大口径血栓切除术与导管定向溶栓治疗肺栓塞的比较
Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary Embolism.
作者信息
Feroze Rafey, Arora Shilpkumar, Tashtish Nour, Dong Tony, Jaswaney Rahul, Castro-Dominguez Yulanka, Hammad Tarek, Osman Mohammad Najeeb, Carman Teresa, Schilz Robert, Shishehbor Mehdi H, Li Jun
机构信息
Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio.
Department of Medicine, University Hospitals, Cleveland, Ohio.
出版信息
J Soc Cardiovasc Angiogr Interv. 2023 Jan 4;2(1):100453. doi: 10.1016/j.jscai.2022.100453. eCollection 2023 Jan-Feb.
BACKGROUND
There is significant debate on whether large-bore thrombectomy (LBT) or catheter-directed thrombolysis (CDT) is superior for the treatment of intermediate- and high-risk pulmonary embolism (PE) while employing an early invasive strategy through endovascular therapies.
METHODS
Between 2018 and 2021, 147 patients who presented to our institution with acute intermediate- or high-risk PE and had undergone PE Response Team-guided endovascular intervention with either LBT (Inari FlowTriever) or CDT (EKOSonic) were retrospectively reviewed. Data on the patients' clinical characteristics, comorbidities, serum biomarkers, hemodynamics, and imaging characteristics were obtained. The primary outcome was all-cause mortality; the secondary outcomes were all-cause readmission, readmission for PE, and length of stay in the intensive care unit and hospital. The safety outcome of procedure-related bleeding was evaluated. Kaplan-Meier curves were used to estimate the cumulative event rate. Multivariate Cox-proportional hazard regression and inverse propensity weighting were used to adjust for confounders.
RESULTS
The median age of the patients was 63 (IQR, 53-73) years, and 48.3% of the patients were women. Patients in the LBT group had a higher PE Severity Index score (LBT vs CDT: median, 132 vs 108; = .015) and greater prevalence of malignancy (LBT vs CDT: median, 22.7% vs 6%; = .011). After propensity matching for baseline characteristics, there was no significant difference in all-cause mortality (LBT vs CDT: median, 15.8% vs 9.1%; hazard ratio, 0.64; 95% CI, 0.21-1.98; = .442) for up to 1 year. The secondary outcomes or safety end points were also similar between the 2 interventions. An exploratory analysis showed elevated PE Severity Index scores, lower systolic blood pressures, and higher lactic acid levels to be associated with an increased risk of early death at 30 days.
CONCLUSIONS
In this retrospective cohort study, there was no significant difference in the cumulative event rate of all-cause mortality between LBT and CDT. Further studies are needed to evaluate the use of LBT versus CDT versus noninvasive therapy to understand outcomes and appropriate patient selection among those with intermediate- and high-risk PE.
背景
在采用血管内治疗的早期侵入性策略治疗中高危肺栓塞（PE）时，关于大口径血栓切除术（LBT）或导管定向溶栓术（CDT）哪种方法更具优势存在重大争议。
方法
回顾性分析了2018年至2021年间147例因急性中高危PE就诊于本机构并接受了PE反应团队指导的血管内介入治疗的患者，这些患者接受了LBT（Inari FlowTriever）或CDT（EKOSonic）治疗。获取了患者的临床特征、合并症、血清生物标志物、血流动力学和影像学特征等数据。主要结局为全因死亡率；次要结局为全因再入院、因PE再入院以及重症监护病房和医院的住院时间。评估了与手术相关出血的安全性结局。采用Kaplan-Meier曲线估计累积事件发生率。使用多变量Cox比例风险回归和逆倾向加权法对混杂因素进行调整。
结果
患者的中位年龄为63岁（四分位间距，53 - 73岁），48.3%的患者为女性。LBT组患者的PE严重指数评分更高（LBT组与CDT组：中位数，132对108；P = 0.015），恶性肿瘤患病率更高（LBT组与CDT组：中位数，22.7%对6%；P = 0.011）。在对基线特征进行倾向匹配后，长达1年的全因死亡率无显著差异（LBT组与CDT组：中位数，15.8%对9.1%；风险比，0.64；95%置信区间，0.21 - 1.98；P = 0.442）。两种干预措施的次要结局或安全性终点也相似。一项探索性分析显示，PE严重指数评分升高、收缩压降低和乳酸水平升高与30天内早期死亡风险增加相关。
结论
在这项回顾性队列研究中，LBT和CDT的全因死亡率累积事件发生率无显著差异。需要进一步研究评估LBT与CDT以及与非侵入性治疗的使用情况，以了解中高危PE患者的结局和合适的患者选择。
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