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Update on Pulmonary Embolism Management Kenneth Rosenfield, MD, MHCDS Mass General Hospital Boston, MA... Why worry about Pulmonary Embolus?. Pathophysiology of Pulmonary Embolism Abra

Update on Pulmonary Embolism Management

Kenneth Rosenfield, MD, MHCDS

Mass General Hospital

Boston, MA

PE (and DVT): An international crisis!

long-term sequelae

mortality, and sequelae

Kearon C et al Chest 2008; 133: 454S-545S

“Treatment gap” in PE

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therapy”, including those with clear indications (hypotension, RV dysfunction, biomarkers, etc.)

integrate data in “real-time”

PULMONARY EMBOLISM Aggressive vs Conservative Rx?

• Numerous therapeutic options now available

…many quite effective

• Paucity of “organized” data regarding

outcomes and effectiveness

• Consequently, often make decisions or

operate in a “data-free” or “data-poor” zone

• Much of the data available are incomplete or

even misleading

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76 yo female with sickle cell

PE in 2005 after spinal surgery

3 wks PTA…colitis  Coumadin stopped

3 d PTA, acute onset SOB, lightheadness OSH ED: SBP 80/40, tachypneic @ 32

O2 sat 90% on non-rebreather

Case Vignette

‹#›

Mechanical Thrombo-aspiration: VORTEX AngioVac

TEE guided Thrombo-aspiration

Case Vignette: 54 year old man

pain

Will removal or lysis of thrombus make a

difference in his clinical course and outcome?

Why worry about Pulmonary Embolus?

in 10%

of cases

Pathophysiology of Pulmonary Embolism

Abrahams van-Doorn P and Hartmann IJC Imaging Insights 2011; 2: 705-715

Eur Heart J 2014 Nov 14;35(43):3033-69, 3069a-3069k

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Pulmonary Embolism Types

SUBMASSIVE

Normotensive + RV Strain

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Most Patients with PE do well, but some do not!

Becattini C, Agnelli G Predictors of mortality from pulmonary embolism and their influence on clinical management Thromb Haemost 2008; 100(5): 747–751 Abrahams van-Doorn P and Hartmann IJC Imaging Insights 2011; 2: 705-715 Dalen JE Chest 2002; 122: 1801-17

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– Direct Thrombin Inhibitors

Which therapy to use???

– No “standard approach”

– No “Appropriate Use Criteria” for intervention

– Practice variation by medical service, location, size and threat to patient, etc

– No standard algorithm or consistency in decision-making

– No single “team” or “clearing-house”

– No centralized locations for care or “centers of excellence”

– No systematic evaluation of results

How do we decide whether to “intervene” and by what

modality? Who decides? What is the endpoint?

ED / ICU / Floor Team Pulmonary Vascular Medicine/Cardiology

Cardiac Surgery

Pulmonary Embolism – previous paradigm

…Chaos

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Objectives

• Respond expeditiously to treat patients with massive and

submassive PE

• Provide best therapeutic option(s) available for each patient

• Leverage the input of a multidisciplinary team of experts

• Coordinate care among services involved in management of PE

• Develop protocols for the full range of therapies available

• Collect data on clinical presentation, treatment efficacy, and

outcomes (short and long-term)

…Fill unmet clinical need and provide evidence base to close gap in our knowledge base…

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Pulmonary Embolism Response Team (PERT)

Chest 2013;144:1738

PERT Program Flow Map

On Discharge: Multidisciplinary Follow-Up Clinic

Surgery

Vortex ECMO

Lytic Submassive

CDT Low Risk

Expeditious input and clinical judgment from

multiple specialties to optimize therapy

A/C

ACTIVATE PERT MULTIDISCIPLIARY

TEAM

Electronic Meeting Vascular Medicine Cardiac Surgery ICU/Pulmonary Hematology Emergency Medicine Rad, Echo

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Multidisciplinary Collaboration

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PERT

Vascular Medicine and Intervention Pulmonary/

Critical Care

Cardiac Surgery

Cardiac and Thoracic Imaging Nursing

Quality & Safety

Vascular Surgery Echocardiography

Cardiology

Hematology/

Oncology

Emergency Medicine

Physiological Benefits of Early Clot Removal (Thrombolysis or Extraction)

pressors and life-support

RV systolic function

perfusion

PIOPED Investigators Chest 1990; 97: 528-33

Levine M et al Chest 1990; 98(6): 1473-9

Dalla-Volta S et al JACC 1992 20(3): 520-6

Goldhaber SZ et al Lancet 1993; 341(8844): 517-11

Jaff MR et al Circulation 2011; 123: 1788-1830

Daniels LB AJC 1997; 80: 184-8

• Fewer in hospital complications from the PE (e.g pressor requirements, etc.)?

• Removal of threatening “clot in transit”

• Less clot to become “impacted” into distal

pulmonary arteries?

• Earlier discharge?

• Earlier return to functional baseline?

• Reduced incidence of CTEPH??

PEITHO: Advantage driven by reduced hemodynamic collapse

N Engl J Med 2014;370:1402-11

Numerous contraindications to thrombolysis

Davies et al, Ann Vasc Surg 2015

Direct Thrombus “Removal”

What are the options?

the device…central or proximal (or in

transit)

Kearon C et al Chest 2008; 133: 454S-545S

Bilateral Saddle PE with RV

compromise – candidate for CDT

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Surgical Embolectomy: Embolus in Transit

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Right atrium

Left PA

Right PA

PRE AND POST

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Courtesy of Jim Benenati

• assisted thrombectomy

Vacuum-33

‒ Median age: 62 yrs

IV Lysis CDT

Aspiration Thrombectomy ECMO

Surgery

“It will be necessary to elaborate on:

(i) whether reduced-dose intravenous thrombolysis is indeed safe and effective

(ii) whether catheter-directed treatment can evolve to become a widely available (and affordable)

g e r s

?

Will these change the paradigm completely?

How do we integrate these into existing treatments?

Underscores need for integrated, “PERT” approach to PE

…with multi-disciplinary decision-making

Deciding Optimal Therapy…

Game changers for PE Treatment?

PERTTM Consortium

History

2016 Map of Member Institutions

PERT Consortium - June 27, 2016 - Boston, MA