1/ We clinched the Dx, but how do we treat it?
Are these clot 📸 the best approach for #PE Rx?
Let’s dive into the 🌎 of "escalation of care" therapies
@CardioNerds 🧵 part 2...
Hold on to your 🎩 for this one
@PERTConsortium #PERT #CardioTwitter #ACCMedStudent
Are these clot 📸 the best approach for #PE Rx?
Let’s dive into the 🌎 of "escalation of care" therapies
@CardioNerds 🧵 part 2...
Hold on to your 🎩 for this one
@PERTConsortium #PERT #CardioTwitter #ACCMedStudent
2/ Why is PE so dangerous❓
⚠️thrombus in 🫁 ➡️obstruction ➡️ sudden ⬆️ RV afterload ➡️ pressure➕volume overload ➡️ ⬇️RV output➕RV ischemia ➡️ ⬇️LV preload ➡️ ⬇️ 🫀output ➡️ shock ❤️🔥
⚠️Hypoxic & neurohormonal mediated pulmonary vasoconstriction ➡️ ⬆️ RV afterload
⚠️thrombus in 🫁 ➡️obstruction ➡️ sudden ⬆️ RV afterload ➡️ pressure➕volume overload ➡️ ⬇️RV output➕RV ischemia ➡️ ⬇️LV preload ➡️ ⬇️ 🫀output ➡️ shock ❤️🔥
⚠️Hypoxic & neurohormonal mediated pulmonary vasoconstriction ➡️ ⬆️ RV afterload
3/ How do we treat❓
Based on risk stratification, we have several options: ⭐️Anticoagulation (AC) alone
Escalation of Care (EOC) therapies:
⭐️Systemic Thrombolysis (ST)
⭐️Catheter Directed Therapies (CDT)
⭐️Surgical Embolectomy (SE)
⭐️ECMO
Based on risk stratification, we have several options: ⭐️Anticoagulation (AC) alone
Escalation of Care (EOC) therapies:
⭐️Systemic Thrombolysis (ST)
⭐️Catheter Directed Therapies (CDT)
⭐️Surgical Embolectomy (SE)
⭐️ECMO
4/
▶️High Risk
👉ESC class IIa: SE or CDT (if failed ST)
▶️Low Risk
👉Anticoagulation
👉ESC class IIa: IVC filter if failed or ineligible for AC
▶️Intermediate Risk
🔥area of active research
Let's get to the 🥩 & 🥔 and the nuances of intermediate-risk PE Rx
▶️High Risk
👉ESC class IIa: SE or CDT (if failed ST)
▶️Low Risk
👉Anticoagulation
👉ESC class IIa: IVC filter if failed or ineligible for AC
▶️Intermediate Risk
🔥area of active research
Let's get to the 🥩 & 🥔 and the nuances of intermediate-risk PE Rx
5/ AC alone in intermediate risk: 3%-4% mortality rate
jamanetwork.com
What about ST❓
👉PEITHO study: tenecteplase vs AC
▶️ ⬇️☠️ or hemodynamic (HD) collapse (2.6% vs 5.6%)
▶️ BUT ⬆️ major 🩸 (6.3% vs 1.5%) and Intracranial hemorrhage (ICH) (2% vs 0.2%)
jamanetwork.com
What about ST❓
👉PEITHO study: tenecteplase vs AC
▶️ ⬇️☠️ or hemodynamic (HD) collapse (2.6% vs 5.6%)
▶️ BUT ⬆️ major 🩸 (6.3% vs 1.5%) and Intracranial hemorrhage (ICH) (2% vs 0.2%)
6/
👉In a meta-analysis of ST trials
▶️⬇️☠️ (2.2% vs 3.9%) but ⬆️ICH (1.5% vs 0.2%)
👉MOPETT trial
▶️Reduced-dose ST
▶️no🩸in 👫 who didn't qualify for full-dose ST
🛑ST definitely has its drawbacks
What if we get closer to the thrombus & minimize bleeding?!
👉In a meta-analysis of ST trials
▶️⬇️☠️ (2.2% vs 3.9%) but ⬆️ICH (1.5% vs 0.2%)
👉MOPETT trial
▶️Reduced-dose ST
▶️no🩸in 👫 who didn't qualify for full-dose ST
🛑ST definitely has its drawbacks
What if we get closer to the thrombus & minimize bleeding?!
