Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
J Vasc Surg Venous Lymphat Disord. 2018 Jul;6(4):425-432. doi: 10.1016/j.jvsv.2017.12.058. Epub 2018 Mar 31.
Catheter-directed interventions (CDIs) are increasingly performed for acute pulmonary embolism (PE) as they are presumed to provide similar therapeutic benefits to systemic thrombolysis (ST) while decreasing the associated complications. The purpose of this study was to compare outcomes between CDI and ST.
Consecutive patients who underwent CDIs or ST for massive or submassive PE between 2006 and 2016 were identified. Clinical and echocardiographic parameters at baseline and after treatment were recorded. Clinical success was defined as decompensation resolution (or prevention) without major bleeding, stroke, other major treatment-related event, or in-hospital death. The χ test and t-test were used for between-groups comparisons.
There were 213 patients who received CDIs (standard catheter thrombolysis in 56, ultrasound-assisted thrombolysis in 146, suction thrombectomies in 10, and pharmacomechanical thrombolysis in 1) and 104 patients who received ST (94 high dose [100 mg], 10 low dose [50 mg]). At baseline, CDI and ST groups had comparable echocardiographic parameters, demographics, and comorbidities, except for PE type (massive PE, 8.5% for CDIs vs 69.2% for ST; P < .001), age (60.2 ± 14.9 years for CDIs vs 55.9 ± 17.3 years for ST; P = .023), and renal function (glomerular filtration rate, 78.1 ± 33.7 mL/min/1.73 m for CDIs vs 64.1 ± 35.2 mL/min/1.73 m for ST; P = .001). Without stratifying per PE type, CDIs had a higher clinical success rate (87.8% vs 66.3%; P < .001) and a lower rate of major bleed (8.0% vs 19.2%; P = .003), stroke (1.4% vs 4.8%; P = .120), and death (1.4% vs 13.5%; P < .001). On stratifying by PE type, there was no difference in clinical success between groups. The mean reduction in right ventricular/left ventricular diameter ratio between baseline and the first post-treatment echocardiographic examination (within 30 days) was significantly higher for CDI (0.27 ± 0.20 vs 0.18 ± 0.15; P = .037). Beyond 30 days, there was no echocardiographic difference between groups. There was no significant difference in clinical outcomes and echocardiographic parameters between standard and ultrasound-assisted CDIs.
CDIs provide improved recovery of right ventricular function compared with ST. Major bleeding and stroke complications may be lower, but larger studies are needed to validate this. CDIs are complementary to ST, and their use should be individualized on the basis of the patients' clinical presentation, risk profile, and local resources.
导管介入治疗（CDI）在急性肺栓塞（PE）中的应用越来越广泛，因为它被认为在提供与全身溶栓（ST）相似的治疗效果的同时，降低了相关并发症。本研究旨在比较 CDI 和 ST 的结果。
回顾性分析 2006 年至 2016 年间接受 CDI 或 ST 治疗的大量或次大量 PE 患者。记录治疗前后的临床和超声心动图参数。临床成功定义为无重大出血、卒中等主要治疗相关事件或住院死亡的代偿失调缓解（或预防）。使用 χ 检验和 t 检验进行组间比较。
共纳入 213 例接受 CDI 治疗的患者（标准导管溶栓 56 例，超声辅助溶栓 146 例，抽吸血栓切除术 10 例，药物机械溶栓 1 例）和 104 例接受 ST 治疗的患者（94 例高剂量[100mg]，10 例低剂量[50mg]）。基线时，CDI 和 ST 组的超声心动图参数、人口统计学特征和合并症相似，但 PE 类型（大量 PE，CDI 组为 8.5%，ST 组为 69.2%；P<0.001）、年龄（CDI 组为 60.2±14.9 岁，ST 组为 55.9±17.3 岁；P=0.023）和肾功能（肾小球滤过率，CDI 组为 78.1±33.7 mL/min/1.73 m，ST 组为 64.1±35.2 mL/min/1.73 m；P=0.001）存在差异。不按 PE 类型分层，CDI 的临床成功率（87.8% vs 66.3%；P<0.001）更高，大出血（8.0% vs 19.2%；P=0.003）、卒中和死亡（1.4% vs 4.8%；P=0.120）发生率更低。按 PE 类型分层，两组的临床成功率无差异。与基线相比，CDI 治疗后第 1 次超声心动图检查（30 天内）右心室/左心室直径比的平均降低幅度更大（0.27±0.20 vs 0.18±0.15；P=0.037）。30 天后，两组间无超声心动图差异。两组在临床结局和超声心动图参数方面无显著差异。标准 CDI 和超声辅助 CDI 之间在临床结局和超声心动图参数上无显著差异。
与 ST 相比，CDI 可改善右心室功能的恢复。大出血和卒中并发症的发生率可能更低，但需要更大规模的研究来验证这一点。CDI 是 ST 的补充治疗方法，应根据患者的临床表现、风险状况和当地资源进行个体化选择。
