Upadhyay Henil, Barnes Jonathan, Beattie Anna, Reicher John
Respiratory Medicine, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, GBR.
Radiology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, GBR.
Cureus. 2024 Nov 20;16(11):e74086. doi: 10.7759/cureus.74086. eCollection 2024 Nov.
Pulmonary embolism (PE) is the third most frequent cause of acute cardiovascular presentation after myocardial infarction and stroke. The treatment approach for PE consists of hemodynamic and respiratory support, anticoagulation, reperfusion treatment, and vena cava filters. Reperfusion treatment consists of systemic thrombolysis (recombinant tissue-type plasminogen activator, streptokinase, and urokinase); percutaneous catheter-directed therapy (CDT); and surgical embolectomy. CDT is an emerging treatment, with most data derived from randomized controlled trials (RCTs) or case series. Currently, there is a lack of data on clinical efficacy and safety outcomes and a lack of large studies that directly compare CDT with systemic thrombolysis or surgical embolectomy. This narrative review aims to explore the efficacy and safety of systemic thrombolysis and CDT in pulmonary embolism. Clinical trials have studied CDT for more than a decade now and have shown that CDT improves the post-procedural right ventricular (RV)/left ventricular (LV) ratio and has a reduced rate of bleeding episodes and all-cause mortality. However, there is a lack of large prospective RCTs studying the effects of CDT in intermediate-high-risk PE patients to determine which patients from this sub-group require CDT both in terms of improving short-term mortality risk and long-term morbidity (such as chronic thromboembolic pulmonary hypertension (CTEPH) and post-PE syndrome). Future clinical trials need to focus on identifying which patient groups will benefit from CDT over anticoagulation and if there are any advantages of using the EkoSonic endovascular system (EKOS) (ultrasound (US)-assisted CDT) over standard CDT. In addition, the scientific community needs to study the healthcare costs of CDT over traditional treatment, which is relevant for public health systems such as the National Health Service (NHS). Lastly, we need standardized guidelines for the use of thrombectomy systems since pulmonary embolism is a complex disease requiring a multifaceted and nuanced treatment approach.
肺栓塞（PE）是继心肌梗死和中风之后急性心血管疾病的第三大常见病因。PE的治疗方法包括血流动力学和呼吸支持、抗凝、再灌注治疗以及腔静脉滤器。再灌注治疗包括全身溶栓（重组组织型纤溶酶原激活剂、链激酶和尿激酶）；经皮导管定向治疗（CDT）；以及手术取栓术。CDT是一种新兴的治疗方法，大多数数据来自随机对照试验（RCT）或病例系列。目前，缺乏关于临床疗效和安全性结果的数据，也缺乏直接比较CDT与全身溶栓或手术取栓术的大型研究。本叙述性综述旨在探讨全身溶栓和CDT在肺栓塞中的疗效和安全性。临床试验对CDT的研究已有十多年，结果表明CDT可改善术后右心室（RV）/左心室（LV）比率，并降低出血事件发生率和全因死亡率。然而，缺乏大型前瞻性RCT研究CDT对中高危PE患者的影响，以确定该亚组中哪些患者在改善短期死亡风险和长期发病率（如慢性血栓栓塞性肺动脉高压（CTEPH）和PE后综合征）方面需要CDT。未来的临床试验需要专注于确定哪些患者群体将从CDT而非抗凝治疗中获益，以及使用EkoSonic血管内系统（EKOS）（超声（US）辅助CDT）相对于标准CDT是否有任何优势。此外，科学界需要研究CDT相对于传统治疗的医疗成本，这对国家医疗服务体系（NHS）等公共卫生系统具有重要意义。最后，由于肺栓塞是一种需要多方面细致治疗方法的复杂疾病，我们需要关于取栓系统使用的标准化指南。
