• David Dexter, MD • Sentara Vascular Specialists • Assistant Professor of Surgery EVMS
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Management of Acute Pulmonary Embolism
DVT Awareness Subtitle of other information
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Epidemiology Subtitle of other 350,000 to 600,000 DVT and PE occur information annually
• Up to 200,000 Deaths Presenter name Titlewith • Up to 50% of cases of DVT are silent the first symptom being fatal PE Date
A National Public Health Crisis Subtitle of other Cause of Death # of Annual Deaths information 3
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PE
Up to 200,000
AIDS
18,017
Breast Cancer
40,870
Presenter name – Of these, 30 percent die within 30 days, one fifth suffer sudden death dueTitle to PE, and about 30 percent develop recurrent VTE within 10 years Approximately 600,000 experience pulmonary embolism (PE) Date It is estimated that more than 250,000 patients are hospitalized annually with VTE1 2
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For up to 200,000 of those with PE, the blood clot in the lung proves fatal— killing more people than AIDS and breast cancer combined3
1. Goldhaber SZ. Pulmonary embolism. N Engl J Med. 1998;339:93-104. 2. Heit JA. Venous thromboembolism epidemiology: implications for prevention and management. Semin Thromb Hemost. 2002;28(suppl 2):3-13.)) 3. American Heart Association Fact Sheet - 2008
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Long-term Health Complications of DVT: Pulmonary Embolism Subtitle of other • • •
PE: most preventable cause of in-hospital death1 70%-80% of fatal PEs occur in nonsurgical patients2 Improved treatment might have a minimal impact on the number of deaths, more effective prevention of recurrent PE would represent the greatest opportunity to prevent fatal recurrent PE1
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The first manifestation of DVT/PE may be fatal PE3 1. 2. 3.
Clinical Syndromes and Clinical Outcome in Patients With Pulmonary Embolism: Findings From the RIETE Registry - CHEST 2006 – Lobo et al Geerts WH, et al. Chest. 2008;133:381S-453S. Geerts et al. Chest. 2004;126(suppl):338S-400S
Diagnosis of PE Subtitle of other information
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Wells Criteria for PE Subtitle of other information
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PE Patient Risk Stratification Minor PE • 55% PE population • Good prognosis • Low mortality rate
Subtitle of other information Massive PE • 5% PE population • Sustained hypotension • Inotropic support • 58% mortality @ 3 mo
RV/LV ratio
Presenter name Title Date Jaff et al. Circulation 2011;123(16):1788-1830. Goldhaber et al. Lancet. 1999;353(9162):1386-9. Quiroz et al. Circulation (2004);109;2401-2404 Frémont, Chest 2008; 133;558-362 Schoef, Circ 2004; 110:3276-3280 Kucher, Arch Intern Med 2005; 165:1777-1781
Submassive PE • 40% PE population • Systemic normotension • RV dysfunction • 22% mortality @ 3 mo
Why Treat Submassive PE? Subtitle of other information Presenter name RV/LV ratio > 0.9 is an independent predictor of Title Date mortality1-4 1.Quiroz, Circ 2004; 109:2401-2404 2.Frémont, Chest 2008; 133;558-362 3.Schoef, Circ 2004; 110:3276-3280 4. Kucher, Arch Intern Med 2005; 165:1777-1781
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Patients with persistent RV dysfunction at discharge:
8 times more likely to have recurrent PE 4 times higher mortality rate Presenter name Title than patients with RV dysfunction regressed at discharge6 Date Grifoni, Arch Intern Med 2006; 166:2151-215
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Rationale Subtitle of other Systemic PE thrombolysis is assoicated information with a 13% risk of major bleeding and 1.8% risk of intracranial hemorrhage – Real world 20% major bleeding and 3% ICH • As such, systemic thrombolysis is witheld in 2/3 of Presenter name patients with massive PE
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Tools Required for Clot Removal Subtitle of other Pharmacologic information Thrombolytics ▪ Tissue Plasminogen Activator TPA ▪ Urokinase and Streptokinase (Historic) Anticoagulant ▪ Heparin ▪ Bivalruden
Presenter name Antiplatelets Title ▪ IIB/IIIA Inhibitors (Aggrostat, Integrelin and Reopro) Date ▪ Clopidogrel ▪ ASA
Mechanism of TPA 1. Clot is made up of tight fibrin strands. of other Subtitle • The strands protect the clot information 2. Plasminogen is present in the clot • •
When Activated: Plasminogen converts to plasmin Plasmin digests fibrin
3. tPA activates plasminogen
Presenter name Title 4. The speed of lysis depends on ability of lytic Date agent to access plasminogen receptors sites. • Creating more plasmin to digest fibrin
Francis, Charles W. et al. “Ultrasound Accelerates Transport of Recombinant Tissue Plasminogen Activator into Clots.” Ultrasound in Medicine and Biology 21.3 (1995):419-424.
