Download PE Response Teams

PulmonaryEmbolism
ConflictsofInterest
I proctor for:
• St. Jude/AGA Medical
• Endologics/Trivascular
I speak for:
• Abbott Vascular
• AngioDynamics
Background
•
300,000-500,000casesofPEannually.3rdmostcommon
CVdisorder.
•
80%ofPEpatientshavelowerextremityDVT.
•
50%ofuntreatedproxDVTpatientswillhaveaPE.
•
ElevatedRVtensionleadstodilation,dysfunction,and
ischemia.
•
DeathisduetoRVfailure.
1. Jaff. Circ. 2011; 123: 1788-1830
2. Roger. Heart Disease and Stroke Statistics—2012
Update. Circ. 2012;125(1):e2-e220.
3. Heit. Blood. 2005; 106: 267a
4. Tapson. Nejm. 2008; 358: 1037 - 1052
EpidemiologyofVTE
• IncidenceofnewVTEis1in1000peryearinUS.
• 2/3developDVTalone.
• 1/3ofsymptomaQcDVTmanifestPE.
• VTEisresponsiblefor250Khospitaladmit/yr.
• 30%diewithin30days.
• 1/5suddendeathduetoPE
• 30%recurrentVTEin10years.
• SymptomaQcPE.
• 10%diewithin1hour.
• 50%diewithin3months.
• 50%duetorecurrentPE.
WhiteRH.CirculaQon.2003;107:14-18.
HeirJA.SeminThrombHemost.2002;28:3-13.
GoldhaberSZ.NEnglJMed.1998;339:93-104.
HeartDiseaseandStrokeStaQsQceCirculaQon2007.
KearonC.CirculaQon.2003;107:122-130.
RV failure leads to hemodynamic
collapse and death
ESC PE guidelines. 2014. European Heart Journal
We fear under treatment and over treatment with
traditional systemic fibrinolysis.
RV dysfunction = mortality
Goldhaber. Lancet. 1999; 353:1386-89.
AHA Categorization of PE
•
LowRisk:
Sub-
massive PE
Massive PE
No right ventricular
(RV) strain or
hemodynamic
instability.
• Favorable prognosis
• 30-50% of PE
patients.
• 3-21% mortality
• “hemodynamically
stable” with RV
strain
• 5% of PE patients.
• 90-day mortality rate
50%.
• Hemodynamically
unstable
Definitions
•
Massive PE - Acute PE with sustained hypotension (SBP < 90mmHg for
at least 15 minutes or requiring inotropic support and not due to a cause
other than PE)
•
Submassive PE - Acute PE without systemic hypotension but with either
RV dysfunction or myocardial necrosis
RV dysfunction:
RV dilatation (RV/LV diameter > 0.9)
RV dysfunction on ECHO
RV dilatation on CT
Elevated BNP (>90pg/mL)
Elevation of N-terminal pro-BNP (>500pg/mL)
ECG changes (new complete or incomplete RBBB, anteroseptal
STE or ST-dep, anteroseptal TWI)
Myocardial necrosis
Elevated troponin I (> 0.4 ng/mL)
Elevated troponin T (>0.1 ng/mL)
•
Low Risk
JaffMR.Circula.on2011;123:1788-830.
Catheter Embolectomy/Fragmentation
or Surgical Embolectomy for PE
•
Depending on local expertise - Massive PE and contraindications to
fibrinolysis (Class IIa; Level of Evidence C).
•
Massive PE who remain unstable after receiving fibrinolysis (Class IIa;
Level of Evidence C).
•
Massive PE and contraindications to fibrinolysis or unstable after
fibrinolysis, transfer to an institution experienced in either catheter
embolectomy or surgical embolectomy (Class IIa; Level of Evidence C).
•
Submassive acute PE with clinical evidence of adverse prognosis (new
hemodynamic instability, worsening respiratory failure, severe RV
dysfunction, or major myocardial necrosis) (Class IIb; Level of Evidence C).
