  18. 18. LABORATORY TESTING BioMarkers in Pulmonary Embolism
  19. 19. LABORATORY TESTING BioMarkers in Pulmonary Embolism BNP <ul><li>Normal BNP: Benign Prognosis </li></ul><ul><li>Elevated BNP associated with adverse outcome </li></ul><ul><li>Other causes of elevated BNP in RV pressure overload: </li></ul><ul><ul><li>Primary pulmonary hypertension </li></ul></ul><ul><ul><li>Chronic thromboembolic pulmonary hypertension </li></ul></ul><ul><ul><li>Chronic lung disease </li></ul></ul>Circulation. 2003 Apr 1;107(12):1576-8
  20. 20. LABORATORY TESTING BioMarkers in Pulmonary Embolism Troponin
  21. 21. LABORATORY TESTING BioMarkers in Pulmonary Embolism Troponin
  22. 22. LABORATORY TESTING BioMarkers in Pulmonary Embolism Troponin <ul><li>In acute pulmonary embolism elevated troponin levels have been shown to predict an adverse outcome. </li></ul><ul><li>Serum troponin levels should help stratify patients with submassive acute pulmonary embolism into a group in which aggressive medical or surgical intervention would be considered </li></ul>Curr Opin Pulm Med. 2003 Sep;9(5):374-7.
  23. 23. V/Q SCAN NORMAL PERFUSION ABNORMAL PERFUSION NORMAL- AND HIGH-PROBABILITY SCANS ARE CONSIDERED DIAGNOSTIC
  24. 24. PIOPED: PREDICTIVE VALUE V/Q SCAN SCAN CATEGORY CLINICAL SUSPICION 80-100% 20-79% 0-19% HIGH 96% 88% 56% INTERMEDIATE 66% 28% 16% LOW 40% 16% 4% PIOPED INVESTIGATORS. JAMA. 1990; 263: 2753-2759
  25. 25. PULMONARY ANGIOGRAPHY <ul><li>Gold Standard </li></ul><ul><li>Death in 0.5% </li></ul><ul><li>Major, nonfatal complications in 1% </li></ul><ul><li>Visualizes distal segments </li></ul><ul><li>Role in primary therapy for PE </li></ul>
  26. 26. ANGIOGRAPHIC SEVERITY SCORING Miller, et al. Amer Journ Roent,Rad Therapy & Nuc Med. 125(4):895-9, 1975 Dec.
  27. 27. Multi Slice CT 92 % SENSITIVITY , 95% SPECIFICITY COMPARED TO ANGIOGRAPHY OR TO HIGH-PROB OR NORMAL SCINTIGRAM (3 rd generation scanner, 1mm slice thickness) van Rossum,et al. Radiology. 1996;201:467-70
  28. 28. Multi Slice CT
  29. 29. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography JAMA 2006; 295:172-179 January 11, 2006 Writing Group for the Christopher Study Investigators
  30. 30. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer and CT
  31. 31. VTE Events During 3 month F/U in 3138 patients <ul><li>PE unlikely and Nl D-Dimer 1028 5(0.5) 0(0) </li></ul><ul><li>PE excluded by CT 1436 18(1.3) 7(0.5) </li></ul><ul><ul><li>CT Normal 764 9(1.2) 3().4) </li></ul></ul><ul><ul><li>CT alternative Dx 672 9(1.3) 4(0.6) </li></ul></ul><ul><ul><li>PE diagnosed by CT 674 20(3) 11(1.6) </li></ul></ul><ul><ul><li>mortality 7.2% (55) </li></ul></ul><ul><ul><li>Inconclusive CT 20 2+by V/Q, 1/18 non-fatal PE </li></ul></ul><ul><ul><li>mortality 5% (1/20) </li></ul></ul><ul><ul><li>CT indicated but not done 50 3+by V/Q, 2 had DVT by CUS </li></ul></ul><ul><ul><li>1/45 fatal PE, </li></ul></ul><ul><ul><li>mortality 14% (7/50) </li></ul></ul>Pts Total VTE Fatal PE
  32. 32. ECHOCARDIOGRAPHY PULMONARY EMBOLISM <ul><li>Direct visualization of thrombus </li></ul><ul><li>Right ventricular dilatation & hypokinesis (except apex, McConnell’s sign) </li></ul><ul><li>Abnormal interventricular septal motion </li></ul><ul><li>Tricuspid valve regurgitation >2.8 m/s </li></ul><ul><li>Lack of decreased inspiratory collapse of inferior vena cava </li></ul>
  33. 33. TRANS ESOPHAGEAL ECHOCARDIOGRAPHY AND PATENT FORAMEN OVALE in PULMONARY EMBOLISM <ul><li>Patent foramen ovale detected on TEE is an important predictor of adverse outcome in patients with major pulmonary embolism. </li></ul><ul><li>These patients had a death rate of 33% as opposed to 14% in patients without PFO </li></ul><ul><li>There is significantly higher incidence of ischemic stroke (13% versus 2.2%; P=.02) and peripheral arterial embolism (15 versus 0%; P<.001). </li></ul><ul><li>Overall, the risk of a complicated in-hospital course was 5.2 times higher in this patient group (P<.001). </li></ul><ul><li>Circulation. 1999 Jun 29;99(25):3323. </li></ul> 
