Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
J Vasc Surg Venous Lymphat Disord. 2018 Jul;6(4):530-540. doi: 10.1016/j.jvsv.2018.03.010.
During the past few years, there has been a surge in the use of catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE), in the form of either standard CDT or ultrasound-assisted CDT (usCDT). This is a systematic review and meta-analysis of all published series on contemporary CDT for acute PE seeking to determine their clinical efficacy, stratifying by PE severity and CDT modality.
A comprehensive MEDLINE and Embase search was performed to identify studies that reported outcomes of CDT for acute PE published from 2009 to July 2017. Outcomes included clinical success (in-hospital survival with stabilization of hemodynamics, without decompensation or any major complication), in-hospital mortality, major bleeding, right ventricular/left ventricular ratio, and Miller score changes after CDT. Meta-analyses assumed random effects.
Twenty studies with 1168 patients were included in the meta-analysis. Available for subgroup analysis were 210 patients with high-risk PE and 945 patients with intermediate-risk PE; 181 patients received CDT using a standard multiside hole catheter, and 850 received usCDT. The pooled average right ventricular/left ventricular improvement and Miller score drop after CDT were 0.30 (95% confidence interval [CI], 0.22-0.39) and 8.8 (95% CI, 7.1-10.5). For high-risk PE, the pooled estimate for clinical success was 81.3% (95% CI, 72.5%-89.1%), the 30-day mortality estimate was 8.0% (95% CI, 3.2%-14.0%), and major bleeding was 6.7% (95% CI, 1.0%-15.3%). For intermediate-risk PE, the pooled estimate for clinical success was 97.5% (95% CI, 95.3%-99.1%), the 30-day mortality was 0% (95% CI, 0%-0.5%), and major bleeding was 1.4% (95% CI, 0.3%-2.8%). In high-risk PE, clinical success for CDT and usCDT was 70.8% (95% CI, 53.4%-85.8%) and 83.1% (95% CI, 68.5%-94.5%), respectively. In intermediate-risk PE, clinical success for CDT and usCDT was 95.0% (95% CI, 88.5%-99.2%) and 97.5% (95% CI, 95.0%-99.4%), respectively.
Catheter thrombolysis has high clinical success rates in both high- and intermediate-risk PE, but higher mortality and bleeding rates should be anticipated in high-risk PE. Ultrasound-assisted thrombolysis may be more effective than standard CDT in the higher risk population.
在过去的几年中，急性肺栓塞（PE）的导管溶栓（CDT）使用率呈上升趋势，包括标准 CDT 或超声辅助 CDT（usCDT）。本系统评价和荟萃分析旨在评估所有关于急性 PE 的当代 CDT 系列的临床疗效，并根据 PE 严重程度和 CDT 方式进行分层。
全面检索 MEDLINE 和 Embase 数据库，以确定自 2009 年至 2017 年 7 月发表的关于急性 PE 行 CDT 治疗的研究。结局指标包括临床成功（院内生存率稳定，无失代偿或任何重大并发症）、院内死亡率、大出血、右心室/左心室比值以及 CDT 后 Miller 评分的变化。荟萃分析采用随机效应模型。
纳入 20 项研究共 1168 例患者，其中 210 例高危 PE 患者和 945 例中危 PE 患者可进行亚组分析。181 例患者接受标准多侧孔导管 CDT，850 例患者接受 usCDT。CDT 后右心室/左心室比值和 Miller 评分的平均改善值分别为 0.30（95%置信区间，0.22-0.39）和 8.8（95%置信区间，7.1-10.5）。高危 PE 患者中，临床成功的合并估计值为 81.3%（95%置信区间，72.5%-89.1%），30 天死亡率估计值为 8.0%（95%置信区间，3.2%-14.0%），大出血发生率为 6.7%（95%置信区间，1.0%-15.3%）。中危 PE 患者中，临床成功的合并估计值为 97.5%（95%置信区间，95.3%-99.1%），30 天死亡率为 0%（95%置信区间，0%-0.5%），大出血发生率为 1.4%（95%置信区间，0.3%-2.8%）。高危 PE 患者中，CDT 和 usCDT 的临床成功率分别为 70.8%（95%置信区间，53.4%-85.8%）和 83.1%（95%置信区间，68.5%-94.5%）。中危 PE 患者中，CDT 和 usCDT 的临床成功率分别为 95.0%（95%置信区间，88.5%-99.2%）和 97.5%（95%置信区间，95.0%-99.4%）。
CDT 在高危和中危 PE 中的临床成功率均较高，但高危 PE 的死亡率和出血率较高。超声辅助溶栓可能比标准 CDT 在高危人群中更有效。