•
Not recommended for low-risk PE or submassive acute PE with minor RV
dysfunction, minor myocardial necrosis, and no clinical worsening (Class III;
Level of Evidence C).
JaffMR.Circula.on2011;123:1788-830.
Fibrinolysis for acute PE
1. Massive acute PE and acceptable risk of bleeding complications
(Class IIa; Level of Evidence B). 2. Submassive acute PE with adverse prognosis (new
hemodynamic instability, worsening respiratory insufficiency,
severe RV dysfunction, or major myocardial necrosis) and low risk
of bleeding complications (Class IIb; Level of Evidence C). 3. Not recommended for low-risk PE (Class III; Level of Evidence B)
or submassive acute PE with minor RV dysfunction, minor
myocardial necrosis, and no clinical worsening (Class III; Level of
Evidence B). 4. Not recommended for undifferentiated cardiac arrest (Class III;
Level of Evidence B). JaffMR.Circula.on2011;123:1788-830.
Catheter Directed Therapies
Mechanical fragmentation
(Rotating pigtail, aspirex
and helix thrombectomy
catheters)
•
Balloon angioplasty
•
Aspiration thrombectomy
•
Infusion balloon+ TPA
•
Todoran. Prog cardiovasc dis. 2010; 52:429-37
Kuo. J Vasc Interv Radiol 2012; 23:167-179
Inari FlowTrieverTM catheter
FRC Retraction with Aspiration
Device and delivery
catheter are
retracted into the
guide catheter
FRC Retraction with Aspiration
Device and delivery
catheter are retracted
into the guide catheter
Thrombus Disrupted
Retracted device,
delivery catheter and
guide catheter are all
removed from the
patient
Aspiration Catheter
•Penumbra Indigo Aspiration Systemtm (Penumbra inc., Alameda, CA).
•6 to 8 french straight or angled aspiration catheter connected to the pump.
•Separator wires (arrows) clear the catheter of thrombus.
Ultrasound assisted lytic therapy
(EKOS)
FDA approved for the
treatment of PE (may, 2014)
Fibrin
Separation
Fibrin
without
Ultrasound
Fibrin With
Ultrasound
Drug Delivery
Acoustic Streaming Drives
Lytic into clot
AngioVacDevice
AllowsMechanicalTreatmentofVenous
ThromboembolismandotherUndesirable
IntravascularMaterial
AngioVacAnatomicSpectrum
RightAtrialMass
Vegetations,Thrombus,Tumor
Lead/CatheterAssociated
TricuspidValveEndocarditis
InferiorVenaCava
IVCThrombosis
IVCFilterAssociated
IntracavalTumor
“ProximalProtection”
Pulmonary
Pulmonary
Embolism
PulmonicValve
Endocarditis
DVT
Iliofemoral
ProcedureKit
Stopcock
Assemblyon
InflationLumen
VsLuer
Circuit
HowitWorks
Proprietaryfunnelshapedtip:
•Enhancesvenousdrainageflowwhenballoonis
inflated
•Preventscloggingofthecannulaandfacilitatesen
blocremovalofcommonlyencounteredfresh,soft
thrombioremboli
22Fcoil-reinforcedcannulawithballoonactuatedexpandingtip
22
CannulaPlacements
SuperiorVenaCava
(SVC)
RightAtrium(RA)
InferiorVenaCava
(IVC)
CASE2
SaddlePE
JACC VOL. 67, NO. 8, 2016 MARCH 1, 2016:991–1002
PERT Protocol and sPESI Score
JACC VOL. 67, NO. 8, 2016 MARCH 1, 2016:991–1002
PERT Protocol
JACC VOL. 67, NO. 8, 2016 MARCH 1, 2016:991–1002
Conclusions
•
Transcatheter based therapies of acute PE is guided by understanding high
risk / massive, intermediate risk / submassive, and low risk PE.
•
•
•
Retrospective studies form the basis for current recommendations
regarding CDT.
Contemporary data and technology may suggest utilizing therapies beyond
anticoagulation.
In the absence of large, controlled studies, a team approach should be
utilized.
THANK YOU