7/ Let's talk about Catheter Directed therapies
⭐️Catheter Directed Thrombolysis (CDT)
▶️Catheters are passed into the 🫁 arteries & deliver thrombolytic agents over longer duration
▶️1/4 of the ST dose
▶️ensure thrombolytics get to the right place
⭐️Catheter Directed Thrombolysis (CDT)
▶️Catheters are passed into the 🫁 arteries & deliver thrombolytic agents over longer duration
▶️1/4 of the ST dose
▶️ensure thrombolytics get to the right place
8/ Two approaches for thrombolytic delivery:
1️⃣Give the drug locally to attempt thrombus breakdown
2️⃣Break up the thrombus to increase surface area for thrombolytic access
1️⃣Give the drug locally to attempt thrombus breakdown
2️⃣Break up the thrombus to increase surface area for thrombolytic access
9/
⭐️Catheter-directed lytic therapy with infusion catheters
▶️placing a catheter through the thrombus & delivering local tPA (thrombolytic)
Commonly used catheters:
▶️Unifuse
▶️Cragg-McNamara
⚠️Limitation: tPA may not have access to the entire thrombus
⭐️Catheter-directed lytic therapy with infusion catheters
▶️placing a catheter through the thrombus & delivering local tPA (thrombolytic)
Commonly used catheters:
▶️Unifuse
▶️Cragg-McNamara
⚠️Limitation: tPA may not have access to the entire thrombus
10/ How can we lighten the load for our friendly thrombolytics❓
1️⃣Utilize ultrasound waves to break up fibrin strands
2️⃣Mechanically disrupt the thrombus (pharma-mechanical CDT)
1️⃣Utilize ultrasound waves to break up fibrin strands
2️⃣Mechanically disrupt the thrombus (pharma-mechanical CDT)
11/ The predominant ultrasound-assisted thrombolysis (USAT) catheter used is the EKOS catheter
12/ To mechanically disrupt or macerate the thrombus, options include:
▶️Pigtail catheter with a guide-wire or peripheral balloons
▶️Bashir Catheter: expandable basket of 6 Nitinol-reinforced infusion limbs
▶️Pigtail catheter with a guide-wire or peripheral balloons
▶️Bashir Catheter: expandable basket of 6 Nitinol-reinforced infusion limbs
13/
✔️ less thrombolytics
✔️ thrombus maceration can THEORETICALLY partially decompress the RV by quickly establishing forward flow
⚠️ Beware of distal embolization‼️
✔️ less thrombolytics
✔️ thrombus maceration can THEORETICALLY partially decompress the RV by quickly establishing forward flow
⚠️ Beware of distal embolization‼️
14/ The RESCUE trial showed improvement in RV/LV ratio at 48 hrs in intermediate-risk pts using the Bashir catheter with 7 mg tPA
Caveat: not powered for clinical outcomes
jacc.org
Caveat: not powered for clinical outcomes
jacc.org
15/
⚠️limitation of CDT
▶️as long as you’re using thrombolytics,🩸is a concern
What if we can take out the thrombus itself without the need for lytics at all 🤯❓
Two main forms of embolectomy:
1️⃣Rheolytic thrombectomy
2️⃣Mechanical thrombectomy
⚠️limitation of CDT
▶️as long as you’re using thrombolytics,🩸is a concern
What if we can take out the thrombus itself without the need for lytics at all 🤯❓
Two main forms of embolectomy:
1️⃣Rheolytic thrombectomy
2️⃣Mechanical thrombectomy
16/
⭐️Rheolytic thrombectomy utilizes the Bernoulli principle
▶️High speed saline jets sent backwards from the catheter➡️⬆️ speed➡️⬇️ pressure➡️creating a pressure gradient➡️vacuum the thrombus
⭐️Rheolytic thrombectomy utilizes the Bernoulli principle
▶️High speed saline jets sent backwards from the catheter➡️⬆️ speed➡️⬇️ pressure➡️creating a pressure gradient➡️vacuum the thrombus
17/
⭐️Mechanical Thrombectomy utilizes aspiration to suction 🪠the thrombus🩸
▶️Ideally obviates the need for thrombolytics
The main catheters being studied:
⭐️Flowtriever system, AlphaVac system (manual suction)
⭐️Indigo Thrombectomy System (continuous suction)
⭐️Mechanical Thrombectomy utilizes aspiration to suction 🪠the thrombus🩸
▶️Ideally obviates the need for thrombolytics
The main catheters being studied:
⭐️Flowtriever system, AlphaVac system (manual suction)
⭐️Indigo Thrombectomy System (continuous suction)
18/
What are the risks❓
⚠️Hemodynamic collapse from rapid changes in RV afterload with the passage of wires and catheters (rare)
⚠️Perforation, tamponade
⚠️Ventricular arrhythmias triggered by catheters through the RV
⚠️Vascular access complications
What are the risks❓
⚠️Hemodynamic collapse from rapid changes in RV afterload with the passage of wires and catheters (rare)
⚠️Perforation, tamponade
⚠️Ventricular arrhythmias triggered by catheters through the RV
⚠️Vascular access complications
19/
⚠️Acute respiratory collapse due to:
▶️pulmonary hemorrhage
▶️sudden changes in ventilation/perfusion from distal embolization
⚠️Bleeding (meta-analysis) (CDL)
▶️4.5% non-ICH major bleeding
▶️0.7% ICH
⚠️Acute respiratory collapse due to:
▶️pulmonary hemorrhage
▶️sudden changes in ventilation/perfusion from distal embolization
⚠️Bleeding (meta-analysis) (CDL)
▶️4.5% non-ICH major bleeding
▶️0.7% ICH
20/ The big question: Do EOC therapies work⁉️
▶️Studies to date have shown short-term improvement in RV/LV ratio compared with ST but no mortality difference & no long-term difference in RV/LV ratio.
