Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3727_Библиотеки_им_академика_М_И_Перельмана
.pdf
244 Chapter 23 Endovascular and surgical management of acute pulmonary embolism
https://t.me/med1917
mismatch between ventilation and perfusion, intracardiac or intrapulmonary shunting of mixed venous blood,
and alveolar hypoventilation may result in hypoxemia in
patients suffering from PE.
6
Increased RV afterload generated by the extent of
thrombus and hypoxemic vasoconstriction can cause signicant RV strain. This results in RV dilation, hypokinesis, tricuspid regurgitation, myocardial ischemia, and
ultimately right heart failure. RV dilation also leads to
intraventricular septal attening, which can impair left
ventricular (LV) function. These factors can then result in
systemic hypotension from reduced LV preload and overall
reduced LV function, compounding myocardial ischemia.
This process occurs over time, such that hemodynamic
collapse may actually occur after 12–48hours of relative
“normotension” and hemodynamic stability.
5,7
23.3 INDICATIONS FOR
INTERVENTION
Given the pathological milieu of acute PE, treatment needs
to address (1) prevention of new thrombus formation, (2)
clearance of the obstructing thrombus from the PA (either
rapidly or over time), and (3) reducing RV dysfunction
when present. Current guidelines recommend thrombolysis for patients with low bleeding risk who have massive PE. In addition, patients with submassive PE who are
thought to be at risk for adverse prognosis (new hemodynamic instability, worsening respiratory insufciency,
severe RV dysfunction, or major myocardial necrosis) may
be considered for thrombolysis (Figure23.1).
3,4
However,
some patients have a contraindication to systemic thrombolysis (recent intracranial hemorrhage or surgery, recent
spinal surgery, recent head trauma, intracranial neoplasm,
uncontrolled hypertension, or active or recent bleeding).
In addition, systemic thrombolysis carries a 20% risk
of bleeding and a 3%–5% risk of hemorrhagic stroke.
8
Moreover, there may be insufcient time to allow for
infusion and the effect of systemic thrombolytics in the
acute setting. Finally, some patients will fail to improve
despite thrombolytic treatment. In these instances, alternative treatments for expediting thrombus removal and/
or reducing thrombolytic dosage, such as CBT or surgical embolectomy, remain important treatment considerations.
In massive and submassive PE, RV outow obstruction
can cause severe RV strain. Therefore, interventional efforts
to remove the obstructing thrombus can potentially reverse
23.1 Treatment algorithm for pulmonary embolism. PE: pulmonary embolism; SBP: systolic blood pressure.
23.5 Mechanical thrombectomy devices 245
https://t.me/med1917
this pathological state faster than systemic thrombolytic
infusion. Percutaneous CBTs and open embolectomy can
debulk the offending thrombus, expedite thrombolysis,
improve lung perfusion, and/or improve right heart strain
over heparin therapy alone if systemic thrombolytics are
not possible. Some CBTs may use low-dose or zero thrombolytics to minimize bleeding risk. Although CBTs are
appealing for expedited care, they currently remain second-line therapies to systemic thrombolysis as the initial
treatment. No additional benet of CBTs has been proven
over systemic thrombolysis. However, they remain recommended over no intervention (i.e., systemic thrombolysis)
in conjunction with anticoagulation for massive and submassive PE.
3
Due to the multitude of approaches for the treatment
of PE, the concept of a PE response team has emerged as
a multidisciplinary coordinated effort to streamline and
improve the evolving and complex care of acute PE.
9
This
multidisciplinary approach may lead to broader national
efforts at improving processes and outcomes for PE. Specialties that are usually part of the pulmonary embolism
response team (PERT) include cardiac and vascular surgery, interventional radiology, interventional cardiology,
pulmonary medicine, anesthesia, and critical care.
23.4 FRAGMENTATION AND SUCTION
THROMBECTOMY
The most widely used simple technique is the use of rational
pigtail fragmentation (Figure23.2). This technique requires
femoral or jugular venous access. A guidewire is passed
into the pulmonary vasculature through the thrombus. In
comparison to a traditional pigtail catheter, for fragmentation of acute PE, the catheter has an oval side-hole on its
outer curvature. This allows the catheter to be advanced
over the wire, and the wire is used as an axis around which
to rotate (Figure23.2b). An 8-mm catheter may be useful
for segmental branches and a 12-mm catheter for the main
right and left pulmonary arteries.
performed in less than 30 minutes, resulting in rapid fragmentation of the thrombus. This technique embolizes the
thrombus distally into smaller branches to restore partial
perfusion of large vessels, improving pulmonary hemodynamics (Figure 23.2c). Additionally, this intervention
increases the surface area of the thrombus for brinolytic
activity. In a review of interventional techniques, pulmonary fragmentation appears to be clinically effective 80%
of the time, with few complications.
fragmentation can be accomplished by deploying an angioplasty balloon (9–14 mm) into the thrombus.
loon must be undersized compared to the vessel in which it
is used to avoid complications.