Infusion Soaker Catheters • Varying lengths of
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Soaker Holes • Need Wire Occlusion (0.35”) through tip
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Infusion Soaker Catheters Subtitle of other • Direct Drug Delivery into thrombus information – Decreases dosages needed – Decreased drug decreases risk of bleeding – Provides access for Venogram, IVUS and angioplasty or stenting Presenter name Title Date
EKOS Subtitle of other information
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EKOS Catheter Subtitle of other 1. Transport the drug TO the clot information (Infusion Catheter) 2. Transport the drug INTO the clot (Ultrasound Core)
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EKOS Mechanism Subtitle of other Mechanism of Action • Ultrasonic energy causes fibrin information strands to thin, exposing WITHOUT ULTRASOUND ENERGY
plasminogen receptor sites and fibrin strands to loosen • Thrombus permeability and lytic penetration are dramatically increased • Ultrasound pressure waves force lytic agent deep into the clot and keep it there
Braaten et al. Thromb Haemost 1997:; 78:1063-8.
WITH ULTRASOUND ENERGY
Presenter name Title ULTRASOUND ENERGY & THROMBOLYTIC Date
EKOS Mechanism Subtitle of other information
Standard Infusion Catheter Plasma Clot
EkoSonic® Endovascular Device
Plasma Clot Spread of Stained t-PA
Spread of Stained t-PA
Thrombus exposed to ultrasound absorbed 48% more t-PA in one hour, 84% more t-PA in two hours and 89% more t-PA in Presenter name 4 hours than thrombus not exposed to microsonic pressure.3
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3Francis,
CW, et al. “Ultrasound Accelerates Transport of Recombinant Tissue Plasminogen Activator into Clots.” Ultrasound in Medicine and Biology 21.3 (1995): 419-424.
Pharmacomechanical Thrombectomy • Advantages – – – –
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Single Stage procedure May decrease total time of indwelling catheters Rapid resolution of symptoms. Reduce or eliminate the exposure to thrombolytics and/or anticoagulants. – Provides access for other venous adjuvant surgery
• Disadvantages
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– Severe Arrhythmias – Potential for hemolysis and ATN/Shock Kidney – Potential hemolytic induced pancreatitis
Angiojet Subtitle of other information
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PEITHO Trial Subtitle of other • Prospective randomized information • Acute PE: normotensive with evidence of Right Heart Strain Presenter name • Treatment within 2 weeks Title • Tenectaplase IV Bolus vs. Date IV Heparin
PEITHO Trial Subtitle of other information
0.23
0.44
Thrombolysis superior
0.88
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PEITHO Trial Subtitle of other information
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Outcomes by Age Subtitle of other Age ≤ 75 years information 0.12 0.33 0.85 0
1.00 Odds ratio
Presenter name Title 1.66 Date
Age >75 years 0.23 0
2.00
0.63 1.00 Odds ratio
2.00
Conclusions Subtitle of other • Systemic Thrombolytics reduce the information change of death or hemodynamic collapse • This benefit comes at the cost of increased major bleeding Presenter name • Patient age and comorbidities need to be Title evaluated before dosing with Date thrombolytics.
