高、中危肺栓塞导管溶栓治疗结局的荟萃分析。

A meta-analysis of outcomes of catheter-directed thrombolysis for high- and intermediate-risk pulmonary embolism.

机构信息

Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.

出版信息

J Vasc Surg Venous Lymphat Disord. 2018 Jul;6(4):530-540. doi: 10.1016/j.jvsv.2018.03.010.

DOI:10.1016/j.jvsv.2018.03.010

PMID:29909859

Abstract

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

摘要

目的

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。

方法

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。

结果

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%）。