In addition to fragmentation, it may be possible to
remove the thrombus by aspiration from smaller vessels.
This can be accomplished with any end-hole guide catheter
(8 or 9 Fr) placed into the thrombus with the application
of negative pressure by means of a syringe. In a review of
CDT treatments, suction thrombectomy, with or without
fragmentation, was technically successful in 40%–100%
of cases.
11
8,10
This procedure can be
11
Finally, additional
8
12
The bal-
23.5 MECHANICAL THROMBECTOMY
DEVICES
The FlowTriever system (Inari Medical, Irvine, CA) is the
rst mechanical thrombectomy device with FDA indication for the treatment of acute PE as well as treating clots
in transit in the right atrium without the need for thrombolytics.
beyond the thrombus within the PA, allowing for a large-lumen directional catheter (available in 16, 20, and 24 Fr)
to be positioned near and engaging the thrombus. Alargebore syringe is then used to aspirate. If acute thrombus
remains adherent, the FlowTriever Catheter Gen 1 allows
for the use of three self-expanding nitinol mesh disks to
disrupt and allow for aspiration and extraction. Recently
the addition of the FlowSaver blood return system has
allowed for ltration of the aspirated thrombus and blood
for reinfusion of the ltered blood to the patient. In 2019,
the FLARE trial was published including 106 patients prospectively across 18 sites in the United States with acute
intermediate-risk PE treated with the FlowTriever system.
The trial appeared to demonstrate safety and efcacy in
this population with an improvement in RV/LV ratio, with
an average reduction of 0.38 (25.1%) and limited major
bleeding events, with a major bleeding event in one patient.
Notably, the mean ICU stay was 1.5 days, and 41.3% of
patients did not require any ICU stay.
meda, CA) also shows an indication for the treatment of
acute PE. The most recent iteration of the Indigo system
for PE treatment is the Lightning.
allows for directional aspiration thrombectomy but is connected to the Penumbra Engine capable of providing and
maintaining a near-complete vacuum (98.2 kPa). Notably the addition of the Lightning technology addresses
concerns with the risk of excess procedural blood loss by
providing continuous aspiration when sensing that the
catheter is engaged with the thrombus and intermittent
aspiration otherwise.
in 2021 included 119 patients prospectively across 22 U.S.
sites with submassive acute PE. This trial demonstrated a
mean RV/LV ratio reduction of 0.43 major adverse events
in 1.7% of patients. Additionally, intraprocedural thrombolytics were used in only 1.7% of patients.
is a rheolytic mechanical thrombectomy device based on
Bernoulli’s principle. It creates a low-pressure zone (up to
−600 mmHg) in a region of high jet velocity. The throm-
bus is fragmented and brought back into the catheter for
removal. This can be combined with tissue plasminogen
activator (tPA) infusion for a pharmacomechanical thrombectomy, whereby tPA is laced into the thrombus (using
either 10 or 20 mg tPA and the appropriate AngioJet pulse
spray-enabled catheter). Then, saline is used for standard
rheolytic thrombectomy. Despite its successful use in the
periphery and the initial enthusiasm from good technical
success in the treatment of PE,
have been encountered when it is used in the pulmonary
circulation. The device now carries a black box warning
about risks of adverse events and death when used for
PE. Thus, it should not be used in this setting, since other
13
In this system an 0.035ʺ guidewire is advanced
14
The Indigo Aspiration System (Penumbra, Inc., Ala-
12
This 12 Fr catheter also
13
The EXTRACT-PE trial published
15
The AngioJet (Boston Scientic, Marlborough, MA)
16,17
signicant complications
23
246 Chapter 23 Endovascular and surgical management of acute pulmonary embolism
https://t.me/med1917
23.2 Pigtail fragmentation for pulmonary embolism. (a) Large pulmonary embolism in the main left pulmonary artery obstructing
ow. (b) Pigtail catheter is rotated around the wire axis to fragment the thrombus causing distal embolization but restoring ow
through the main pulmonary artery. (c) Flow restored with small distal embolization of thrombus.
options with a lower risk are readily available (e.g., fragmentation).