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Low Dose TPA Delivery Subtitle of other 2 trials on catheter directed ultrasound information enhanced (EKOS) treatment
• Less than 20mg TPA • SEATTLE and Ultima Presenter name Title • Prelim results on SEATTLE are positive Date but not published
Ultima Trial Subtitle of other Multicenter, randomized controlled trial information
• • Ultrasound assisted catheter directed thrombolysis • Superior to heparin alone for reversing RV enlargement Presenter name TitleCT • Acute symptomatic PE confirmed by Date • RV/LV ration >1 on echo (normal is 0.6)
Utima Trial Subtitle of other information
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Ultima Trial Subtitle of other information
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Conclusions Subtitle of other Catheter directed (ultrasound accelerated) information thrombolysis was superior to heparin in
reversing right heart dysfunction. • No increase in bleeding complications • At 90 days the right heart function is name Presenter improved with CDT over Heparin Title Date
SEATTLE II Subtitle of other A prospective, single-arm, multicenter trial to: information • Assess the Safety and Efficacy of low dose thrombolytic for acute massive and submassive PE Presenter name Title Date
Intervention Subtitle of other Standard Anticoagulation for PE information UFH goal PTT 40-60 sec during procedure
Catheter Placement and Treatment Based on Extent of Disease Unilateral: 1 catheter infusing t-PA 1 mg/hour for 24 hours
Bilateral: 2 catheters infusing t-PA 1 mg/hour/catheter for 12 hours
Baseline Right Heart Catheter Measurements
Presenter name TitleFibrinolysis Ultrasound-Facilitated, Low-Dose, Catheter-Directed t-PA Infusion Activation of high-frequency, low-power ultrasound Date Including pulmonary artery systolic pressure
Monitoring in intermediate care or ICU setting
Procedure Completion Post-Procedure Right Heart Catheter Measurements
Catheter Removal
Outcomes: RV/LV Ratio Subtitle of other p < 0.0001 information RV/LV Ratio
2
1.55 1.13
1.5 1 0.5
0 Pre-Procedure
Presenter name Title Date 48 Hours
Outcomes: PA Systolic Pressure
Mean PA Systolic Pressure (mmHg)
60
51.4
Subtitle of other p < 0.0001 information p < 0.0001
50 37.5
40
36.9
30
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20 10
0 Pre-Procedure Post-Procedure
48 Hours
Pulmonary Embolism Lysis: Technique
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Retrievable Filter protection??
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Supine Placement
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Double IJ puncture
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Guidewire and catheter to the main pulmonary artery
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Pulmonary Angiogram
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Check Pulmonary Pressures
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Cross the lesions with guidewire and then infusion catheter
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Infusion of thrombolytic agent
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Pulmonary Embolism Lysis: Technique
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After 20-30 mg tPA, recheck pressures
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Remove catheters vs. return to angiogram for repeat picture
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Therapeutic Anticoagulation
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Filter Removal as soon as possible
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PA Systolic 76
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PA Systolic 76
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PA Systolic 34
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PA Systolic 34
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Catheter Directed Pulmonary Embolectomy Subtitle of other information
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Options Subtitle of other Surgical Embolectomy information
• • Suction Embolectomy • Large Cannula Suction Embolectomy with venous perfusion
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Angio-Vac Subtitle of other Large Cannula Suction Embolectomy information
• • Venous Perfusion in OR
– Less Blood Loss – Less morbid than open surgery – Retrieval of Pulmonary as wellPresenter as Caval name Thrombus Title Date
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Developing a PE Protocol Subtitle of other information
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Step 1: Early Recognition Subtitle of other information
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Step 2: Treatment Algorithm Subtitle of other information
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Step 3: Multidisciplinary Approach Subtitle of other information
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Thank You Subtitle of other information
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