Vol 31, No 2 (2024)
Original Article
Published online: 2023-07-28

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Treatment of high- and intermediate-high-risk pulmonary embolism by the Pulmonary Embolism Response Team: Focus on catheter-directed therapies

Arkadiusz Pietrasik1, Paweł Kurzyna1, Piotr Szwed2, Karolina Jasińska-Gniadzik1, Aleksandra Gąsecka1, Szymona Darocha2, Dariusz Zieliński3, Łukasz Szarpak45, Janusz Kochman1, Marcin Grabowski1, Grzegorz Opolski1, Adam Torbicki2, Marcin Kurzyna2
Pubmed: 37519055
Cardiol J 2024;31(2):215-225.

Abstract

Background: Multidisciplinary Pulmonary Embolism Response Teams (PERTs) were established to individualize the treatment of high-risk (HR) and intermediate-high-risk (IHR) pulmonary embolism (PE) patients, which pose a challenge in clinical practice.

Methods: We retrospectively collected the data of all HR and IHR acute PE patients consulted by PERT CELZAT between September 2017 and October 2022. The patient population was divided into four different treatment methods: anticoagulation alone (AC), systemic thrombolysis (ST), surgical embolectomy (SE), and catheter-directed therapies (CDTx). Baseline clinical characteristics, risk stratification, PE severity parameters, and treatment outcomes were compared between the four groups.

Results: Of the 110 patients with HR and IHR PE, 67 (61%) patients were treated with AC only, 11 (10%) with ST, 15 (14%) underwent SE, and 17 (15%) were treated with CTDx. The most common treatment option in the HR group was reperfusion therapy, used in 20/24 (83%) cases, including ST in 7 (29%) patients, SE in 5 (21%) patients, and CTDx in 8 (33%) patients. In contrast, IHR patients were treated with AC alone in 63/86 (73%) cases. The in-hospital mortality rate was 9/24 (37.5%) in the HR group and 4/86 (4.7%) in the IHR group.

Conclusions: The number of advanced procedures aimed at reperfusion was substantially higher in the HR group than in the IHR PE group. Despite the common use of advanced reperfusion techniques in the HR group, patient mortality remained high. There is a need further to optimize the treatment of patients with HR PE to improve outcomes.