Finally, the AngioVac device (Angiodynamics, Latham,
NY) is a catheter-based modality for the treatment of
PE. Based on the instructions for use, the AngioVac (Figure23.3) is a venous drainage cannula for extracorporeal
bypass (up to 6hours). It carries an additional indication
for the removal of unwanted intravascular material (soft
thrombus or embolus). It is an 18 or 22 French, coil-reinforced cannula with a funneled balloon-actuated tip to
direct the thrombus into the cannula (Figure 23.4). It is
attached to a specially designed lter that can be connected
23.5 Mechanical thrombectomy devices 247
https://t.me/med1917
to any venovenous bypass centrifugal pump. A second
venous access is necessary for venous return to complete
the circuit, as the device can drain up to 5 L per minute
(Figure23.4). The device is advanced through a 22 or 24 Fr
AngioVac outer sheath or Gore Dryseal sheath (W.L. Gore,
23.3 AngioVac cannula.
Flagstaff, AZ) from the jugular or femoral approach to
enter the pulmonary vasculature. Results from the Registry
of AngioVac Procedures in Detail (RAPID) study were published in 2021 and 2022, containing prospectively collected
data for 234 patients across 21 sites from March2016 to
August2019.
went use for PE alone with another 3 treated for PE in
conjunction with another site of venous thrombus or mass.
The remaining patients underwent use of the AngioVac for
caval thromboemboli (35.9%), right heart masses (48.3%),
and catheter-related thrombi (8.5%). Between 70% and
100% of thrombi were removed in 57.1% of patients with
PE. Among all patients in the registry, 36 complications,
including 3 deaths (1 procedure-related), 8 (3.4%) access
site complications, 9 (3.8%) hemorrhages, 7 (3.0%) distal
19,20
Of the 234 patients, only 4 (1.7%) under-
23
23.4 AngioVac setup for venous thrombectomy. Jugular access is obtained and the blood drawn through the specially designed
lter via a centrifugal pump that returns the blood to the femoral vein through a standard venous cannula.
248 Chapter 23 Endovascular and surgical management of acute pulmonary embolism
https://t.me/med1917
embolizations, 1 (0.4%) cardiac perforation, and 1 (0.4%)
ischemic cerebral vascular accident, were reported. The
study concluded that the AngioVac system could be safely
and effectively used in patients with vascular thrombi and
cardiac masses, but cautioned that with the limited use of
the device for patients with PE that recommendation was
not able to be made for this group.
19
The authors’ institution has used the AngioVac for PE
cases where thrombolytic treatment is contraindicated, and
treatment is warranted (massive or submassive PE with
risk for deterioration). In our limited experience, a jugular approach is preferred and can be accessed percutaneously. The use of a stiff, precurved wire (such as a manually
curved Amplatz wire [Boston Scientic, Natick, MA]) is
necessary to direct the device from the RV into the PA (Figure23.5). Extreme care must be taken, as RV rupture has
been reported with this technique. Treatment is limited to
the rst 2cm of the main right and left PAs, although theoretically, further distal thrombus may be able to be extracted
due to the drainage force of the device. Additionally, due
to the RV outow obstruction created by the device, the
patient may require temporary peripheral extracorporeal
membrane oxygenation (ECMO) for safety. This can be
weaned immediately after the procedure, before case completion. For simplicity, the AngioVac drainage can be linked
to the ECMO circuit (Figure23.6). Overall, this device can
deliver rapid removal of thrombus from the PA without the
need for thrombolysis. However, large doses of heparin are
needed for the venovenous bypass circuit to obtain an activated clotting time (ACT) >350 seconds. Additionally, there
is a risk of dilutional anemia from the uid the circuit adds
to the patient’s intravascular volume. Finally, coordination
with cardiac surgery is a prerequisite, due to the risks of
injury to the heart or pulmonary vessels and the need for
ECMO. Overall, this device may be overly complex compared with newer technology for acute PE management.
23.5 AngioVac in the right main pulmonary artery via a right
jugular approach.
23.6 CATHETER-DIRECTED
THROMBOLYSIS
In an attempt to reduce the need for large systemic tPA
infusions (typically 50–100 mg over 1–2 hours) in the
treatment of PE, the delivery of local thrombolytic agents
has been proposed as a potentially safer option and can be
used as a standalone treatment or as an adjunct in nearly
two-thirds of all reported CDTs for massive and submassive PE.
and catheterization of the pulmonary vasculature. Amultiholed lytic catheter (UniFuse [Angiodynamics, Lytham,
NY]) is then placed within the thrombus, and a thrombolytic agent (urokinase or, more commonly, tPA) is infused
unilaterally or bilaterally (Figure23.7). For tPA, 1–2 mg/
hour is typically delivered for approximately 15hours, and
then a follow-up pulmonary arteriogram is performed.
This can usually be done with <30 mg of tPA, thus carrying a theoretically lower risk of bleeding complications. If
extended infusions (>24hours) are planned, brinogen levels should be monitored. If the brinogen levels fall precipitously (>50%) or are under 200 mg/dL, the dose should be
reduced, or the infusion stopped. In a meta-analysis of CDT
series, the frequency of success was higher if at least 80%
of patients received locally delivered thrombolytic therapy
during the procedure (91.2% vs 82.8%, P=0.01) or for
an extended period of time (89.2% vs 84.2%, P=0.045).
