Catheter-directed interventions compared with systemic thrombolysis achieve improved ventricular function recovery at a potentially lower complication rate for acute pulmonary embolism

• Published in: Journal of vascular surgery. Venous and lymphatic disorders (New York, NY) Vol. 6; no. 4; pp. 425 - 432
• Main Authors: Avgerinos, Efthymios D., Abou Ali, Adham N., Liang, Nathan L., Rivera-Lebron, Belinda, Toma, Catalin, Maholic, Robert, Makaroun, Michel S., Chaer, Rabih A.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-07-2018
• Subjects: Acute Disease; Adult; Aged; Catheterization, Peripheral - adverse effects; Catheterization, Peripheral - mortality; Chi-Square Distribution; Echocardiography; Female; Fibrinolytic Agents - administration & dosage; Fibrinolytic Agents - adverse effects; Humans; Infusions, Intravenous; Male; Middle Aged; Propensity Score; Pulmonary Embolism - diagnostic imaging; Pulmonary Embolism - drug therapy; Pulmonary Embolism - mortality; Pulmonary Embolism - physiopathology; Recovery of Function; Retrospective Studies; Risk Factors; Thrombolytic Therapy - adverse effects; Thrombolytic Therapy - methods; Thrombolytic Therapy - mortality; Time Factors; Treatment Outcome; Ventricular Dysfunction, Right - diagnostic imaging; Ventricular Dysfunction, Right - physiopathology; Ventricular Function, Right
• ISSN: 2213-333X; 2213-3348
• DOI: 10.1016/j.jvsv.2017.12.058

Catheter-directed interventions (CDIs) are increasingly performed for acute pulmonary embolism (PE) as they are presumed to provide similar therapeutic benefits to systemic thrombolysis (ST) while decreasing the associated complications. The purpose of this study was to compare outcomes between CDI and ST.
Consecutive patients who underwent CDIs or ST for massive or submassive PE between 2006 and 2016 were identified. Clinical and echocardiographic parameters at baseline and after treatment were recorded. Clinical success was defined as decompensation resolution (or prevention) without major bleeding, stroke, other major treatment-related event, or in-hospital death. The χ2 test and t-test were used for between-groups comparisons.
There were 213 patients who received CDIs (standard catheter thrombolysis in 56, ultrasound-assisted thrombolysis in 146, suction thrombectomies in 10, and pharmacomechanical thrombolysis in 1) and 104 patients who received ST (94 high dose [100 mg], 10 low dose [50 mg]). At baseline, CDI and ST groups had comparable echocardiographic parameters, demographics, and comorbidities, except for PE type (massive PE, 8.5% for CDIs vs 69.2% for ST; P < .001), age (60.2 ± 14.9 years for CDIs vs 55.9 ± 17.3 years for ST; P = .023), and renal function (glomerular filtration rate, 78.1 ± 33.7 mL/min/1.73 m2 for CDIs vs 64.1 ± 35.2 mL/min/1.73 m2 for ST; P = .001). Without stratifying per PE type, CDIs had a higher clinical success rate (87.8% vs 66.3%; P < .001) and a lower rate of major bleed (8.0% vs 19.2%; P = .003), stroke (1.4% vs 4.8%; P = .120), and death (1.4% vs 13.5%; P < .001). On stratifying by PE type, there was no difference in clinical success between groups. The mean reduction in right ventricular/left ventricular diameter ratio between baseline and the first post-treatment echocardiographic examination (within 30 days) was significantly higher for CDI (0.27 ± 0.20 vs 0.18 ± 0.15; P = .037). Beyond 30 days, there was no echocardiographic difference between groups. There was no significant difference in clinical outcomes and echocardiographic parameters between standard and ultrasound-assisted CDIs.
CDIs provide improved recovery of right ventricular function compared with ST. Major bleeding and stroke complications may be lower, but larger studies are needed to validate this. CDIs are complementary to ST, and their use should be individualized on the basis of the patients' clinical presentation, risk profile, and local resources.