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Clot In Transit Is Associated With Higher Mortality In Patients With Acute Pulmonary Embolism
Mary A. Binko, MS, Elizabeth Andraska, MD, Fanny S. Alie-Cusson, MD, Rabih A. Chaer, MD, Catalin Toma, MD, Nathan L. Liang, MD, Belinda Rivera-Lebron, MD, Natalie D. Sridharan, MD.
University of Pittsburgh, Pittsburgh, PA, USA.

OBJECTIVES Clot in transit (CIT) is defined as an actively embolizing right heart thrombus. CIT in the setting of concurrent pulmonary embolism (PE) is a rare form of venous thromboembolism, and clinical outcomes of these patients remain unclear.
METHODS We retrospectively reviewed a single institution pulmonary embolism response registry between 2014-2022 at a tertiary referral center, identifying patients diagnosed with CIT on CT and echocardiogram and matching them 3:1 to patients without CIT based on sex and simplified PE severity index (PESI) with 93% of patients categorized as intermediate risk and 7% as high risk PE. High risk is defined as systolic blood pressure <90 mm Hg or vasopressor support, and intermediate risk is defined as sPESI ≥ 1 or right heart strain or elevated biomarkers and no high-risk features. Univariate analyses were used to compare groups.
RESULTS There were 41 patients (age 59.516.8, male 60.9%) diagnosed with CIT with concurrent PE who were matched to 123 PE patients without CIT. Demographics, clinical characteristics and medical history were not significantly different between the two groups. The average length of stay was significantly longer for patients with CIT at 12.6 13.2 days compared to 4.4 3.5 days for patients without CIT (p<0.01). The majority of patients with CIT required ICU level care (87.8%, 36/41) with common complications including mechanical ventilation (53.7%, 22/41), vasopressor support (46.3%, 19/41), and acute kidney injury (46.3%, 19/41). In-hospital and 30-day mortality were significantly higher in patients diagnosed with CIT (Table 1). Subgroup analysis showed that mortality was higher for CIT patients who received anticoagulation alone (27.8%, 5/18) compared to those who received advanced interventions in addition to anticoagulation (4.3%, 1/23, p=0.035). Advanced interventions in CIT patients included surgical thrombectomy (31.7%, 13/41), systemic thrombolysis (12.2%, 5/41), and catheter-based interventions (14.6%, 6/41).
CONCLUSION In-hospital and 30-day mortality is significantly higher for PE patients with concurrent CIT. These patients may have limited cardiopulmonary reserve increasing their risk of clinical decompensation and death. Advanced interventions were associated with improved clinical survival when compared to anticoagulation in CIT patients and should be considered in the management of this subpopulation.

Table 1. Clinical outcomes of patients with and without CIT represented as number (percent).
Variable CIT (n = 41) No CIT (n = 123) p-value
Length of stay12.613.2 days4.43.5 days<0.010
In hospital mortality6 (14.6%)5 (4.1%)0.020
30d mortality8 (19.5%)8 (6.5%)0.016


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