However, the included studies were quite heterogeneous,
making a denitive benet of catheter-directed thrombolytic treatment over other CDTs difcult to prove.
ture and decrease tPA infusion times (and subsequently tPA
doses), ultrasound-assisted thrombolysis (USAT) for the
treatment of massive and submassive PE may be used. Currently, the EkoSonic Endovascular System (EKOS Corp.,
Bothwell, WA) is the only USAT device that is approved
for use in the United States. The use of ultrasound energy
results in reversible disaggregation of non-cross-linked
brin bers and opens up sites for tPA binding in order
to facilitate the drug effect. Additionally, ultrasound pressure waves may increase thrombus penetration by acoustic
streaming.
latter of which is more common. The USAT catheter is 6
Fr compatible; however, if bilateral treatment is planned, a
10 Fr femoral venous sheath is necessary. The pulmonary
vasculature is selected using standard techniques. Once
wire access to the lobar branches is obtained, the infusion
catheter is advanced over the wire and the ultrasound core
is inserted that delivers high-frequency (2.2 GHz), low-energy (0.5 W per transducer) ultrasound waves.
diate-risk PE (RV/LV ratio ≥1.0) to heparin therapy or heparin
plus USAT with the EkoSonic Endovascular System to deliver
either unilateral or bilateral tPA at 1 mg/hour for 15hours.
The primary endpoint was the RV/LV ratio change from baseline to 24hours after treatment. In the USAT group, placement of the catheter was successful in 100% of patients (87%
received bilateral catheter placement). There was a signicant
difference in the RV/LV ratio for the USAT group (1.28 ± 0.19
to 0.99 ± 0.17 [P < 0.001] vs heparin 1.2 ± 0.14 to 1.17 ± 0.2
[P=0.31]). The mean RV/LV ratio difference was 0.3 ± 0.2
11
This is performed after femoral or jugular access
11
To improve delivery of tPA to the pulmonary vascula-
21
This can be done unilaterally or bilaterally, the
21
The ULTIMA trial randomized 59 patients with interme-
22
23.6 Catheter-directed thrombolysis 249
https://t.me/med1917
23
23.6 AngioVac setup with extracorporeal membrane oxygenation.
23.7 Bilateral placement of EKOS catheters into the right and
left pulmonary arteries.
for USAT compared to 0.03 ± 0.16 for the heparin group (P <
0.001). However, these differences were not signicant at 90
days. Most RV hemodynamics were signicantly improved
at 24hours with USAT compared to heparin treatment. The
mean hospital stay was not different. At 90 days, mortality
was not different, and no major bleeding occurred. Four
minor bleeding events occurred with USAT, and one occurred
in the heparin-only group.
21
In several larger retrospective series (Table23.2), USAT
had similar effects on RV/LV ratio improvement. Engelberger etal. reported on 52 patients with intermediate- and
high-risk PE. The RV/LV ratio decreased from 1.42 ± 0.21
to 1.06 ± 0.23 after 24hours (P < 0.001). The greatest
benet appeared to be in high-risk patients. Complications
included a 3.8% mortality rate, major bleeding in 3.8% of
patients, and minor bleeding in 21% of patients.
23
Additionally, Kennedy et al. reported on 60 patients treated
with USAT. All patients had successful catheter placement.
Complete thrombolysis occurred in 57% of cases, and PA
pressures decreased signicantly. Their series reported a
5% mortality rate.
with similar improvements in RV/LV ratio, PA pressures,
and a 9.4% bleeding rate.
reviewed have shown that USAT can be performed with
bleeding rates of 2%–20% and low mortality.
24
McCabe etal. reported on 53 patients
25
Other series that have been
21
Finally, in
250 Chapter 23 Endovascular and surgical management of acute pulmonary embolism
https://t.me/med1917
TABLE 23.2 Clinical trials of ultrasound-assisted thrombolysis
Study Year Type Number of
Kucher
et al.
Engelberger
et al.
Kennedy
et al.
McCabe
et al.
Lin et
26
al.
