Ultrasound Accelerated Thrombolysis May Be an Effective and Safe Treatment Modality for Intermediate Risk/Submassive Pulmonary Embolism

Abstract

SummaryPulmonary embolism (PE) is a potentially life-threatening condition and the fact that 90% of PE originate from lower limb veins highlights the significance of early detection and treatment of deep vein thrombosis.1) Massive/high risk PE involving circulatory collapse or systemic arterial hypotension is associated with an early mortality rate of approximately 50%, in part from right ventricular (RV) failure.2) Intermediate risk/submassive PE, on the other hand, is defined as PE-related RV dysfunction, troponin and/or B-type natriuretic peptide elevation despite normal arterial pressure. 3)Without prompt treatment, patients with intermediate risk PE may progress to the massive category with a potentially fatal outcome. In patients with PE and right ventricular dysfunction (RVD), in hospital mortality ranges from 5% to 17%, significantly higher than in patients without RVD. 4,5) (Int Heart J 2016; 57: 91-95)

Interventional radiology treatment for pulmonary embolism

“…The use of new devices for fragmentation and/or aspiration of the thrombi can improve these results. The use of ultrasound through a 5.4 Fr catheter with infusion of fibrinolytic leads to rapid lysis of the thrombi located in the pulmonary artery[40,50,51]. Seattle II, a prospective study of 150 patients diagnosed with massive or submassive PE using EKO-sonic and a low dose of r-TPA through CDT, reduced the RV/LV ratio measured with CT by 25% in 48 h, showed a 30% improvement of the systolic pressure and another 30% in the pulmonary artery obstruction[41].…”

Arrhythmogenic Right Ventricular Cardiomyopathy with Multiple Thrombi and Ventricular Tachycardia of Atypical Left Branch Bundle Block Morphology

“…Thrombolytic and anticoagulation therapy, therapy for heart failure, and implantable cardioverter defibrillator are important after disappearance of the thrombi. Furthermore, ultrasound accelerated thrombolysis 5) or veno-arterial extracorporeal membrane oxygenation 6) can be effective treatments for submassive or massive pulmonary embolism. The present case demonstrates that VT is not always the sole contributor to syncope and death in patients with ARVC, and pulmonary embolism should be considered.…”

Outcome Measures for Acute Submassive Pulmonary Embolisms at a Community-Based Hospital Using Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis

“…10,11,12 CDTs have demonstrated improved RV dysfunction, decreased pulmonary artery pressures, and reduced risks of major bleeds. 1,4,13,14,15,16 The recent development of ultrasound-assisted, low-dose fibrinolysis therapy (USAT), a variation of CDT, has provided another treatment modality for the management of acute submassive PEs (ASMPEs). 17 USAT incorporates ultrasound-generated acoustic energy to facilitate disruption of the PE allowing for improved fibrinolytic penetration.…”

“…17 USAT incorporates ultrasound-generated acoustic energy to facilitate disruption of the PE allowing for improved fibrinolytic penetration. 16 Two landmark studies, SEATTLE II and ULTIMA, demonstrated the efficacy and safety of USAT for ASMPEs while maintaining low rates of bleeding complications. 8,9 Another study, OPTALYSE PE, determined the lowest optimal tissue plasminogen activator (tPA) dose and delivery duration using USAT for the treatment of ASMPEs.…”