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References

  1. Giordano NJ, Jansson PS, Young MN, et al. Epidemiology, pathophysiology, stratification, and natural history of pulmonary embolism. Tech Vasc Interv Radiol. 2017; 20(3): 135–140.
  2. Turetz M, Sideris AT, Friedman OA, et al. Epidemiology, pathophysiology, and natural history of pulmonary embolism. Semin Intervent Radiol. 2018; 35(2): 92–98.
  3. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019; 54(3).
  4. Smith SB, Geske JB, Kathuria P, et al. Analysis of national trends in admissions for pulmonary embolism. Chest. 2016; 150(1): 35–45.
  5. Stein PD, Matta F, Hughes PG, et al. Nineteen-year trends in mortality of patients hospitalized in the united states with high-risk pulmonary embolism. Am J Med. 2021; 134(10): 1260–1264.
  6. Liang Y, Nie SP, Wang X, et al. Role of Pulmonary Embolism Response Team in patients with intermediate- and high-risk pulmonary embolism: a concise review and preliminary experience from China. J Geriatr Cardiol. 2020; 17(8): 510–518.
  7. Kohls N, Konstantinides SV, Lang IM, et al. Risk stratification and risk-adapted management of acute pulmonary embolism. Wien Klin Wochenschr. 2023; 135(1-2): 22–27.
  8. Büller HR, Prins MH, Lensin AWA, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012; 366(14): 1287–1297.
  9. Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014; 311(23): 2414–2421.
  10. Piazza G. Advanced management of intermediate- and high-risk pulmonary embolism: JACC Focus Seminar. J Am Coll Cardiol. 2020; 76(18): 2117–2127.
  11. Araszkiewicz A, Kurzyna M, Kopeć G, et al. Expert opinion on the creating and operating of the regional Pulmonary Embolism Response Teams (PERT). Polish PERT Initiative. Cardiol J. 2019; 26(6): 623–632.
  12. Araszkiewicz A, Kurzyna M, Kopeć G, et al. Pulmonary embolism response team: A multidisciplinary approach to pulmonary embolism treatment. Polish PERT Initiative Report. Kardiol Pol. 2021; 79(12): 1311–1319.
  13. Chaudhury P, Gadre SK, Schneider E, et al. Impact of multidisciplinary pulmonary embolism response team availability on management and outcomes. Am J Cardiol. 2019; 124(9): 1465–1469.
  14. Rosovsky R, Chang Y, Rosenfield K, et al. Changes in treatment and outcomes after creation of a pulmonary embolism response team (PERT), a 10-year analysis. J Thromb Thrombolysis. 2019; 47(1): 31–40.
  15. Hobohm L, Farmakis IT, Keller K, et al. Pulmonary embolism response team (PERT) implementation and its clinical value across countries: a scoping review and meta-analysis. Clin Res Cardiol. 2022 [Epub ahead of print]: 1–11.
  16. Schultz J, Giordano N, Zheng H, et al. EXPRESS: A Multidisciplinary Pulmonary Embolism Response Team (PERT) - Experience from a national multicenter consortium. Pulm Circ. 2019 [Epub ahead of print]; 9(3): 2045894018824563.
  17. Pietrasik A, Gąsecka A, Kurzyna P, et al. Characteristics and outcomes of patients consulted by a multidisciplinary pulmonary embolism response team: 5-year experience. J Clin Med. 2022; 11(13).
  18. Zieliński D, Zygier M, Dyk W, et al. Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients. Eur J Cardiothorac Surg. 2023; 63(4).
  19. Araszkiewicz A, Sławek-Szmyt S, Jankiewicz S, et al. Continuous aspiration thrombectomy in high- and intermediate-high-risk pulmonary embolism in real-world clinical practice. J Interv Cardiol. 2020; 2020: 4191079.
  20. Mathews SJ. Mechanical thrombectomy of pulmonary emboli with use of the indigo system and lightning 12 intelligent aspiration. Tex Heart Inst J. 2021; 48(5).
  21. Kurzyna M, Pietrasik A, Opolski G, et al. Contemporary methods for the treatment of pulmonary embolism - is it prime-time for percutaneous interventions? Kardiol Pol. 2017; 75(11): 1161–1170.
  22. Pietrasik A, Gasecka A, Kotulecki A, et al. Catheter-directed therapy to treat intermediateand high-risk pulmonary embolism: Personal experience and review of the literature. Cardiol J. 2023; 30(3): 462–472.
  23. Myc LA, Solanki JN, Barros AJ, et al. Adoption of a dedicated multidisciplinary team is associated with improved survival in acute pulmonary embolism. Respir Res. 2020; 21(1): 159.
  24. Carroll BJ, Beyer SE, Mehegan T, et al. Changes in care for acute pulmonary embolism through a multidisciplinary pulmonary embolism response team. Am J Med. 2020; 133(11): 1313–1321.e6.
  25. Pietrasik A, Gąsecka A, Kurzyna P, et al. Cancer associated thrombosis: comparison of characteristics, treatment, and outcomes in oncological and non-oncological patients followed by Pulmonary Embolism Response Team. Pol Arch Intern Med. 2023 [Epub ahead of print].
  26. Pietrasik A, Gąsecka A, Szarpak Ł, et al. Catheter-based therapies decrease mortality in patients with intermediate and high-risk pulmonary embolism: evidence from meta-analysis of 65,589 patients. Front Cardiovasc Med. 2022; 9: 861307.
  27. Avgerinos ED, Saadeddin Z, Abou Ali AN, et al. A meta-analysis of outcomes of catheter-directed thrombolysis for high- and intermediate-risk pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 2018; 6(4): 530–540.
  28. Liang NL, Chaer RA, Marone LK, et al. Midterm outcomes of catheter-directed interventions for the treatment of acute pulmonary embolism. Vascular. 2017; 25(2): 130–136.
  29. Dilektasli AG, Demirdogen Cetinoglu E, Acet NA, et al. Catheter-directed therapy in acute pulmonary embolism with right ventricular dysfunction: a promising modality to provide early hemodynamic recovery. Med Sci Monit. 2016; 22: 1265–1273.
  30. Bloomer TL, El-Hayek GE, McDaniel MC, et al. Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: Results of a multicenter registry and meta-analysis. Catheter Cardiovasc Interv. 2017; 89(4): 754–760.
  31. Sista AK, Horowitz JM, Tapson VF, et al. Indigo Aspiration System for Treatment of Pulmonary Embolism: Results of the EXTRACT-PE Trial. JACC Cardiovasc Interv. 2021; 14(3): 319–329.
  32. Sedhom R, Abdelmaseeh P, Haroun M, et al. Complications of penumbra indigo aspiration device in pulmonary embolism: insights from MAUDE database. Cardiovasc Revasc Med. 2022; 39: 97–100.
  33. Pruszczyk P, Klok FA, Kucher N, et al. Percutaneous treatment options for acute pulmonary embolism: a clinical consensus statement by the ESC Working Group on Pulmonary Circulation and Right Ventricular Function and the European Association of Percutaneous Cardiovascular Interventions. EuroIntervention. 2022; 18(8): e623–e638.
  34. Kopeć G, Araszkiewicz A, Kurzyna M, et al. Role of catheter-directed therapies in the treatment of acute pulmonary embolism. Expert opinion of the Polish PERT Initiative, Working Group on Pulmonary Circulation, Association of Cardiovascular Interventions, and Association of Intensive Cardiac Care of the Polish Cardiac Society. Kardiol Pol. 2023; 81(4): 423–440.
  35. Burton J, Madhavan M, Finn M, et al. Advanced therapies for acute pulmonary embolism: a focus on catheter-based therapies and future directions. Structural Heart. 2021; 5(2): 103–119.
  36. Stępniewski J, Magoń W, Podolec P, et al. The PENUMBRA Lightning 12 system for treatment of acute intermediate-high pulmonary embolism. Initial experience in Pulmonary Circulation Center Krakow, Poland. Postepy Kardiol Interwencyjnej. 2022; 18(3): 314–316.
  37. Araszkiewicz A, Sławek-Szmyt S, Jankiewicz S, et al. Lightning 12: A new player in the field of pulmonary percutaneous mechanical thrombectomy. Kardiol Pol. 2022; 80(9): 956–957.