2014 RCT 59 Interme-
22
2013 Retro-
23
24
25
spective
review
2013 Retro-
spective
review
2015 Retro-
spective
review
2009 Retro-
spective
review
patients
52 Intermedi-
60 Intermedi-
53 Intermedi-
25 Massive PE
Patient
population
diate-risk
acute PE
(RV/LV ≥1)
ate-risk (38)
and highrisk (14) PE
ate-risk (48)
and highrisk (12) PE
ate-risk PE
treated with
USAT (11)
vs CDT (14)
Treatment Outcomes Major
USAT (EKOS
with10 mg tPA)
and heparin
versus heparin
therapy alone
USAT with tPA
10 mg per side
for 15hours
USAT with tPA
35.1 ± 11.1
mg over 19.6 ±
6hours
USAT with tPA
24 ± 9 mg over
15.9 ± 3hours
Urokinase and
tPA
Change in RV/LV ratio:
USAT 1.28 ± 0.19 to 0.99
± 0.17 (P < 0.001); heparin
1.2 ± 0.14 to 1.17 ± 0.2
(P=0.31)
ND 3.80% 21% 3.8% at
Complete lysis 57%,
near-complete lysis 41%,
partial lysis 1.7%
Reduced RV/LV ratio
(1.12 ± 0.3 to 0.98 ± 0.2
[P=0.03]) and signicantly
reduced PA systolic (51.4
± 15.5 to 40 ± 10.8) and
mean pressure (33.8 ± 10.5
to 27 ± 7.6 [P < 0.01])
USAT complete lysis 100%
vs CDT 50%; Miller score
not different
bleeding
0% 10%
1.70% 1.70% 7% at 90
9.4% Overall
USAT
0% (0)
vs CDT
21% (3)
Minor
bleeding
USAT,
3%
heparin
bleeding
Mortality
1 death
(1.7%) in
heparin
group at
90 days
90 days
days
0% at
discharge
USAT
9.1% (1)
vs CDT
14.2%
(2)
Abbreviations: RCT: randomized controlled trial; RV: right ventricle; LV: left ventricle; USAT: ultrasound-assisted thrombolysis; tPA: tissue plasminogen activator; PE: pulmonary embolism; ND: no data; PA: pulmonary artery; CDT: catheter-directed thrombolysis.
the only report to compare USAT to standard catheter-directed thrombolytic treatment, Lin et al. reported more
complete thrombolysis, shorter infusion times (17.4 ± 5.2
vs 25.3 ± 7.3 [h], P=0.03), lower tPA doses (17.2 ± 2.4
vs 25.4 ± 5.3 [mg], P=0.03), and fewer bleeding complications (0% vs 21%, P=0.02) with USAT compared to
standard catheter-directed thrombolysis.
26
Overall, these studies demonstrate the feasibility of
USAT for the treatment of intermediate-risk PE. However,
there are no randomized trials of USAT compared to standard catheter-directed thrombolytic infusion. Additionally,
the endpoints for these studies are usually markers of cardiac and pulmonary hemodynamics. They represent surrogate endpoints without clear correlation to long-term
outcomes. There has been no long-term mortality or morbidity benet demonstrated with many of these techniques
to date, which would support changing current guidelines
for treatment in submassive PE. Further efforts are necessary to delineate the patients who will receive the most
benet from these techniques.
thrombolysis and other procedures are contraindicated.
These are often best performed in centers with experience
in these procedures, as candidates for this procedure are
inherently unstable. Historically, SPE was reserved for
massive PE with hemodynamic instability and when standard treatment had failed, or thrombolytics were contraindicated, as a last-line effort. It is not unexpected that
those selected for treatment have been reported to have a
poor prognosis. However, outcomes of SPE have greatly
improved and may offer benets over medical therapy or
attempts at repeated thrombolytic treatment.
27
In a literature review by Stein etal. of SPE from 1985 to 2005, average mortality declined from 32% to 20% over this period,
although there were slightly fewer patients with preoperative cardiac arrest in the latter group (33% vs 27%). Not
surprisingly, those undergoing surgery with preoperative
cardiac arrest had a 59% mortality rate compared to 20%
for those who did not have a preoperative arrest.
28
At Brigham and Women’s Hospital, which has taken
an aggressive approach to SPE, Leacche etal. reported on
47 patients undergoing emergent SPE.
29
Nearly all (95%)
had RV dysfunction by echo, and indications included a
23.7 SURGICAL PULMONARY
EMBOLECTOMY
contraindication to anticoagulation (47%), failed medical treatment (10%), and RV hemodynamic dysfunction
(32%). Their technique includes mandatory transesoph-
ageal echocardiogram (TEE) to assess RV function and
Surgical pulmonary embolectomy (SPE) remains a viable
and effective means of treating massive acute PE, as well
as submassive acute PE with adverse prognosis, when
the presence of a patent foramen ovale (PFO) and atrial
septal defects (ASDs; these would change operative cannu-
lation and myocardial protective strategies). After median
References 251
https://t.me/med1917
sternotomy, patients are placed in cardiopulmonary bypass
with normothermia and without cardioplegic arrest (unless
PFO or ASD is present). Alongitudinal or transverse PA
arteriotomy is made and clots are removed under direct
visualization with forceps and suction. Fogarty catheters
are avoided to prevent distal vessel injury. An inferior vena
cava lter is placed at the end of the case. Thirty-day mortality occurred in three patients (6%), of which two had a
preoperative cardiac arrest, and two of the three who died
needed an RV assist device. Other complications included
two patients requiring reoperation and two deep sternal
wound infections. Median follow-up was 27 months, and
the 1- and 3-year survival rates were 86% (95% CI: 70%–
90%) and 83% (95% CI: 66%–92%), respectively. Most
late deaths were due to cancer.