  34. 34. RV OVERLOAD DIASTOLE SYSTOLE RV DILATATION & ABNORMAL SEPTAL MOTION
  35. 35. MORTALITY RV DYSFUNCTION Goldhaber, et al. Lancet. 353: 1386-89;24 April 1999 RV HYPOKINESIS NO RV HYPOKINESIS
  36. 36. PRIMARY THERAPY VS SECONDARY PREVENTION HEPARIN NORMAL BP RV DYSFUNCTION SBP<90 THROMBOLYSIS MECHANICAL INTERVENTION
  37. 37. Heparin Anticoagulation <ul><li>While diagnostic work-up in progress begin with UFH 80/kg IV bolus, then 18 U/kg per hour, target PTT 60-80 secs </li></ul><ul><li>Rapid reversibility for patients who may require thrombolysis, thrombectomy, or who have alternative diagnosis </li></ul>
  38. 38. Heparin Anticoagulation <ul><li>For stable patients recommendations include either weight based protocols for UFH, or </li></ul><ul><li>Low Molecular weight heparin, trials suggest better efficacy with less bleeding </li></ul><ul><li>LMWH can be considered as alternative to oral anticoagulation </li></ul><ul><li>Monitor platelet counts and CBC </li></ul><ul><li>When HIT complicates therapy, use direct thrombin inhibitors </li></ul><ul><ul><li>Argatroban </li></ul></ul><ul><ul><li>Lepirudin </li></ul></ul>
  39. 39. Low Molecular Weight Heparins
  40. 40. THROMBOLYSIS UNSTABLE PATIENTS Jerges-Sanchez et al. J Thromb Thrombolysis 1995;2:227-229
  41. 41. Cardiac CT
  42. 42. Cardiac CT
  43. 43. THROMBOLYSIS RV DYSFUNCTION Goldhaber et al. The Lancet 341:8844; 507-511, Feb 27 1993
  44. 44. THROMBOLYSIS STABLE MAJOR PE Konstantinides S et al. Circulation. 1997;96:882-888
  45. 45. THROMBOLYSIS STABLE MAJOR PE ONLY INDEPENDENT PREDICTOR OF SURVIVAL (719 PATIENTS) Konstantinides et al. Circulation. 1997;96:882-888
  46. 46. Management Strategies and Prognosis of Pulmonary Emobolism MAPPET-3 <ul><li>Rt-PA + Heparin vs Heparin alone </li></ul><ul><li>256 patients with RV dysfunction but no hypotension/shock </li></ul><ul><li>Primary endpoint: death or escalation of therapy eg: need for catecholamine, thrombolytics, CPR, intubation, embolectomy </li></ul><ul><li>Primary endpoint achieved in 25% of patients with heparin alone vs 10% patients with rt-PA plus heparin (p=0.006) </li></ul><ul><li>No ICH in the controlled trial </li></ul><ul><li>ICH occurred in 3.0% of 304 patients receiving thrombolytics in registry (2454 pts) </li></ul>NEJM 2002 347:1143
  47. 47. THROMBOLYSIS CONTRAINDICATIONS <ul><li>Active internal bleed </li></ul><ul><li>CVA </li></ul><ul><li>Diastolic HTN>110 </li></ul><ul><li>Surgery < 10 days </li></ul><ul><li>CPR </li></ul><ul><li>Pregnancy </li></ul><ul><li>Post-partum < 10 days </li></ul><ul><li>Trauma </li></ul>
  48. 48. THROMBOLYSIS COMPLICATIONS <ul><li>Major bleeding frequency after noninvasive diagnosis= 4.2% </li></ul><ul><li>Major bleeding frequency after invasive diagnosis= 14% </li></ul><ul><li>Fewer complications would occur with noninvasive management </li></ul>Stein et al. Annals of Internal Medicine. 121:313-317, Sept 1994
  49. 49. THROMBOLYSIS IN-VITRO <ul><li>Streptokinase has slowest rate of clot lysis. </li></ul><ul><li>Urokinase has intermediate rate of clot lysis, but most fibrinolytic specificity. </li></ul><ul><li>rt-PA improved efficacy early, but rt-PA and urokinase difference dissipated after 30 min. </li></ul>Ouriel K, et al. J Vasc Surg . 1995; 22: 593-597
