Review Articles
Current Trends in Catheter-Directed Therapy for Acute Pulmonary Embolism
Main Article Content
Silvio Leal
Abstract
Acute pulmonary embolism is a leading cause of in-hospital and cardiovascular mortality, and it keeps posing important diagnostic and therapeutic challenges. Traditional treatment options such as anticoagulation, thrombolysis, and surgery are increasingly being challenged by new catheter-based procedures, including catheter-directed thrombolysis, mechanical thrombectomy, and pharmacomechanical hybrid techniques.
Emerging evidence supports the effectiveness and safety of these percutaneous methods, which may facilitate faster recovery of right ventricular function and hemodynamics in selected patients, with a lower risk of bleeding compared to standard medical therapy. These interventions may be particularly beneficial for high-risk patients for whom thrombolysis is contraindicated or has proven ineffective, as well as for initially stable intermediate-risk patients who experience hemodynamic decline despite appropriate anticoagulation.
Nevertheless, significant knowledge gaps continue to impede the optimization of these techniques and limit the shifting of treatment recommendations for acute pulmonary embolism. This paper provides a summary of the various catheter-directed interventions currently available, highlighting their indications, technical considerations, clinical effectiveness, and potential complications, offering a comprehensive overview of their current future trends in the management of acute pulmonary embolism.
Article Details
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References
Heit JA. Epidemiology of venous thromboembolism. Nat Rev Cardiol. 2015;12:464-74. doi: 10.1038/nrcardio.2015.83.
Huang W, Goldberg RJ, Anderson FA, Kiefe CI, Spencer FA. Secular trends in occurrence of acute venous thromboembolism: the Worcester VTE study (1985-2009). Am J Med. 2014;127:829-39.e5. doi: 10.1016/j.amjmed.2014.03.041.
Tapson VF. Acute pulmonary embolism. N Engl J Med. 2008;358:1037-52. doi: 10.1056/NEJMra072753.
Jiménez D, Kopecna D, Tapson V, Briese B, Schreiber D, Lobo JL, et al. Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism. Am J Respir Crit Care Med. 2014;189:718-26. doi: 10.1164/rccm.201311-2040OC.
Becattini C, Agnelli G, Lankeit M, Masotti L, Pruszczyk P, Casazza F, et al. Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model. Eur Respir J. 2016;48:780-6. doi: 10.1183/13993003.00024-2016.
Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014;311:2414-21. doi: 10.1001/jama.2014.5990.
Bhatt A, Al-Hakim R, Benenati JF. Techniques and Devices for Catheter-Directed Therapy in Pulmonary Embolism. Tech Vasc Interv Radiol. 2017;20:185-192. doi: 10.1053/j.tvir.2017.07.008.
Giri J, Sista AK, Weinberg I, Kearon C, Kumbhani DJ, Desai ND, et al. Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association. Circulation. 2019;140:e774-e801. doi: 10.1161/CIR.0000000000000707.
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41:543-603. doi: 10.1093/eurheartj/ehz405.
Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172:1041-6. doi: 10.1164/rccm.200506-862OC.
Jiménez D, Aujesky D, Moores L, Gómez V, Lobo JL, Uresandi F, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170:1383-9. doi: 10.1001/archinternmed.2010.199.
Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353:1386-9. doi: 10.1016/s0140-6736(98)07534-5.
Lobo JL, Zorrilla V, Aizpuru F, Uresandi F, Garcia-Bragado F, Conget F, et al. Clinical syndromes and clinical outcome in patients with pulmonary embolism: findings from the RIETE registry. Chest. 2006;130:1817-22. doi: 10.1378/chest.130.6.1817.
Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol. 1997;30:1165-71. doi: 10.1016/s0735-1097(97)00319-7.
Miller GA, Sutton GC, Kerr IH, Gibson RV, Honey M. Comparison of streptokinase and heparin in treatment of isolated acute massive pulmonary embolism. Br Med J. 1971;2:681-4. doi: 10.1136/bmj.2.5763.681.
Qanadli SD, El Hajjam M, Vieillard-Baron A, Joseph T, Mesurolle B, Oliva VL, et al. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol. 2001;176:1415-20. doi: 10.2214/ajr.176.6.1761415.
Erkens PM, Prins MH. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev. 2010:CD001100. doi: 10.1002/14651858.CD001100.pub3.
Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med. 2013;369:799-808. doi: 10.1056/NEJMoa1302507.
Büller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012 Apr 5;366(14):1287-97. doi: 10.1056/NEJMoa1113572.
Hao Q, Dong BR, Yue J, Wu T, Liu GJ. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev. 2018;12:CD004437. doi: 10.1002/14651858.CD004437.pub5.
Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370:1402-11. doi: 10.1056/NEJMoa1302097.
Lee T, Itagaki S, Chiang YP, Egorova NN, Adams DH, Chikwe J. Survival and recurrence after acute pulmonary embolism treated with pulmonary embolectomy or thrombolysis in New York State, 1999 to 2013. J Thorac Cardiovasc Surg. 2018;155:1084-1090.e12. doi: 10.1016/j.jtcvs.2017.07.074.