29
Based on these encouraging results, the authors have extended SPE for submassive
PE patients with massive proximal clot burden and RV
dysfunction. This aggressive approach has been replicated
by others, with comparable outcomes.
30
Overall, SPE remains a viable and potentially critical
component of comprehensive care in acute PE. Patients
should be referred before the onset of cardiogenic shock
and have large central thrombus burdens (within the
main trunk or right or left main PA). Surgery can be performed with normothermia and with or without bypass,
aortic cross-clamping, and cardioplegic arrest. Only visualized thrombus is removed, and inferior vena cava lters
are placed at case completion due to the risk of recurrent PE.
4,29
As outcomes with this re-emerging technique
have improved, this remains a viable treatment option for
those with massive and submassive PE, making a coordinated multidisciplinary approach to PE critical to tailoring treatment based on patient factors and institutional
expertise.
Guidelines 23.0 of the American Venous Forum on the endovascular and surgical management of acute pulmonary
embolism
No. Guideline Grade of
23.1 Thrombolysis is recommended for massive PE if bleeding risk is acceptable.
23.2 Thrombolysis is suggested for submassive acute PE that is felt to have a
poor prognosis if bleeding risk is acceptable.
23.3 Catheter thrombectomy, thrombus fragmentation, or surgical embolectomy
is recommended for patients with massive PE and contraindications for
thrombolysis depending on local expertise.
23.4 Catheter thrombectomy, thrombus fragmentation, or surgical embolectomy
is recommended for patients with massive PE who remain unstable after
thrombolysis if local expertise is available.
23.5 Catheter thrombectomy or surgical embolectomy is suggested for patients
with submassive PE judged to have a poor prognosis.
23.6 We suggest against catheter thrombectomy or surgical embolectomy for
low-risk PE or submassive PE with minor RV dysfunction.
recommendation
1
(strong)
2
(weak)
1
(strong)
1
(strong)
2
(weak)
2
(weak)
Quality
of evidence
B
(moderate)
C
(low to very low)
C
(low to very low)
C
(low to very low)
C
(low to very low)
C
(low to very low)
23
Source: Adapted from Jaff MRetal. Circulation 2011;123(16):1788–830.
Abbreviations: LMWH: low-molecular-weight heparin; IV: intravenous; UFH: unfractionated heparin; PE: pulmonary embolism; RV: right ventricle.
REFERENCES
• Key primary paper
★ Systematic review
♦ Guidelines
1. Cushman M., Tsai A.W., White R.H.,
etal. Deep vein thrombosis and pulmonary embolism in two cohorts: The longitudinal investigation of thromboembolism
etiology. Am J Med 2004;117(1):19–25.
2. Lloyd-Jones D., Adams R.J., Brown T.M.,
etal. Executive summary: Heart disease
and stroke statistics—2010 update:
Areport from the American Heart Association. Circulation 2010;121(7):948–954.
♦
3. Kearon C., Akl E.A., Comerota A.J., etal.
Antithrombotic therapy for VTE disease:
Antithrombotic therapy and prevention
of thrombosis, 9th ed: American College
of chest physicians evidence-based clinical
practice guidelines. Chest 2012;141(2
Suppl.):e419S–e494S.
*4. Jaff M.R., McMurtry M.S., Archer
S.L., etal. Management of massive and
submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic
thromboembolic pulmonary hypertension: Ascientic statement from the
American Heart Association. Circulation
2011;123(16):1788–1830.
*5. Goldhaber S.Z., and Elliott C.G.
Acute pulmonary embolism: Part I:
Epidemiology, pathophysiology, and diagnosis. Circulation 2003;108(22):
2726–2729.
6. Elliott C.G. Pulmonary physiology during
pulmonary embolism. Chest 1992;101(4
Suppl.):163S–171S.
7. Castillo C., and Tapson V.F. Right ventricular responses to massive and submassive pulmonary embolism. Cardiol Clin
2012;30(2):233–241.
8. Kuo W.T. Endovascular therapy for
acute pulmonary embolism. J Vasc Interv
Radiol 2012;23(2):167–179.e4; quiz 179.
9. Provias T., Dudzinski D.M., Jaff M.R.,
etal. The Massachusetts General Hospital
Pulmonary Embolism Response Team
(MGH PERT): Creation of a multidisciplinary program to improve care of
patients with massive and submassive
pulmonary embolism. Hosp Pract (1995)
2014;42(1):31–37.
252 Chapter 23 Endovascular and surgical management of acute pulmonary embolism
https://t.me/med1917
10. Schmitz-Rode T., Janssens U., Duda
S.H., Erley C.M., and Gunther R.W.
