Thrombolysis With a Novel Modified Tissue-Type Plasminogen Activator, Monteplase, Combined With Catheter-Based Treatment for Major Pulmonary Embolism

Abstract

Circ J 2009; 73: 106 -110 ajor pulmonary embolism (PE) is a life-threatening disorder with high mortality and morbidity. [1][2][3] Most of the deaths of patients presenting in shock occur within the first hour after presentation, 1 so rapid therapeutic action is essential to save lives. Thrombolysis with a tissue-type plasminogen activator (t-PA) produces a much faster improvement in vascular obstruction and hemodynamics than heparin treatment 4 and is the established treatment for acute major PE. 5 In Japan, a novel modified t-PA, monteplase, was approved in 2005 for high-risk patients with acute PE. Compared with the properties of native t-PA, the third-generation, bioengineered thrombolytic agent, monteplase, has a longer half-life, greater clot sensitivity, and more rapid lytic capacity. 6 In a double-blinded, randomized study of patients with acute myocardial infarction, monteplase administration led to greater rates of coronary recanalization and at an earlier stage than was achieved with native t-PA. 6 Initial experience of thrombolysis with the third-generation agents for acute PE has been reported, 7,8 the efficacy and safety of the third-generation thrombolytic agents, including monteplase, with or without catheter-based treatment in patients with major PE has not been clarified and were examined in the present study. Methods Patient PopulationAll patients referred with symptoms suggestive of acute major PE were considered for inclusion in the study. Major PE included massive and submassive types in severity; 9 definitions followed the guideline of the European Society of Cardiology. 10 Massive PE involves shock or hypotension and the subgroup of patients with submassive PE can be identified by the echocardiographic findings of right ventricular (RV) overload without hypotension. All patients had confirmation of PE by pulmonary angiography. A total of 50 patients were included in the study between June 2003 and March 2008. During the same period, 13 patients with major PE were not included because of a contraindication to thrombolytic therapy (n=4), use of urokinase as the initial thrombolytic agent (n=5), anticoagulation only with unfractionated heparin (n=3), and 1 death soon after admission. Treatment Regimen and Assessment of EfficacyOf the 50 patients, 46 received monteplase (Cleactor, Eisai, Japan) through a catheter tip placed in the most diseased segment of the pulmonary artery and 4 were adminis- Background A novel modified tissue-type plasminogen activator, monteplase, has been approved for acute major pulmonary embolism (PE) in Japan. Monteplase has rapid and sustained lytic effects because of a steep rise in concentration after bolus infusion and a longer half-life. Methods and ResultsTo assess the efficacy and safety of thrombolysis with monteplase in combination with catheter-based treatment, acute hemodynamic changes and clinical outcomes were assessed in 50 patients with angiographically confirmed major PE. Thrombolysis with monteplase in combination with embolus fragmentation and t...

Massive Pulmonary Embolism Requiring Extracorporeal Life Support Treated With Catheter-Based Interventions

“…This allows patients to receive a reduced thrombolytic dosage, based on the range and quantity of the thrombus. 9,10) Catheter thrombus fragmentation techniques disrupt the clot into multiple smaller fragments, and effectively increase the available thrombus surface area for effective thrombolysis. 10) Our study showed the thrombi were located in the more proximal areas of the pulmonary artery, and after catheter-based intervention, the amount of such thrombus tended to decrease in patients with collapsed massive PE.…”

Usefulness of Computed Tomographic Pulmonary Angiography in the Risk Stratification of Acute Pulmonary Thromboembolism - Comparison With Cardiac Biomarkers -

“…1,2 Despite advances in diagnostic modalities and therapeutic options including catheter-based intervention, approximately 6-15% of the patients died during hospitalization. [3][4][5][6][7][8] It has been proven that the patients with massive APE, defined by systemic hypotension, constitute a high-risk group and should be treated with thrombolysis or embolectomy. 9- 11 Right ventricular (RV) dysfunction is also a well-known independent predictor of early death, and thus thrombolysis or embolectomy has become a preferred treatment modality in APE patients with RV dysfunction.…”

Management of patients with high-risk pulmonary embolism: a narrative review

“…Accelerated regimens involving administration of tissue plasminogen activator (t-PA) during a 2-h period are preferable to prolonged infusions of first-generation thrombolytic agents during a 12- to 24-h period [ 34 ]. Compared with the properties of native t-PA, third-generation bioengineered thrombolytic agents (tenecteplase and monteplase) have a longer half-life, greater clot sensitivity, and more rapid lytic capacity [ 19 , 35 , 36 ]. Monteplase has been approved for acute PE with hemodynamic instability in Japan [ 35 , 36 ].…”

“…Compared with the properties of native t-PA, third-generation bioengineered thrombolytic agents (tenecteplase and monteplase) have a longer half-life, greater clot sensitivity, and more rapid lytic capacity [ 19 , 35 , 36 ]. Monteplase has been approved for acute PE with hemodynamic instability in Japan [ 35 , 36 ]. Overall, more than 90% of patients appear to respond favorably to thrombolysis as judged by clinical and echocardiographic improvement within 36 h [ 37 ].…”