Catheter directed thrombolysis versus suction thrombectomy in the management of acute pulmonary embolism
Efthymios Avgerinos, MD, Adham Abou Ali, MD, Catalin Toma, MD, Bryan Wu, MD, Barry McDaniel, BS, George Al-Khoury, MD, Rabih Chaer, MD, MSc.
University of Pittsburgh, Pittsburgh, PA, USA.
OBJECTIVES: Catheter Directed Thrombolysis (CDT) is increasingly performed for acute Pulmonary Embolism (PE) as it is presumed to provide similar therapeutic benefits to systemic thrombolysis, but at a lower risk. Contemporary suction thrombectomy (ST) devices are minimal or no-lytic alternatives, but there is no evidence on their comparative effectiveness. This study aims to compare clinical outcomes of these two interventional alternatives.
METHODS: Consecutive patients who underwent a ST catheter intervention for massive or submassive PE between 2011 and 2017 were identified. For each of these patients, a nearest-neighbor matching was implemented to identify at least three CDT patients that matched as closely as possible on six variables: PE type, age, gender, acute deep venous thrombosis, pulmonary disease and year of procedure. Endpoint was clinical success defined as survival to hospital discharge without major bleeding (GUSTO moderate or severe), stroke or other major adverse procedure-related event, decompensation for submassive or persistent shock for massive PE. Standard statistical techniques were used. Significance was set at P≤.05.
RESULTS: Out of 277 patients who received an intervention for acute PE, 54 CDT (63.5±14.2 years, 18 massive, 36 submassive PE) were matched to 18 ST (64.1±14.1 years, 6 massive, 12 submassive PE) patients. In the CDT group 38 (70.4%) received ultrasound assisted thrombolysis. In the ST group 1 Arrow-Trerotola PTD (Teleflex, USA), 1 AngioVac (Angiodynamics, NY, USA), 8 Indigo (Penumbra, CA, USA) and 8 FlowTriever (INARI Medical, CA, USA) devices were used. The ST group had significantly more patients with a major contraindication for lytics (1.9% for CDT vs 50% for ST, P<.001) and/or hyper-acute hemodynamic collapse (0 for CDT vs 22.2% for ST, P<.001). There was no difference in major bleeding (14.8% for CDT vs 16.7% for ST, P=.850), stroke (3.7% for CDT vs 0 for ST, P=.408) or death (3.7% for CDT vs 16.7% for ST, P=.096). One patient (AngioVac) of the ST group suffered tricuspid valve rupture and 2 patients in the CDT group required surgical thrombectomy. Clinical success was significantly higher for the CDT group (83.3% for CDT vs 61.1% for ST, P=.05).
CONCLUSIONS: CDT may be more effective for the management of acute PE. Suction thrombectomy should be viewed as a complimentary alternative for patients with contraindication for thrombolytics or severely compromised hemodynamics.
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