Massive pulmonary embolism: Percutaneous emergency treatment by pigtail
rotation catheter. J Am Coll Cardiol
2000;36(2):375–380.
★11. Kuo W.T., Gould M.K., Louie J.D.,
Rosenberg J.K., Sze D.Y., Hofmann L.V.
Catheter-directed therapy for the treatment of massive pulmonary embolism:
Systematic review and meta-analysis of
modern techniques. J Vasc Interv Radiol
2009;20(11):1431–1440.
12. Kuo W.T., van den Bosch M.A., Hofmann
L.V., Louie J.D., Kothary N., and Sze D.Y.
Catheter-directed embolectomy, fragmentation, and thrombolysis for the treatment
of massive pulmonary embolism after
failure of systemic thrombolysis. Chest
2008;134(2):250–254.
13. Moore K., Kunin J., Alnijoumi M., etal.
Current endovascular treatment options
in acute pulmonary embolism. J Clin
Imaging Sci 2021;11(5).
14. Tu T., Toma C., Tapson. V., etal. Aprospective, single-arm, multicenter trial of
catheter-directed mechanical thrombectomy for intermediate-risk acute pulmonary embolism: The FLARE study. JACC
Cardiovasc Interv 2019;12(9):859–869.
15. Sista A., Horowitz J., Tapson V., etal.
Indigo aspiration system for treatment
of pulmonary embolism: Results of the
EXTRACT-PE trial. JACC Cardiovasc
Interv 2021;14(3):319–329.
16. Koning R., Cribier A., Gerber L., etal. Anew
treatment for severe pulmonary embolism:
Percutaneous rheolytic thrombectomy. Circu-
lation 1997;96(8):2498–2500.
17. Zeni P.T., Jr., Blank B.G., and Peeler
D.W. Use of rheolytic thrombectomy
in treatment of acute massive pulmonary embolism. J Vasc Interv Radiol
2003;14(12):1511–1515.
18. Dwarka D., Schwartz S.A., Smyth S.H.,
and O’Brien M.J. Bradyarrhythmias
during use of the AngioJet system. J Vasc
Interv Radiol 2006;17(10):1693–1695.
19. Moriarty J.M., Rueda V., Liao M., etal.
Endovascular removal of thrombus
and right heart masses using the
angiovac system: Results of 234
patients from the prospective, multicenter Registry of AngioVac Procedures in
Detail (RAPID). J Vasc Interv Radiol
2021;32(4):549–557.
•20. Moriarty J.M., Liao M., Kim G.H., etal.
Procedural outcomes associated with use
of the AngioVac System for right heart
thrombi: Asafety report from RAPID
registry data. Vasc Med 2022;27(3):
277–282.
★21. Engelberger R.P., and Kucher N. Ultra-
sound-assisted thrombolysis for acute pulmonary embolism: Asystematic review.
Eur Heart J 2014;35(12):758–764.
•22. Kucher N., Boekstegers P., Muller O.J.,
etal. Randomized, controlled trial of
ultrasound-assisted catheter-directed
thrombolysis for acute intermediate-risk
pulmonary embolism. Circulation
2014;129(4):479–486.
23. Engelberger R.P., Moschovitis A., Fahrni
J., etal. Fixed low-dose ultrasound-assisted catheter-directed thrombolysis for
intermediate and high-risk pulmonary
embolism. Eur Heart J 2015;36(10):
597–604.
24. Kennedy R.J., Kenney H.H., and Dunfee
B.L. Thrombus resolution and hemodynamic recovery using ultrasound-accelerated
thrombolysis in acute pulmonary embolism. J Vasc Interv Radiol 2013;24(6):
841–848.
25. McCabe J.M., Huang P.H., Riedl L.,
Eisenhauer A.C., and Sobieszczyk P. Usefulness and safety of ultrasound-assisted
catheter-directed thrombolysis for submassive pulmonary emboli. Am J Cardiol
2015;115(6):821–824.
•26. Lin P.H., Annambhotla S., Bechara C.F.,
etal. Comparison of percutaneous
ultrasound-accelerated thrombolysis
versus catheter-directed thrombolysis in
patients with acute massive pulmonary
embolism. Vascular 2009;17(Suppl.
3):S137–S147.
27. Meneveau N., Seronde M.F., Blonde
M.C., etal. Management of unsuccessful
thrombolysis in acute massive pulmonary
embolism. Chest 2006;129(4):1043–1050.
28. Stein P.D., Alnas M., Beemath A.,
and Patel N.R. Outcome of pulmonary embolectomy. Am J Cardiol
2007;99(3):421–423.
