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Catheter-directed thrombolytic therapy appropriate for PE treatment

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HOLLYWOOD, Fla. — Modern catheter-directed thrombolytic therapies are safe and effective for treating patients with acute massive or submassive pulmonary embolism, an expert said at the International Symposium on Endovascular Therapy.

Multiple trials have shown that catheter-directed thrombolytic therapies decrease mortality, morbidity, length of stay and hospital readmissions, Keith M. Sterling, MD, director of cardiovascular and interventional radiology, Inova Alexandria Hospital, Alexandria, Virginia, and associate professor of radiology at George Washington University School of Medicine, said during a presentation.

The goals of catheter-directed thrombolytic therapy in patients with acute massive or submassive PE are recovery of right vascular dysfunction, a decrease in pulmonary vascular resistance and pulmonary artery pressure, an increase in systemic arterial pressure, an improvement in symptoms and odds of survival and a decrease in risk for chronic thromboembolic pulmonary hypertension, he said.

He explained that there is a continuum of presentation for patients with acute massive and submassive PE and in choosing the best therapeutic option, physicians should consider a patient’s bleeding risk and the skills and equipment available at their institution.

IV thrombolysis alone has been shown to decrease mortality and improve quality of life, but there is a 13% risk for major bleeding and a 1.8% risk for intracranial hemorrhage in clinical trials, and a 20% risk for major bleeding and a 3% risk for intracranial hemorrhage in clinical practice, according to Sterling. Due to these risks, treatment with systemic thrombolysis is withheld in up to two-thirds of patients with high-risk PE, he said.

The best results with catheter-directed thrombolytic therapies are obtained when the catheter is properly placed to enable direct infusion of the lytic agent into the clot, because this allows for higher local concentration but lower overall dose of the therapy, he said.

The literature contains multiple trials utilizing ultrasound-accelerated catheter-directed thrombolysis to treat acute massive and submassive PE. “These studies have shown a consistent reversal of RV dysfunction and a decrease in pulmonary artery pressure and clot burden utilizing 20% to 25% of the typical systemic dose of tissue plasminogen activator,” he said. “In addition, the mean rate of major bleeding is just 2%, while there have been no reported cases of intracranial hemorrhage.”

It is not uncommon for patients to report feeling better as soon as 2 hours after the start of therapy, he said, noting that this prompted the OPTALYPSE-PE trial, which is looking at decreased doses and infusion times of tPA using catheter-directed thrombolysis.

Reviewing the literature, he reported that short-term mortality rates of patients treated with catheter-directed thrombolytic therapies have been around 2%, compared with risk-adjusted 6-month mortality rates of 20% in patients admitted to the hospital with acute massive or submassive PE.

Sterling said that while overall readmission rates for patients with PE are around 15%, one study of 45 patients treated with catheter-directed thrombolysis showed a 0% 30-day readmission rate. Also, another study found that patients treated with a catheter-based therapy had a shorter length of stay than those treated with anticoagulation (3.2 days vs. 6.7 days).

“We need longer-term data; a lot of quality-of-life outcome information is also needed,” Sterling said. “We want to look at head-to-head [comparisons of] catheter-directed thrombolytic therapies to other treatments, including catheter-based mechanical techniques, anticoagulation and possibly systemic thrombolytic regimens.” – by Erik Swain

Reference:

Sterling KM. Session V: New Horizons: Advances in Management of Pulmonary Embolus. Presented at: International Symposium on Endovascular Therapy; Feb. 6-10, 2016; Hollywood, Fla.

Disclosure: Sterling reports consulting for BTG/EKOS and Penumbra and receiving institutional research funding from BTG/EKOS.