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.
Introduction: Catheter Directed Thrombolysis (CDT) is increasingly performed for acute Pulmonary Embolism (PE) as it is presumed to provide similar therapeutic benefits to systemic thrombolysis, while decreasing the dose of thrombolytic required and the associated risks. Contemporary suction thrombectomy (ST) devices have entered the market as 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 suction thrombectomy 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 the following six variables: PE type, age, gender, acute deep venous thrombosis, pulmonary disease and year of procedure. Endpoint was clinical success defined as meeting all the following criteria: survival to hospital discharge without major bleeding (GUSTO moderate or severe), perioperative stroke or other major adverse procedure-related event, decompensation for sub-massive 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 PE) were matched to 18 ST (64.1±14.1 years, 6 massive, 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 who had a major contraindication for lytics (1.9% for CDT vs 50% 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 CDT group required surgical thrombectomy. Clinical success was higher, but not significantly, for the CDT group (75.9% for CDT vs 61.1% for ST, P=.224). The association was similar when assessing the subgroup of patients with submassive PE (86.1% for CDT vs 66.7% for ST, P=.135)
Conclusion: CDT may be more effective for the management of acute pulmonary embolism. Suction thrombectomy should be viewed as a complimentary better alternative for patients with contraindication for thrombolytics or severely compromised hemodynamic profile and can yield good outcomes in an otherwise highly morbid population.
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