Stegman Brian, Kumar Anirudh, Dahle Thom, Schmidt Wade, Dutcher Jacob, Glenz Tanya, Appelbaum Daniel
CentraCare Heart & Vascular Center, St. Cloud, Minnesota.
Northwestern Medicine Central DuPage Hospital, Winfield, Illinois.
J Soc Cardiovasc Angiogr Interv. 2023 Dec 19;3(2):101260. doi: 10.1016/j.jscai.2023.101260. eCollection 2024 Feb.
Residual pulmonary vascular obstruction (RPVO) following pulmonary embolism (PE) is associated with residual dyspnea, recurrent venous thromboembolism, and chronic thromboembolic pulmonary hypertension. Historically, acute PE treated with anticoagulation alone results in high rates of significant RPVO. Contemporary treatment of submassive PE often involves catheter-based interventions, including mechanical thrombectomy (MT), although their relation to RPVO is not characterized. In this study, we aimed to evaluate the rate of ≥10% RPVO in patients treated with MT.
Twenty consecutive patients with submassive PE in a single center underwent MT and subsequent planar ventilation/perfusion scintigraphy scan at a median of 4 months after thrombectomy. A quantitative perfusion score was calculated for each planar ventilation/perfusion scintigraphy study to provide a % perfusion defect. Complete hemodynamic data were collected during the procedure and Miller score was calculated using prepulmonary and postpulmonary angiography. Echocardiographic data were collected prior to, 24 to 48 hours after, and 30 days after the procedure.
Four of 20 patients (20%) had ≥10% RPVO at a median of 4 months follow-up. Following MT, the mean Miller score decreased from 24.5 ± 2.9 to 15.8 ± 3.3 ( < .001) and mean pulmonary artery pressure decreased from 36.1 ± 4.8 mm Hg to 26.8 ± 5.4 mm Hg ( < .001). Right ventricle-to-left ventricle ratio decreased from 1.44 ± 0.2 to 1.05 ± 0.24 by 24 to 48 hours ( < .001) and 0.85 ± 0.1 at 30 days ( < .001) and right ventricular systolic pressure decreased from 63.2 ± 10 mm Hg to 42.1 ± 9.8 mm Hg at 24 to 48 hours ( < .001) and 31.9 ± 10.4 at 30 days ( < .001).
In this prospective study of patients with submassive PE treated with MT, favorable rates of RPVO were noted in comparison to prior studies of anticoagulation alone along with expected acute hemodynamic and echocardiographic improvements. While this study was small in scope, the results suggest the potential for long-term benefits of MT in acute PE in addition to the acute benefits previously described.
肺栓塞（PE）后残留的肺血管阻塞（RPVO）与残留呼吸困难、复发性静脉血栓栓塞及慢性血栓栓塞性肺动脉高压相关。从历史上看，单纯抗凝治疗急性PE会导致较高的显著RPVO发生率。当代对次大面积PE的治疗通常涉及基于导管的干预措施，包括机械血栓切除术（MT），尽管其与RPVO的关系尚不明确。在本研究中，我们旨在评估接受MT治疗的患者中RPVO≥10%的发生率。
在单一中心，连续20例次大面积PE患者接受了MT治疗，并在血栓切除术后中位4个月时进行了平面通气/灌注闪烁扫描。为每次平面通气/灌注闪烁扫描研究计算定量灌注评分，以提供灌注缺损百分比。在手术过程中收集完整的血流动力学数据，并使用肺血管造影术前和术后数据计算米勒评分。在手术前、术后24至48小时以及术后30天收集超声心动图数据。
20例患者中有4例（20%）在中位4个月的随访时出现RPVO≥10%。MT治疗后，平均米勒评分从24.5±2.9降至15.8±3.3（P<.001），平均肺动脉压从36.1±4.8 mmHg降至26.8±5.4 mmHg（P<.001）。右心室与左心室比值在术后24至48小时从1.44±0.2降至1.05±0.24（P<.001），在30天时降至0.85±0.1（P<.001），右心室收缩压在术后24至48小时从63.2±10 mmHg降至42.1±9.8 mmHg（P<.001），在30天时降至31.9±10.4 mmHg（P<.001）。
在这项对接受MT治疗的次大面积PE患者的前瞻性研究中，与既往单纯抗凝治疗的研究相比，RPVO发生率令人满意，同时伴有预期的急性血流动力学和超声心动图改善。虽然本研究规模较小，但结果表明MT除了具有先前描述的急性益处外，对急性PE可能还有长期益处。
