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Predictors of failure and complications of catheter-directed interventions for pulmonary embolism
Efthymios D Avgerinos1, Adham N Abou Ali1, Nathan L Liang1
1Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Insights
Catheter-directed interventions (CDIs) for acute pulmonary embolism (PE) carry risks. Factors like massive PE, older age, and contraindications to thrombolytics increase failure rates, necessitating individualized treatment decisions.
Area of Science:
- Cardiology
- Interventional Radiology
- Pulmonary Medicine
Background:
- Catheter-directed interventions (CDIs) are increasingly used for acute pulmonary embolism (PE).
- CDIs are presumed to offer therapeutic benefits similar to systemic thrombolysis with reduced thrombolytic dose and risks.
- This study investigates factors influencing CDI failure and associated complications.
Purpose of the Study:
- To identify factors associated with catheter-directed intervention (CDI) failure in acute pulmonary embolism (PE).
- To describe anticipated complications of CDIs for PE.
- To evaluate the risk-benefit ratio of CDIs in PE management.
Main Methods:
- Retrospective analysis of consecutive patients undergoing CDI for massive or submassive PE (2009-2015).
- Clinical failure defined by major bleeding, stroke, decompensation, need for surgery, or in-hospital death.
- Univariate analysis to determine factors associated with CDI failure.
Main Results:
- CDI failure occurred in 14.7% of 102 patients, with 7.8% experiencing major bleeding and 7.8% decompensating.
- Factors associated with CDI failure and major bleeding included massive PE, age ≥70 years, and major contraindications to thrombolytics.
- Lysis dose and CDI technique did not impact failure or bleeding events.
Conclusions:
- Catheter-directed interventions (CDIs) for acute PE are not risk-free and require individualized risk-benefit assessment.
- CDIs should be used selectively in patients with major contraindications to systemic thrombolytics.
- Lytic dose and CDI technique do not appear to influence adverse events.
Objective:
Catheter-directed interventions (CDIs) are increasingly performed for acute pulmonary embolism (PE) as they are presumed to provide similar therapeutic benefits to systemic thrombolysis while decreasing the dose of thrombolytic required and the associated risks. This study aimed to identify factors associated with CDI failure and to describe anticipated complications.
Methods:
Consecutive patients who underwent CDI for massive or submassive PE between 2009 and 2015 were identified; outcomes and complications were retrospectively collected. CDI clinical failure was defined as major bleeding, perioperative stroke or other major adverse procedure-related event, decompensation for submassive or persistent shock for massive PE, need for surgical thromboembolectomy, or in-hospital death. Univariate analysis was used to study the factors associated with CDI failure.
Results:
There were 102 patients who received a CDI during the study period (36 standard catheter thrombolysis, 60 ultrasound assisted, 6 other; age, 59.2 ± 15.9 years; male, 50 [49.0%]; massive PE, 14 [13.7%]). Five patients (4.9%) had a major contraindication and 15 patients (14.7%) had a minor contraindication to systemic thrombolysis. The mean alteplase dose was 28.2 ± 18.8 mg (range, 0-123 mg; three patients had already received systemic lysis). CDI failure occurred in 15 patients (14.7%; 7 in massive PE, 8 in submassive PE). Of these patients, seven had major bleeding events, whereas eight patients decompensated. Ten (9.8%) patients had minor bleeding events (four access related). Factors associated with CDI failure and major bleeding included massive PE, age ≥70 years, and major contraindication to thrombolytics. Both failures and bleeding events were independent of lysis dose and CDI technique.
Conclusions:
CDIs for acute PE are not risk-free procedures, and their use should be individualized on the basis of a risk-benefit ratio. Particularly for patients with major contraindications to systemic thrombolytics, CDIs should be used selectively. Lytic dose, within the low-volume range administered in CDI, and type of CDI seem to have no impact on adverse events.