Here’s a quick overview….
▶️Studies to date have shown short-term improvement in RV/LV ratio compared with ST but no mortality difference & no long-term difference in RV/LV ratio.
Here’s a quick overview….
21/
💠CANARY Trial: CDT vs AC
▶️No difference in RV/LV ratio at 3 months, but ⬇️👫with RV/LV ratio >0.9 at 72 hrs
▶️1 case of Major 🩸
👉If you haven’t yet, you MUST check out the 🥇#CardsJC by #HouseThomas and their summary
cardionerds.com
💠CANARY Trial: CDT vs AC
▶️No difference in RV/LV ratio at 3 months, but ⬇️👫with RV/LV ratio >0.9 at 72 hrs
▶️1 case of Major 🩸
👉If you haven’t yet, you MUST check out the 🥇#CardsJC by #HouseThomas and their summary
cardionerds.com
22/
USAT:
💠ULTIMA
▶️Reduced RV/LV ratio at 24 hrs but no dif. at 90 days, no major 🩸
💠SEATTLE II
▶️Reduced RV/LV ratio at 48 hrs, moderate 🩸 10%, major 🩸 0.7%
💠OPTALYSE-PE
▶️Reduced RV/LV ratio, 4% Major 🩸 , 1 attributable ICH
USAT:
💠ULTIMA
▶️Reduced RV/LV ratio at 24 hrs but no dif. at 90 days, no major 🩸
💠SEATTLE II
▶️Reduced RV/LV ratio at 48 hrs, moderate 🩸 10%, major 🩸 0.7%
💠OPTALYSE-PE
▶️Reduced RV/LV ratio, 4% Major 🩸 , 1 attributable ICH
23/
USAT vs CDT:
💠SUNSETsPE
▶️No difference btwn USAT vs CDL
Mechanical Embolectomy:
💠EXTRACT-PE
▶️Reduced RV/LV ratio at 48 hrs, avoided thrombolytics in 98.3%, 1.7% major 🩸
USAT vs CDT:
💠SUNSETsPE
▶️No difference btwn USAT vs CDL
Mechanical Embolectomy:
💠EXTRACT-PE
▶️Reduced RV/LV ratio at 48 hrs, avoided thrombolytics in 98.3%, 1.7% major 🩸
24/
💠FLARE
▶️Intermediate-risk patients
▶️Reduced RV/LV at 48 hrs, 98.1% avoided thrombolytics, 1.0% major 🩸
💠FLASH
▶️93.2% intermediate-high risk, 6.8% high risk
▶️All-cause mortality: 0.3% 48 hrs, 0.8% 30d
▶️Reduced RV/LV ratio, 1.2% major 🩸
💠FLARE
▶️Intermediate-risk patients
▶️Reduced RV/LV at 48 hrs, 98.1% avoided thrombolytics, 1.0% major 🩸
💠FLASH
▶️93.2% intermediate-high risk, 6.8% high risk
▶️All-cause mortality: 0.3% 48 hrs, 0.8% 30d
▶️Reduced RV/LV ratio, 1.2% major 🩸
25/
Here are some studies to keep an 👁️ out for in intermediate-risk PE:
💠HI-PEITHO: USAT vs AC
💠PEERLESS: Mechanical Thrombectomy vs CDT
💠APEX-AV: Single arm study of AlphaVac
💠PE-Tract: Catheter-based therapy vs AC
Bottom Line: promising results but…..VERDICT PENDING!
Here are some studies to keep an 👁️ out for in intermediate-risk PE:
💠HI-PEITHO: USAT vs AC
💠PEERLESS: Mechanical Thrombectomy vs CDT
💠APEX-AV: Single arm study of AlphaVac
💠PE-Tract: Catheter-based therapy vs AC
Bottom Line: promising results but…..VERDICT PENDING!
26/ Want to learn more? check out this great case from the vascular medicine team at @MGHHeartHealth
cardionerds.com
cardionerds.com
27/ Once again, a HUGE shoutout to @dinubalanescu for guiding me through this 🧵 and to @AmitGoyalMD @TDonisan and @Gurleen_Kaur96 for reviewing!
28/ Want to read more?
Check out these references:
ahajournals.org
structuralheartjournal.org
pubmed.ncbi.nlm.nih.gov
pubmed.ncbi.nlm.nih.gov
Check out these references:
ahajournals.org
structuralheartjournal.org
pubmed.ncbi.nlm.nih.gov
pubmed.ncbi.nlm.nih.gov
Loading suggestions...