  50. 50. Thrombolytic Regimens for Pulmonary Embolism <ul><li>Streptokinase: 250K loading dose IV over 30min followed by 100K U/hr for 24 hr (FDA ok) </li></ul><ul><li>Alteplase(t-PA): 100mg, peripheral IV infused over 2 hrs </li></ul><ul><li>(FDA ok) </li></ul><ul><li>Urokinase 2000 U/lb IV loading dose over 10 min, then 2000 U/lb per hour for 12 to 24 hours (FDA ok) </li></ul><ul><li>Reteplase (retavase): 10U IV over 2min, </li></ul><ul><li>then 30 min later 10U over 2 min </li></ul>
  51. 51. Potential Indications for Thrombolytic Therapy for VTE <ul><li>Commonly Accepted </li></ul><ul><li>Presence of hypotension or hemodynamic instability </li></ul><ul><li>Careful Case Selection </li></ul><ul><li>Presence of severe hypoxemia </li></ul><ul><li>Substantial perfusion defect V/Q or thrombus burden CT </li></ul><ul><li>Right ventricular dysfunction associated with PE </li></ul><ul><li>Concomitant extensive deep vein thrombosis </li></ul><ul><li>Free-floating RA/RV thrombus </li></ul><ul><li>Patent Foramen Ovale (PFO) / paradoxical embolus </li></ul>
  52. 52. PERCUTANEOUS
  53. 53. PERCUTANEOUS INTERVENTION <ul><li>1969- Greenfield: Vacuum pump embolectomy </li></ul><ul><li>1994- Mazeika: Percutaneous catheter fragmentation </li></ul><ul><li>1994- Dievart: Angiocor Thrombolizer </li></ul><ul><li>1995- Scmitz-Rode: Pigtail catheter fragmentation </li></ul><ul><li>1996- Uflacker: Amplatz thrombectomy device </li></ul><ul><li>1997- Koning: Rheolytic thrombectomy catheter </li></ul>
  54. 54. UROKINASE INTRAPULMONARY INFUSION <ul><li>26 patients with PE received intrapulmonary arterial infusions of urokinase. </li></ul><ul><li>9/26 had systemic thrombolytic contraindications. </li></ul><ul><li>20 pts returned to baseline state, 1 minimal change, 5 deaths </li></ul>McCotter,C.J. et al. Clin. Cardiol. 22, 661-664 (1999)
  55. 55. PULMONARY INTRATHROMBUS INFUSION
  56. 56. THROMBOLYSIS AND FRAGMENTATION
  57. 57. IVC FILTERS <ul><li>TWO PRINCIPAL INDICATIONS </li></ul><ul><ul><li>Absolute contraindication to anticoagulation or complication of anticoagulation therapy. </li></ul></ul><ul><ul><li>Recurrent PE despite adequate duration and level of anticoagulation, or patient not likely to </li></ul></ul><ul><ul><li>survive a recurrent PE because of tenuous hemodynamic status and iliofemoral thrombus burden. </li></ul></ul>
  58. 58. IVC FILTERS <ul><li>Do not prevent further thrombosis </li></ul><ul><li>Serve as a “nidus” for recurrent thrombus </li></ul><ul><li>Re-hospitalization within 1 year of filter placement for recurrent VTE 2.6 X control. </li></ul>Arch Intern Med 2000; 160:2033
  59. 59. CURRENT PERMANENT IVC FILTERS Greenfield Bird’s Nest Simon Nitinol Vena Tech Stainless steel Titanium
  60. 60. RETRIEVABLE VENA CAVA FILTERS <ul><li>Recovery Nitinol Filter </li></ul><ul><li>Gunther Tulip Filter </li></ul><ul><li>OptEase Filter </li></ul>
  61. 61. Recovery Nitinol Filter <ul><li>Bard Peripheral Vascular, Tempe, AZ </li></ul><ul><li>First FDA approved retrievable filter has no barbs for fixation, and therefore has a much longer potential window for retrieval. </li></ul><ul><li>One group has reported successful retrieval of filters as long as 134 days after insertion. There was, however, one filter that migrated after clot capture. </li></ul><ul><li>This emphasizes the one minor weakness of retrievable filters with extended placement times; these filters may have less surface area of contact with the vena cava to avoid tissue ingrowth and fixation. </li></ul>
  62. 62. Gunther Tulip Filter (Cook Inc., Bloomington, IN) has perhaps the widest experience in both the US and Europe. There are several reports in the literature supporting its value as a temporary filter It has the capability of deployment from either a femoral or jugular route. It must be retrieved from a jugular vein approach. Most authors recommended retrieval within 14 days.
