Local Ultrasound-Facilitated Thrombolysis in High-Risk Pulmonary Embolism: First Dutch Experience

Abstract

Purpose To provide insight into the current use and results of ultrasound-facilitated catheter-directed thrombolysis (USAT) in patients with high-risk pulmonary embolism (PE). Introduction Systemic thrombolysis is an effective treatment for hemodynamically unstable, high-risk PE, but is associated with bleeding complications. USAT is thought to reduce bleeding and is therefore advocated in patients with high-risk PE and contraindications for systemic thrombolysis. Methods We conducted a retrospective cohort study of all patients who underwent USAT for high-risk PE in the Netherlands from 2010 to 2017. Characteristics and outcomes were analyzed. Primary outcomes were major (including intracranial and fatal) bleeding and all-cause mortality after 1 month. Secondary outcomes were all-cause mortality and recurrent venous thromboembolism within 3 months. Results 33 patients underwent USAT for high-risk PE. Major bleeding occurred in 12 patients (36%, 95% CI 22–53), including 1 intracranial and 3 fatal bleeding. All-cause mortality after 1 month was 48% (16/33, 95% CI 31–66). All-cause mortality after 3 months was 50% (16/32, 95% CI 34–66), recurrent venous thromboembolism occurred in 1 patient (1/32, 3%, 95% CI 1–16). Conclusions This study was the first to describe characteristics and outcomes after USAT in a study population of patients with high-risk PE only, an understudied population. Although USAT is considered a relatively safe treatment option, our results illustrate that at least caution is needed in critically ill patients with high-risk PE. Further research in patients with high-risk PE is warranted to guide patient selection.

Rationale for catheter-based therapies in acute pulmonary embolism

“…This is further illustrated by our previously published case series of high-risk PE patients, in which ICH following CDT treatment with the EKOS catheter only occurred in two patients, both of whom had absolute contraindications for thrombolytic therapy (i.e. concurrent ischaemic stroke and recent subarachnoid haemorrhage) 20 …”

“…showed that CDT is an effective alternative in patients with failed ST, leading to improvement of clinical outcomes and echocardiographic parameters at a low complication rate. Results from our registry indicate that high-risk PE patients who underwent both ST and CDT with the EKOS catheter had a higher mortality in general but similar incidence of major and fatal bleeding compared to patients who received CDT only 20 . This suggests that patient’s clinical condition is most threatened by haemodynamic instability due to PE rather than bleeding, reflecting the underlying severe disease requiring intensive treatment, such as emergency CDT.…”

Percutaneous thrombectomy in patients with massive and very high‐risk submassive acute pulmonary embolism

“…More recently, deWinter and colleagues analyzed all the high‐risk PE treated in the Netherlands with CDL; in a total of 33 patients bleeding occurred in 12 patients, including one intracranial and three fatal bleeding episodes. The mortality at 1 month was 48% 14 . Despite the relatively low dose of thrombolytics used with CDL, major bleeding complications pooled to 5.4% in a recent meta‐analysis 15 .…”

EHA guidelines on management of antithrombotic treatments in thrombocytopenic patients with cancer

“…[200][201][202][203][204] Catheter-directed approaches allow the use of a considerably lower dose of thrombolytics (~1/10 as compared to systemic treatment), thus these type of procedures are possibly associated with a lower risk of bleeding. 198,203,205 However, data for this therapy is still evolving and it cannot be used in high-risk PE and severely compromised patients, unless intravenous thrombolysis is contraindicated or failed. In high-risk patients with contraindications for systemic treatment, although guidelines may advocate the use of catheter-directed thrombolysis, caution is warranted in patient selection because of the high incidence of major bleeding and mortality in this population.…”