Akin Haley, Al-Jubouri Mustafa, Assi Zakaria, Acino Robin, Sepanski Deb, Comerota Anthony J
Jobst Vascular Institute, Toledo, OH.
Jobst Vascular Institute, Toledo, OH.
Ann Vasc Surg. 2014 Oct;28(7):1589-94. doi: 10.1016/j.avsg.2014.05.004. Epub 2014 Jun 6.
Massive pulmonary embolism (MPE) is a significant cause of mortality and, with submassive pulmonary embolism (SPE), is associated with chronic thromboembolic pulmonary hypertension, resulting in ongoing patient morbidity. Standard treatment is anticoagulation, although systemic thrombolytic therapy has been shown to reduce early mortality in patients with MPE and improve cardiopulmonary hemodynamics in patients with SPE. However, systemic lysis is associated with significant bleeding risk. Early reports of catheter-directed techniques (CDT) suggest favorable outcomes in patients with MPE and SPE with reduced risk of hemorrhage. The purpose of this study is to evaluate efficacy and safety outcomes in MPE and SPE patients treated with CDT.
Seventeen patients treated with CDT for MPE and SPE were clinically and hemodynamically evaluated. Patients were grouped by severity of pulmonary embolism: MPE (n = 5) or SPE (n = 12). Pre- and post-interventional measures were assessed, including pulmonary artery pressures (PAPs), cardiac biomarkers, tricuspid regurgitation, right ventricular (RV) dilatation, and systolic function. Nine patients had contraindications to systemic thrombolytic therapy.
PAP was elevated in 94% at presentation. The average dose of recombinant tissue plasminogen activator (rt-PA) was 31 mg; 44 mg in MPE and 26 mg in SPE. Pre- and post-intervention PAPs were recorded in 13 patients. All demonstrated an acute reduction in posttreatment PAP, averaging 37%. At presentation, all MPE and 10 (83%) SPE patients showed both RV dilatation and reduced function on echocardiography, which normalized in 76% (13/17) and improved in 24% (4/17) after CDT. Patients who demonstrated left ventricle underfilling before CDT (2 [40%] MPE and 2 [20%] SPE) normalized after CDT. All MPE and 11 (92%) SPE patients had tricuspid regurgitation on echocardiography pretreatment, which resolved in 60% and 58% of MPE and SPE patients, respectively. One delayed mortality occurred in an MPE patient who was hypotensive and hypoxic at presentation. There was one puncture site bleed.
CDT was successful in the acute management of patients with MPE and SPE. CDT rapidly restores cardiopulmonary hemodynamics using reduced doses of rt-PA. These observations suggest that CDT should be considered in MPE and SPE patients to rapidly restore cardiopulmonary hemodynamics, reduce acute morbidity and mortality, reduce bleeding complications, and potentially avoid long-term morbidity.
大面积肺栓塞（MPE）是导致死亡的重要原因，并且与次大面积肺栓塞（SPE）一样，会引发慢性血栓栓塞性肺动脉高压，致使患者持续发病。标准治疗方法是抗凝治疗，尽管全身溶栓治疗已被证明可降低MPE患者的早期死亡率，并改善SPE患者的心肺血流动力学。然而，全身溶栓治疗存在显著的出血风险。早期关于导管定向技术（CDT）的报告表明，该技术对MPE和SPE患者疗效良好，且出血风险降低。本研究旨在评估接受CDT治疗的MPE和SPE患者的疗效和安全性结果。
对17例接受CDT治疗的MPE和SPE患者进行临床和血流动力学评估。患者按肺栓塞严重程度分组：MPE组（n = 5）或SPE组（n = 12）。评估介入前后的各项指标，包括肺动脉压（PAP）、心脏生物标志物、三尖瓣反流、右心室（RV）扩张及收缩功能。9例患者存在全身溶栓治疗的禁忌证。
就诊时94%的患者PAP升高。重组组织型纤溶酶原激活剂（rt-PA）的平均剂量为31mg；MPE患者为44mg，SPE患者为26mg。13例患者记录了介入前后的PAP。所有患者治疗后PAP均急性降低，平均降低37%。就诊时，所有MPE患者及10例（83%）SPE患者经超声心动图检查均显示RV扩张且功能降低，CDT治疗后76%（13/17）恢复正常，24%（4/17）有所改善。CDT治疗前出现左心室充盈不足的患者（2例[40%]MPE患者和2例[20%]SPE患者）治疗后恢复正常。所有MPE患者及11例（92%）SPE患者超声心动图检查预处理时存在三尖瓣反流，MPE和SPE患者中分别有60%和58%的患者反流消失。1例MPE患者就诊时出现低血压和低氧血症，发生延迟死亡。有1例穿刺部位出血。
CDT在MPE和SPE患者的急性治疗中取得成功。CDT使用较低剂量的rt-PA迅速恢复心肺血流动力学。这些观察结果表明，对于MPE和SPE患者，应考虑采用CDT来迅速恢复心肺血流动力学、降低急性发病率和死亡率、减少出血并发症，并可能避免长期发病。
