An Integrated Approach to the Treatment of Pulmonary Embolism: Current State of the Problem
Abstract
The aim. Treatment of venous thromboembolism remains perhaps the most challenging problem of modern phlebology. The aim of our study was to analyze current data and guidelines on the use of surgical and minimally invasive approaches in the treatment of pulmonary embolism (PE) and to compare these with our own results.
Materials and methods. The results of treatment of 168 patients with PE, who underwent inpatient treatment at the clinic from 2009 to 2021, were analyzed. Among them, 162 (96%) patients had deep vein thrombosis, in 6 patients the cause of PE could not be identified. Recurrent PE was observed in 2 patients. PE with a high risk of death was observed in 51 (30.3%) patients, with a medium and low risk of death in 117 patients (69.6%).
Systemic thrombolysis was performed in 44 (26%) cases. In 5 (2.9%) cases, vena cava filters were implanted. One (0.6%) patient underwent aspiration thrombectomy of the pulmonary artery using an Aspirex catheter. Two (1.1%) patients underwent pulmonary artery thrombectomy using an artificial circulation device.
Results. Significant improvement in patients treated with thrombolytic therapy was observed in 40 (92.8%) cases. After surgical treatment of PE, significant improvement was observed in 100% of cases, 2 patients after PE showed complete de-obstruction of the pulmonary artery. No hemorrhagic complications were observed during the study period. No fatalities were reported. No recurrent PE was observed during the study period.
Conclusions. The choice of treatment for PE is determined by the degree of the impact on the pulmonary tract, the stability of the patient’s condition, indicators of dysfunction of the right heart, the period from the onset of the disease, the risk of death.
The use of aspiration thrombectomy using an Aspirex catheter (Straub, USA) and pulmonary artery embolectomy in the absence of thrombolytic therapy allows to obtain satisfactory results in patients with PE.
References
2. Woller B, Daw A, Aston V, Lloyd J, Snow G, Stevens SM, et al. Natural Language Processing Performance for the Identification of Venous Thromboembolism in an Integrated Healthcare System. Clin Appl Thromb Hemost. 2021;27:10760296211013108. https://doi.org/10.1177/10760296211013108
3. Zhang J, Komargodski O, McElroy A, Echaide C. Increasing Compliance of Deep Vein Thrombosis Medical Prophylaxis in Acute Inpatient Rehabilitation Setting. Cureus. 2022;14(3):e23134. https://doi.org/10.7759/cureus.23134
4. Wendelboe AM, Raskob GE. Global burden of thrombosis: epidemiologic aspects. Circ Res. 2016;118(9):1340-7. https://doi.org/10.1161/CIRCRESAHA.115.306841
5. Albricker ACL, Freire CMV, Santos SND, Alcantara ML, Saleh MH, Cantisano AL, et al. Joint Guideline on Venous Thromboembolism – 2022. Arq Bras Cardiol. 2022;118(4):797-857. https://doi.org/10.36660/abc.20220213
6. Leidi A, Bex S, Righini M, Berner A, Grosgurin O, Marti C. Risk Stratification in Patients with Acute Pulmonary Embolism: Current Evidence and Perspectives. J Clin Med. 2022;11(9):2533. https://doi.org/10.3390/jcm11092533
7. Ryan L, Maharjan J, Mataraso S, Barnes G, Hoffman J, Mao Q, et al. Predicting pulmonary embolism among hospitalized patients with machine learning algorithms. Pulm Circ. 2022;12(1):e12013. https://doi.org/10.1002/pul2.12013
8. Khrebtiy Y, Chernukha L. Is there a place for aggressive tactics in the treatment of deep vein thrombosis today? Clinical case of aspiration thrombectomy in the treatment of deep vein thrombosis. Acta Phlebol. 2021;22(2):61-8. https://doi.org/10.23736/S1593-232X.20.00476-2
9. Chernuha LM, Skupii OM, Mitiuk OI, Khrebtiy YV. Some aspects of treatment of deep venous thrombosis of the inferior vena cava system complicated by pulmonary embolism – opportunities and outcomes. Novosti Khirurgii. 2015;23(3):309-13.
10. Mitiuk OI, Khrebtiĭ IaV. Application of cava-filter for prophylaxis of the pulmonary artery thromboembolism. Klin Khir. 2006;(10):63-4.
11. Mitiuk OI, Khrebtiĭ IaV. Application of cava-filter for surgical prophylaxis of pulmonary thromboembolism. Klin Khir. 2007;(1):39-41.
12. Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al.; ESC Scientific Document Group. 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(4):543-603. https://doi.org/10.1093/eurheartj/ehz405
13. Kakkos SK, Gohel M, Baekgaard N, Bauersachs R, Bellmunt-Montoya S, Black SA, et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg. 2021;61(1):9-82. https://doi.org/10.1016/j.ejvs.2020.09.023
14. Goldhaber SZ, Come PC, Lee RT, Braunwald E, Parker JA, Haire WD, et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet. 1993;341(8844):507-11. https://doi.org/10.1016/0140-6736(93)90274-k
15. Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020;4(19):4693-738. https://doi.org/10.1182/bloodadvances.2020001830
16. Kline JA, Nordenholz KE, Courtney DM, Kabrhel C, Jones AE, Rondina MT, et al. Treatment of submassive pulmonary embolism with tenecteplase or placebo: cardiopulmonary outcomes at 3 months: multicenter double-blind, placebo-controlled randomized trial. J Thromb Haemost. 2014;12(4):459-68. https://doi.org/10.1111/jth.12521
17. Zuo Z, Yue J, Dong BR, Wu T, Liu GJ, Hao Q. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev. 2021;4(4):CD004437. https://doi.org/10.1002/14651858.CD004437.pub6
18. Daniels LB, Parker JA, Patel SR, Grodstein F, Goldhaber SZ. Relation of duration of symptoms with response to thrombolytic therapy in pulmonary embolism. Am J Cardiol. 1997;80(2):184-8. https://doi.org/10.1016/s0002-9149(97)00315-9
19. Weinstein T, Deshwal H, Brosnahan SB. Advanced management of intermediate-high risk pulmonary embolism. Crit Care. 2021;25(1):311. https://doi.org/10.1186/s13054-021-03679-2
20. Zhang Z, Xi L, Zhang S, Zhang Y, Fan G, Tao X, et al. Tenecteplase in Pulmonary Embolism Patients: A Meta-Analysis and Systematic Review. Front Med (Lausanne). 2022;9:860565. https://doi.org/10.3389/fmed.2022.860565
21. Sardar P, Piazza G, Goldhaber SZ, Liu PY, Prabhu W, Soukas P, et al. Predictors of Treatment Response Following Ultrasound-Facilitated Catheter-Directed Thrombolysis for Submassive and Massive Pulmonary Embolism: A SEATTLE II Substudy. Circ Cardiovasc Interv. 2020;13(6):e008747. https://doi.org/10.1161/CIRCINTERVENTIONS.119.008747
22. Tapson VF, Sterling K, Jones N, Elder M, Tripathy U, Brower J, Maholic RL, Ross CB, Natarajan K, Fong P, Greenspon L, Tamaddon H, Piracha AR, Engelhardt T, Katopodis J, Marques V, Sharp ASP, Piazza G, Goldhaber SZ. 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(14):1401-10. https://doi.org/10.1016/j.jcin.2018.04.008
23. Kuo WT, Banerjee A, Kim PS, DeMarco FJ Jr, Levy JR, Facchini FR, Unver K, Bertini MJ, Sista AK, Hall MJ, Rosenberg JK, De Gregorio MA. Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis (PERFECT): initial results from a prospective multi-center Registry. Chest. 2015;148(3):667-73. https://doi.org/10.1378/chest.15-0119
24. Lee T, Itagaki S, Chiang YP, Egorova NN, Adams DH, Chikwe J.Survivalandrecurrenceafteracutepulmonaryembolism treated with pulmonary embolectomy or thrombolysis in New York State, 1999 to 2013. J Thorac Cardiovasc Surg. 2018;155(3):1084-90.e12. https://doi.org/10.1016/j.jtcvs.2017.07.074
25. Romeu-Prieto JM, Sánchez Casado M, Rodríguez Blanco ML, Ciampi-Dopazo JJ, Sánchez-Carretero MJ, García-López JJ, et al. Aspiration thrombectomy for acute pulmonary embolism with an intermediate-high risk. Med Clin (Barc). 2022;158(9):401-5. English, Spanish. https://doi.org/10.1016/j.medcli.2021.04.033
26. Araszkiewicz A, Sławek-Szmyt S, Jankiewicz S, Żabicki B, Grygier M, Mularek-Kubzdela T, et al. Continuous Aspiration Thrombectomy in High- and Intermediate-High-Risk Pulmonary Embolism in Real-World Clinical Practice. J Interv Cardiol. 2020;2020:4191079. https://doi.org/10.1155/2020/4191079