Avgerinos ED, Saadeddin Z, Abou Ali AN, Fish L, Toma C, Chaer M, et al. A meta-analysis of outcomes of catheter-directed thrombolysis for high- and intermediate-risk pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 20186:530-540. doi: 10.1016/j.jvsv.2018.03.010.
Bloomer TL, El-Hayek GE, McDaniel MC, Sandvall BC, Liberman HA, Devireddy CM, 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;89:754-760. doi: 10.1002/ccd.26900.
Schoepf UJ, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber SZ. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism. Circulation. 2004;110:3276-80. doi: 10.1161/01.CIR.0000147612.59751.4C.
Trujillo-Santos J, den Exter PL, Gómez V, Del Castillo H, Moreno C, van der Hulle T, et al. Computed tomography-assessed right ventricular dysfunction and risk stratification of patients with acute non-massive pulmonary embolism: systematic review and meta-analysis. J Thromb Haemost. 2013;11:1823-32. doi: 10.1111/jth.12393.
Pruszczyk P, Klok FA, Kucher N, Roik M, Meneveau N, Sharp ASP, 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:e623-38. doi: 10.4244/EIJ-D-22-00246.
Schmitz-Rode T, Kilbinger M, Günther RW. Simulated flow pattern in massive pulmonary embolism: significance for selective intrapulmonary thrombolysis. Cardiovasc Intervent Radiol. 1998;21:199-204. doi: 10.1007/s002709900244.
Kuo WT, Banerjee A, Kim PS, DeMarco FJ Jr, Levy JR, Facchini FR, et al. Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis (PERFECT): Initial Results From a Prospective Multicenter Registry. Chest. 2015;148:667-73. doi: 10.1378/chest.15-0119.
Bashir R, Foster M, Iskander A, Darki A, Jaber W, Rali PM, et al. Pharmacomechanical Catheter-Directed Thrombolysis With the Bashir Endovascular Catheter for Acute Pulmonary Embolism: The RESCUE Study. JACC Cardiovasc Interv. 2022;15:2427-36. doi: 10.1016/j.jcin.2022.09.011.
Xue X, Sista AK. Catheter-Directed Thrombolysis for Pulmonary Embolism: The State of Practice. Tech Vasc Interv Radiol. 2018;21:78-84. doi: 10.1053/j.tvir.2018.03.003.
Soltani A, Volz KR, Hansmann DR. Effect of modulated ultrasound parameters on ultrasound-induced thrombolysis. Phys Med Biol. 2008;53:6837-47. doi: 10.1088/0031-9155/53/23/012.
Kucher N, Boekstegers P, Müller OJ, Kupatt C, Beyer-Westendorf J, Heitzer T, et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014;129:479-86. doi: 10.1161/CIRCULATIONAHA.113.005544.
Piazza G, Hohlfelder B, Jaff MR, Ouriel K, Engelhardt TC, Sterling KM, et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism: The SEATTLE II Study. JACC Cardiovasc Interv. 2015;8:1382-92. doi: 10.1016/j.jcin.2015.04.020.
Tapson VF, Sterling K, Jones N, Elder M, Tripathy U, Brower J, et al. A Randomized Trial of the Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Intermediate-Risk Pulmonary Embolism: The OPTALYSE PE Trial. JACC Cardiovasc Interv. 2018;11:1401-10. doi: 10.1016/j.jcin.2018.04.008.
Sadeghipour P, Jenab Y, Moosavi J, Hosseini K, Mohebbi B, Hosseinsabet A, et al. Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial. JAMA Cardiol. 2022;7:1189-97. doi: 10.1001/jamacardio.2022.3591.
Sterling KM, Goldhaber SZ, Sharp ASP, Kucher N, Jones N, Maholic R, et al. Prospective Multicenter International Registry of Ultrasound-Facilitated Catheter-Directed Thrombolysis in Intermediate-High and High-Risk Pulmonary Embolism (KNOCOUT PE). Circ Cardiovasc Interv. 2024;17:e013448. doi: 10.1161/CIRCINTERVENTIONS.123.013448.
Zhang RS, Maqsood MH, Sharp ASP, Postelnicu R, Sethi SS, Greco A, et al. Efficacy and Safety of Anticoagulation, Catheter-Directed Thrombolysis, or Systemic Thrombolysis in Acute Pulmonary Embolism. JACC Cardiovasc Interv. 2023;16:2644-51. doi: 10.1016/j.jcin.2023.07.042.
Avgerinos ED, Jaber W, Lacomis J, Markel K, McDaniel M, Rivera-Lebron BN, et al. Randomized Trial Comparing Standard Versus Ultrasound-Assisted Thrombolysis for Submassive Pulmonary Embolism: The SUNSET sPE Trial. JACC Cardiovasc Interv. 2021;14:1364-73. doi: 10.1016/j.jcin.2021.04.049.
Lin JL, Chen IY, Yang PK. Comparison of the Clinical Efficacy and Safety of Standard and Ultrasound-Assisted Thrombolysis for Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Endovasc Ther. 2023:15266028231181031. doi: 10.1177/15266028231181031.