•29. Leacche M., Unic D., Goldhaber S.Z.,
etal. Modern surgical treatment of massive pulmonary embolism: Results in 47
consecutive patients after rapid diagnosis
and aggressive surgical approach. J Tho-
rac Cardiovasc Surg 2005;129(5):
1018–1023.
30. Yalamanchili K., Fleisher A.G., Lehrman S.G., etal. Open pulmonary
embolectomy for treatment of major
pulmonary embolism. Ann Thorac Surg
2004;77(3):819–823;discussion 823.
CHAPTER
24
https://t.me/med1917
Treatment algorithms for acute
venous thromboembolism
Salim G. Habib and Rabih A. Chaer
24.1 INTRODUCTION
Venous thromboembolism (VTE) is common in the United
States, with an annual incidence of 1 to 2 cases per 1000
people, or 300,000–600,000 cases per year.
thrombosis (DVT), one manifestation of VTE, is a leading
cause of morbidity and mortality.
rarely cause symptoms or pulmonary emboli (PE), more
proximal DVTs (iliac, femoral, popliteal) can be symptomatic, and 40%–50% of patients present with concurrent
PE evidence on lung scans.
responsible for over 100,000 deaths each year.
botic syndrome (PTS) is the most common chronic complication of DVT, most commonly reported after proximal
DVTs (iliac and common femoral).
by a range of clinical symptoms from minor lower extremity discomfort to severe limb pain, edema, heaviness, skin
changes, and irreversible venous ulceration.
develops, treatment is frequently supportive. While much
less common than PTS, phlegmasia is another serious
complication of iliofemoral DVT, ultimately leading to
advanced lower extremity ischemia and gangrene. Prompt
intervention is necessary, as phlegmasia is associated with
an increased risk of limb loss and mortality.
It is estimated that over half of all hospitalized surgical
and medical U.S.patients are at risk of VTE.
lines recommend thromboprophylaxis as a cost-effective
and efcient approach to reducing VTE morbidity and mortality. Chapter25 explores the approach to VTE prevention.
In the absence of bleeding risks, anticoagulation (see
Chapter19) is the current mainstay of treatment for DVT.
Catheter-directed thrombolysis (see Chapter20), mechanical thrombectomy (see Chapter21), and open/hybrid surgery are additional treatment options for selectpatients (see
Chapter22). This chapter summarizes current recommendations for DVT management utilizing visual algorithms
designed to aid quick clinical decision making.
2
While isolated calf DVTs
3
Together, DVT and PE may be
4,5
1
Deep venous
2
Post-throm-
PTS is characterized
4
Once PTS
6
7
Current guide-
few randomized trials have been conducted to assess the
effectiveness of anticoagulation in preventing DVT-related
sequelae, and the results have been inconsistent.
meta-analyses found that there is more evidence supporting the use of anticoagulation to reduce the risks of VTE
recurrence or thrombus propagation. However, the benets of anticoagulation should be carefully balanced against
the increased risks of bleeding.
of Chest Physicians (ACCP) is currently the only source
of guidelines providing recommendations for the management of distal DVT (Figure24.1).
14–16
The American College
17
9–13
Recent
24.3 TREATMENT OF
FEMOROPOPLITEAL DVT
In 2012, the Society of Vascular Surgery (SVS) guidelines
recommended only conventional anticoagulation therapy for isolated DVTs involving the femoral, popliteal,
or both veins without extension to the common femoral veins.
the ATTRACT trial, has compared pharmacomechanical
thrombolysis to systemic anticoagulation in a subgroup of
patients with isolated femoropopliteal DVTs.
bined results of the ATTRACT trial and a number of retrospective studies have failed to demonstrate a clear benet
for procedural intervention over systemic anticoagulation
in femoropopliteal DVTs.
from the Society of Interventional Radiology (SIR) continue to recommend against early thrombus removal in
femoropopliteal DVT and recommend anticoagulation as
the treatment of choice (Figure24.2).
18
Since then, one randomized clinical trial only,
19
The com-
20,21
The more recent guidelines
22
24.4 TREATMENT OF ILIOFEMORAL
DVT
24.2 TREATMENT OF DVT DISTAL TO
THE POPLITEAL VEIN
DVT distal to the popliteal vein is regarded to pose a
low risk of complications.
ment, typically anticoagulation, is subject to debate. Very
DOI: 10.1201/9781003328971-27
8
As a result, the need for treat-
Iliofemoral DVT is known to have a higher rate of recurrence and to be more frequently associated with PTS than
more distal DVT.
anticoagulation is the mainstay treatment for proximal
17,18,22,25,26
DV T.
thrombus extension, it cannot dissolve the clot, and patients
treated solely with anticoagulation are at a high risk of
developing venous hypertension, reux, and ulceration.
23,24
In the absence of contraindications,
However, while anticoagulation can limit
27
253253
Соседние файлы в папке Библиотека им академика М.И. Перельмана