  63. 63. OptEase Filter Cordis Endovascular, a Johnson & Johnson company, Miami, FL Has a unique self-centering design that provides dual-level filtration. It can be deployed from both the transfemoral and transjugular approaches using the same kit. It is the only potentially retrievable filter that is recovered from a femoral vein approach and requires a small retrieval system (10F guiding catheter)
  64. 64. NEW AND PROPHYLACTIC APPLICATIONS OF IVC FILTERS <ul><li>Trauma and major orthopedic surgery will most likely encompass the greatest use of retrievable vena cava filters </li></ul><ul><li>With the increasing number of obese patients undergoing major operations and bariatric surgery, the use of retrievable filters will continue to grow. </li></ul><ul><li>Ongoing prospective studies will probably support elevated body mass index as a major predictor of pulmonary embolism and will have a tremendous impact on the future of retrievable vena cava filters. </li></ul>
  65. 65. NEW AND PROPHYLACTIC APPLICATIONS OF IVC FILTERS <ul><li>Patients with DVT but no PE </li></ul><ul><ul><li>Reduced cardiopulmonary function, would not tolerate a PE </li></ul></ul><ul><ul><li>Free-floating DVT despite adequate anticoag </li></ul></ul><ul><ul><li>Recent DVT, undergoing major surgery </li></ul></ul><ul><ul><li>Pregnancy with proximal DVT, undergoing </li></ul></ul><ul><ul><li>catheter directed therapy </li></ul></ul>
  66. 66. PROPHYLACTIC APPLICATIONS OF IVC FILTERS <ul><li>The treatment of extensive iliofemoral deep venous thrombosis with thrombolytic therapy or surgical thrombectomy can cause pulmonary embolism during the procedure. Although permanent vena cava filters </li></ul><ul><li>have been used in this setting, retrieval of the filter after resolution of the deep vein thrombosis is appealing. </li></ul><ul><li>Patients with Neurological Problems resulting in prolonged immobilization, paralysis, stroke with DVT. </li></ul><ul><li>Patients with advanced malignancy and chemotherapy </li></ul><ul><li>Patients with suspected hypercoagulable state </li></ul><ul><li>Case reports in the literature cite success in the use of retrievable vena cava filters for pregnant patients with thromboembolism </li></ul><ul><li>Retrievable vena cava filters “off label” as temporary filters during resection of renal cell cancers </li></ul><ul><li>with tumor thrombus extension into the inferior vena cava. </li></ul>
  67. 67. FUTURE APPLICATIONS OF IVC FILTERS . Patent Foramen Ovale Recognized as a major contributor to morbidity and mortality Combined procedures of IVC filter and PFO closure may become more frequent
  68. 68. RHEOLYTIC THROMBECTOMY CATHETER
  69. 69. RHEOLYTIC THROMBECTOMY CATHETER
  70. 70. RHEOLYTIC THROMBECTOMY CATHETER
  71. 71. PERCUTANEOUS RHEOLYTIC THROMBECTOMY <ul><li>Koning et al. (Circulation 1997) - Successful thrombectomy in 2 patients with severe symptomatic pulmonary embolism and contraindications to thrombolytics. </li></ul><ul><li>Voigtlander et al. (Cath Card Interv 1999) - Successful thrombectomy in 3/5 patients with massive pulmonary embolism and contraindications to thrombolytics. </li></ul>
  72. 72. PERCUTANEOUS THROMBECTOMY <ul><li>PATIENT 1 </li></ul><ul><ul><li>72 Y/O MAN WITH TIA. +DYSPNEA/ +NEAR-SYNCOPE </li></ul></ul><ul><ul><li>TEE : THROMBUS IN RIGHT INFERIOR PA </li></ul></ul><ul><ul><li>PULMONARY ANGIOGRAM CONFIRMED </li></ul></ul><ul><ul><li>CT SCAN BRAIN: HEMORRHAGIC INFARCT </li></ul></ul><ul><ul><li>PERCUTANEOUS THROMBECTOMY WITH EXCELLENT IMMEDIATE RESULT </li></ul></ul><ul><ul><li>DISCHARGED. 1 MO F/U FREE OF THROMBUS </li></ul></ul>Koning,R et al.C irculation 1997;96:2498-500
