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

Abstract

Objective: Examine FlowTriever thrombectomy feasibility in high-risk PE patients. Background: The FlowTriever thrombectomy system (Inari Medical, Irvine, CA) can reduce right ventricle (RV) strain in acute submassive pulmonary embolism (PE) patients. This technology has not been studied in higher risk PE patients. Methods: This multicenter retrospective analysis included patients treated with FlowTriever between 2017 and 2019 if they met at least one of the following: vasopressor dependence, PE induced respiratory failure, or decreased cardiac index (CI) measured by right heart catheterization. Results: Analysis included 34 patients: 18 massive, four intubated, 12 normotensive but with CI < 1.8. Average age was 56 and their median simplified PE severity index was 2. Patients had high bleeding risk, with 13 having recent surgery, six posttrauma, and four recent strokes. Six patients received cardiopulmonary resuscitation, and two received additional mechanical circulatory support. All patients had RV dilatation and elevated biomarkers. Clot removal was successful in 32/34 patients. CI improved from 2.0 ± 0.1 L/min/m 2 before thrombectomy to 2.4 ± 0.1 L/min/m 2 after (p = .01). The mean pulmonary artery pressure decreased from 33.2 ± 1.6 mmHg to 25.0 ± 1.5 mmHg (p = .01). The two patients-both with no or minimal thrombus removed-deteriorated during the procedure: one died and the other was successfully stabilized on ECMO. There were no other major complications. All other patients were alive at the time of data collection (mean follow-up of 205 days). Conclusion: Aspiration thrombectomy appears feasible in higher risk acute PE patients with immediate hemodynamic improvement and low in-hospital mortality.

Hemodynamic compromise in pulmonary embolism: “A tale of two ventricles”

“…The mandate of the PERT is to urgently risk stratify patients who would most benefit from “Escalation‐of‐Care” interventions (thrombolytic therapy and/or thrombectomy) that directly rectify the offending pulmonary vascular obstruction. The salutary effects of this approach are now supported by observations from recent studies demonstrating the benefits of primary thrombectomy, which may result in prompt and dramatic hemodynamic recovery characterized by reductions in PA pressures associated with increased CO 4,5 . The remarkable resilience of the RV is emphasized in Figure 1, which illustrates the rapid recovery of RV performance in PE following mechanical thrombectomy, as well as in patients with acute RVI undergoing primary angioplasty.…”

Bail‐out treatment of pulmonary embolism using a large‐bore aspiration mechanical thrombectomy device

“…Initial thrombolysis was not effective enough to restore the required pulmonary perfusion most likely due to the mixture of an acute and subacute event. Although in previous publications, even larger thrombi could be extracted by this particular device, 2 the patient benefitted most likely from thrombus aspiration as the need for catecholamines declined quickly, right ventricular function rapidly improved, and the VA‐ECMO could be explanted shortly after.…”

Large-Bore Aspiration Thrombectomy: Catalyst for a Revolution in Treating Pulmonary Embolism

“…A multicenter retrospective study of FlowTriever use in patients critically ill with massive and high-risk submassive PE revealed a markedly low mortality rate and excellent technical success. 4 Finally, an interim analysis of the first 230 patients in a real-world, all-comers registry revealed minimal 48hour 5 and 30-day 6 mortality rates, excellent safety, and acute hemodynamic improvements.…”