Stein PD, Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med. 2012;125:465-70. doi: 10.1016/j.amjmed.2011.10.015.
Jaber WA, McDaniel MC. Catheter-Based Embolectomy for Acute Pulmonary Embolism: Devices, Technical Considerations, Risks, and Benefits. Interv Cardiol Clin. 2018;7:91-101. doi: 10.1016/j.iccl.2017.08.003.
Schmitz-Rode T, Janssens U, Duda SH, Erley CM, Günther RW. Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter. J Am Coll Cardiol. 2000;36:375-80. doi: 10.1016/s0735-1097(00)00734-8.
Kuo WT, Gould MK, Louie JD, Rosenberg JK, Sze DY, Hofmann LV. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol. 2009;20:1431-40. doi: 10.1016/j.jvir.2009.08.002.
Horsch AD, van Oostayen J, Zeebregts CJ, Reijnen MM. The Rotarex® and Aspirex® mechanical thrombectomy devices. Surg Technol Int. 2009;18:185-92.
Dumantepe M, Teymen B, Akturk U, Seren M. Efficacy of rotational thrombectomy on the mortality of patients with massive and submassive pulmonary embolism. J Card Surg. 2015;30:324-32. doi: 10.1111/jocs.12521.
Tu T, Toma C, Tapson VF, Adams C, Jaber WA, Silver M, et al. A Prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism: The FLARE Study. JACC Cardiovasc Interv. 2019;12:859-69. doi: 10.1016/j.jcin.2018.12.022.
Toma C, Jaber WA, Weinberg MD, Bunte MC, Khandhar S, Stegman B, et al. Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism. EuroIntervention. 2023;18:1201-12. doi: 10.4244/EIJ-D-22-00732.
Silver MJ, Gibson CM, Giri J, Khandhar S, Jaber W, Toma C, et al. Outcomes in High-Risk Pulmonary Embolism Patients Undergoing FlowTriever Mechanical Thrombectomy or Other Contemporary Therapies: Results From the FLAME Study. Circ Cardiovasc Interv. 2023;16(:e013406. doi: 10.1161/CIRCINTERVENTIONS.123.013406.
Sista AK, Horowitz JM, Tapson VF, Rosenberg M, Elder MD, Schiro BJ, et al. Indigo Aspiration System for Treatment of Pulmonary Embolism: Results of the EXTRACT-PE Trial. JACC Cardiovasc Interv. 2021;14:319-29. doi: 10.1016/j.jcin.2020.09.053.
Moriarty JM, Dohad SY, Schiro BJ, Tamaddon H, Heithaus RE, Iliadis EA, et al. Clinical, Functional, and Quality-of-Life Outcomes after Computer Assisted Vacuum Thrombectomy for Pulmonary Embolism: Interim Analysis of the STRIKE-PE Study. J Vasc Interv Radiol. 2024;35:1154-65.e6. doi: 10.1016/j.jvir.2024.04.028.
Donaldson CW, Baker JN, Narayan RL, Provias TS, Rassi AN, Giri JS, et al. Thrombectomy using suction filtration and veno-venous bypass: single center experience with a novel device. Catheter Cardiovasc Interv. 2015;86:E81-7. doi: 10.1002/ccd.25583.
Al-Hakim R, Park J, Bansal A, Genshaft S, Moriarty JM. Early Experience with AngioVac Aspiration in the Pulmonary Arteries. J Vasc Interv Radiol. 2016;27:730-4. doi: 10.1016/j.jvir.2016.01.012.
Avgerinos ED, Abou Ali A, Toma C, Wu B, Saadeddin Z, McDaniel B, et al. Catheter-directed thrombolysis versus suction thrombectomy in the management of acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord. 2019;7:623-8. doi: 10.1016/j.jvsv.2018.10.025.
Graif A, Patel KD, Wimmer NJ, Kimbiris G, Grilli CJ, Upparapalli D, et al. Large-Bore Aspiration Thrombectomy versus Catheter-Directed Thrombolysis for Acute Pulmonary Embolism: A Propensity Score-Matched Comparison. J Vasc Interv Radiol. 2020;31:2052-9. doi: 10.1016/j.jvir.2020.08.028.
Monteleone P, Ahern R, Banerjee S, Desai KR, Kadian-Dodov D, Webber E, et al. Modern Treatment of Pulmonary Embolism (USCDT vs MT): Results From a Real-World, Big Data Analysis (REAL-PE). J Soc Cardiovasc Angiogr Interv. 2023;3:101192. doi: 10.1016/j.jscai.2023.101192.
De Gregorio MA, Guirola JA, Kuo WT, Serrano C, Urbano J, Figueredo AL, et al. Catheter-directed aspiration thrombectomy and low-dose thrombolysis for patients with acute unstable pulmonary embolism: Prospective outcomes from a PE registry. Int J Cardiol. 2019;287:106-10. doi: 10.1016/j.ijcard.2019.02.061.