  73. 73. PERCUTANEOUS THROMBECTOMY <ul><li>PATIENT 2 </li></ul><ul><ul><li>74 Y/O MAN, TRAUMA, FX TIBIA </li></ul></ul><ul><ul><li>HD 9: RIGHT SIDE CHEST PAIN AND SEVERE DYSPNEA </li></ul></ul><ul><ul><li>P.E., ECG, CXR SUGGESTIVE OF PE </li></ul></ul><ul><ul><li>PULMONARY ANGIOGRAM: MASSIVE BILATERAL EMBOLISM </li></ul></ul><ul><ul><li>PERCUTANEOUS THROMBECTOMY TO LLL </li></ul></ul><ul><ul><li>DISCHARGED. 1 MO F/U NO THROMBUS LLL. </li></ul></ul>Koning,R et al. Circulation 1997;96:2498-500
  74. 74. PATIENT CHARACTERISTICS PATIENT AGE GENDER CLINICAL STATUS CONTRAINDICATION 1 25 M ORTHOPNEA, LOW BP SKULL INJURY 2 70 M CARDIOGENIC SHOCK RECENT SURGERY 3 72 M CARDIOGENIC SHOCK CRITICAL BLEEDING 4 72 M ORTHOPNEA, LOW BP ACTIVE ULCER 5 52 F CARDIOGENIC SHOCK SURGERY 14 D AGO Voigtlander et al. Cath Card Interv . 47:91-96 1999
  75. 75. CLINICAL RESULTS <ul><li>Patients 1,2,3 successfully treated; Pt 2 died on day 12 of cerebral hemorrhage </li></ul><ul><li>Patients 4,5 underwent surgical thrombectomy </li></ul><ul><li>3-month follow-up (Pts 1,3,4,5): normalized RV function and asymptomatic </li></ul><ul><li>Patients 4,5 histological analysis revealed organized thrombi with partial fibrosis </li></ul>Voigtlander et al. Cath Card Interv. 47:91-96 1999
  76. 76. ANGIOGRAPHIC RESULTS TOTAL MILLER SCORE INVOLVEMENT REDUCTION OF FLOW (X/34) (X/16) (X/18) Voigtlander et al. Cath Card Interv. 47:91-96 1999
  77. 77. HEMODYNAMIC RESULTS Voigtlander et al. Cath Card Interv .47:91-96 1999
  78. 78. THROMBECTOMY LIMITATIONS <ul><li>RISK OF MECHANICAL PERFORATION ? </li></ul><ul><li>AGE OF THROMBUS </li></ul><ul><ul><li>Rate of thrombolysis depends on the age of thrombus </li></ul></ul>ORGANIZED THROMBUS LYSIS RATE 5 MG/ SEC NONORGANIZED THROMBUS LYSIS RATE 70 MG/ SEC Stahr P et al. Z Kardiol 1997: 86 (suppl 2): 289 <ul><li>ANEMIA </li></ul>
  79. 79. EMERGENT SURGICAL EMBOLECTOMY <ul><li>Operative mortality rate 30-40% </li></ul><ul><li>Independent predictors of mortality : Cardiac arrest & assoc. cardiopulmonary disease </li></ul><ul><li>Major causes of mortality: incomplete thrombus removal with persistent RV dysfunction, and severe reperfusion lung injury </li></ul><ul><li>Consider as primary therapy in PE > 14 days old </li></ul>
  80. 80. EMERGENT SURGICAL EMBOLECTOMY <ul><li>Recent series 29 patients treated by a dedicated team </li></ul><ul><ul><li>24 hour availability </li></ul></ul><ul><ul><li>Emergency transport </li></ul></ul><ul><li>Surgical technique without aortic crossclamp or cardioplegia </li></ul><ul><li>IVC Filters in all patients </li></ul><ul><li>Moderate/severe RV dysfunction with extensive PE </li></ul><ul><ul><li>No antecedent CPR </li></ul></ul><ul><li>11% 1-month mortality (89% survival; 26/29 patients) </li></ul>Aklog, Circulation 2002
  81. 81. THROMBOENDARTERECTOMY HEMODYNAMIC VALUES PREOP POSTOP 3 moFOLLOW-UP Moser et al. Circulation 81: 1735,1990
  82. 82. PREVENTION <ul><li>In medical ICU, DVT develops in one third of patients; half of these involved the proximal portion of the leg. </li></ul><ul><li>Choose most adequate prophylactic method </li></ul><ul><li>Keep high index of suspicion, especially in high-risk patients </li></ul>Hirsch et al. JAMA 1995;274:335-7
  83. 83. SUMMARY <ul><li>Pulmonary embolism manifests in spectral fashion, and management (diagnostic and therapeutic) may be just as varied and nonuniform due to options available. </li></ul>
  84. 84. SUMMARY <ul><li>Echocardiography is a useful tool for risk-stratification of “stable” patients who otherwise might benefit from a more aggressive approach. </li></ul><ul><li>Echocardiographic evidence of RV Dysfunction adds weight to a clinical suspicion of PE in an unstable patient unable to undergo further testing, therefore, expedites therapeutics. </li></ul>
  85. 85. SUMMARY <ul><li>The optimum application of thrombolytic therapy remains in doubt. Some authorities argue for treatment of only unstable patients, while others would enlarge indications to include those with echo or CT evidence of RV Dysfunction. </li></ul>
  86. 86. SUMMARY <ul><li>A catheter-based approach seems feasible and safe as primary therapy for massive pulmonary embolism in acute cases (< 14 days old) when thrombolysis is contraindicated or unsuccessful. </li></ul><ul><li>Surgical embolectomy may be a better option for older clots (> 14 days old). </li></ul>
  87. 87. SUMMARY <ul><li>Further studies are needed to answer the questions regarding effectivenes and clinical benefit of the catheter-based approach and emergency thrombectomy compared to thrombolytics. </li></ul>
  88. 88. Protocol for the Treatment of Massive Pulmonary Embolism in Patients Who Have Contraindications to Thrombolytic Therapy using the Possis AngioJet System
  89. 89. Inclusion / Exclusion Criteria <ul><li>Inclusion </li></ul><ul><li>Symptomatic massive PE </li></ul><ul><li>RV Dysfunction </li></ul><ul><li>Contraindications to thrombolysis </li></ul><ul><li>Recent PE < 14 days </li></ul><ul><li>Age > 18 </li></ul><ul><li>Exclusion </li></ul><ul><li>Severe Anemia </li></ul><ul><li>Inability to tolerate hemolysis </li></ul><ul><li>Chronic terminal illness </li></ul><ul><li>PE > 14 days </li></ul><ul><li>Inability to obtain informed consent or follow up </li></ul>
  90. 90. Procedure <ul><li>Establish Diagnosis </li></ul><ul><li>Diagnostic Studies </li></ul><ul><ul><li>VQ Lung Scan </li></ul></ul><ul><ul><li>Spiral CT </li></ul></ul><ul><li>Echocardiogram for RV Function </li></ul><ul><li>Pulmonary Angiography </li></ul><ul><li>Rheolytic Thrombectomy </li></ul><ul><li>Follow Up 24 hours, at hospital D/C and 30 days </li></ul>
  91. 91. Protocol for the Treatment of Patients with Normotensive Submassive Pulmonary Embolism with Right Ventricular Dysfunction <ul><li>Randomize Patients </li></ul><ul><li>Standard Care (anticoagulation) vs. Lytic Therapy </li></ul><ul><li>Subgroup patients with contraindications or high risk for bleeding with thrombolytics can be treated with AngioJet </li></ul><ul><li>Exclude patients with chronic terminal illness </li></ul><ul><li>Follow Up Assessment </li></ul><ul><ul><li>Cardiopulmonary Treadmill Testing </li></ul></ul><ul><ul><li>VQ Lung Scan </li></ul></ul>
  92. 92. Protocol for the Treatment of Patients with Normotensive Submassive Pulmonary Embolism with Right Ventricular Dysfunction:Follow-up Assessment and End-points <ul><li>30 day mortality </li></ul><ul><li>Bleeding complications </li></ul><ul><li>Thrombolytic dose and cost </li></ul><ul><li>Echo </li></ul><ul><li>V/Q lung scan </li></ul><ul><li>Cardiopulmonary Stress test </li></ul>
  93. 93. Contemporary Management of Pulmonary Embolism Lowell I. Gerber M.D.

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