Submassive PE

[Trifling Jester]

Normotensive patient. Signs of RV strain on echo. I know those studies are in progress, but in the meantime, what's the general trend at your facilities? Thrombolytics or no?

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[ORL10]

case by case basis.

If younger healthier less comorbidities they are getting thrombolysis at our shop. If older we tend to have a discussion.

Anyone using surgical thrombectomy for massive PE if they got a CT confirming the diagnosis?

 

[jdh71]

Normotensive patient. Signs of RV strain on echo. I know those studies are in progress, but in the meantime, what's the general trend at your facilities? Thrombolytics or no?

No thrombolytics.

 

[jdh71]

case by case basis.

If younger healthier less comorbidities they are getting thrombolysis at our shop. If older we tend to have a discussion.

Anyone using surgical thrombectomy for massive PE if they got a CT confirming the diagnosis?

lawl surgeons . . .

patients are either doing too well or too poorly to ever to the OR for PE

(and they probably have a point)

 

[souljah1]

Submassive PE doesn't get lytics where I train.

If you have hypotension or relative hypotension with a pancaked LV due to RV dilitation then you are getting lytics. In those patients who have submassive PEs, I've only seen very few move on to get lytics after a decision was made against their use.

We have a very active IR program who occasionally want to do catheter directed lytics, and we don't really move towards surgery except for the rare case where there's absolute contraindication to anticoagulation (though I've never pushed for it). I think both catheter directed lytics and surgical thrombectomies are overkill.

And, if someone does has a big ole RV failure with massive PE they are getting an Epi drip, milrinone, flolan, +/- vasopressin (no receptors on the pulmonary vasculature). Fun stuff..

 

[Hernandez]

Normotensive patient. Signs of RV strain on echo. I know those studies are in progress, but in the meantime, what's the general trend at your facilities? Thrombolytics or no?

I don't give lytics unless they decompensates. Anecdotally I've not had many decompensates even with signs of RV strain. So given the risk of tPa why? Published data for massive bleed has a risk of 6% but if you look at all bleeding complications it's over 20%. tPa isn't benign and won't improve outcomes.

 

[VentdependenT]

Controversial even for massive PE as lytics only reduce incidence of pulmonary htn. Same goes for greenfield filter placement after submassive/massive PE.

 

[Trifling Jester]

I don't give lytics unless they decompensates. Anecdotally I've not had many decompensates even with signs of RV strain. So given the risk of tPa why? Published data for massive bleed has a risk of 6% but if you look at all bleeding complications it's over 20%. tPa isn't benign and won't improve outcomes.

The thought behind it is that it might improve dyspnea down the road, not necessarily mortality. The studies are contradictory, but some have shown decreased dyspnea some months out. So, my understanding is that they are weighing the risk of bleeding against the benefit of less future dyspnea. This is the largest study to date: Chest. 2009;136:1202–1210. There is a study (TOPCOAT) undergoing to get better data.

The AHA/ACC guidelines give it a IIB recommendation, which is the weakest indication. The ICU service where I am tends to push for it very aggressively, which means that they're asking for a lot of stat echos to assess RV function. So, I was curious what they're doing at other places. Thanks for the responses.

case by case basis.

If younger healthier less comorbidities they are getting thrombolysis at our shop. If older we tend to have a discussion.

Anyone using surgical thrombectomy for massive PE if they got a CT confirming the diagnosis?

I have not seen it done at my facility. Have had discussion for patients to be sent to San Diego or Birmingham for a more chronic situation, but never came to fruition (our patients don't usually have funding). Have heard of, but not seen, angiojet to the PA for this, too.

 

[proman]

lawl surgeons . . .

patients are either doing too well or too poorly to ever to the OR for PE

(and they probably have a point)

Are you at an institution that is a referral center for pulmonary thromboendarectomy? I am, and our surgeons have a low threshold to go to the OR. The unstable patients get VA ECMO then the OR. We've had surprisingly good results but it takes a surgeon who is comfortable with the operation as it's extremely complex.

 

[jdh71]

Are you at an institution that is a referral center for pulmonary thromboendarectomy? I am, and our surgeons have a low threshold to go to the OR. The unstable patients get VA ECMO then the OR. We've had surprisingly good results but it takes a surgeon who is comfortable with the operation as it's extremely complex.

No, no referrals for thromboendarectomy, but we also don't have a mickey mouse surgical department either.

By "surprisingly good results" what do you mean?

 

[lord_jeebus]

Are you at an institution that is a referral center for pulmonary thromboendarectomy? I am, and our surgeons have a low threshold to go to the OR. The unstable patients get VA ECMO then the OR. We've had surprisingly good results but it takes a surgeon who is comfortable with the operation as it's extremely complex.

That's interesting. I'm at the Mecca of pulmonary thromboendarterectomy and it is almost unheard of for those surgeons to take an acute PE patient to the OR. Not sure why they are reluctant.

 

[proman]

No, no referrals for thromboendarectomy, but we also don't have a mickey mouse surgical department either.

By "surprisingly good results" what do you mean?

I'd guess about 50% make it out alive. I'll see if I can get the actual number. Without surgery though I think the mortality approaches 100%

That's interesting. I'm at the Mecca of pulmonary thromboendarterectomy and it is almost unheard of for those surgeons to take an acute PE patient to the OR. Not sure why they are reluctant.

Quick lit search was pretty revealing. A lot of places across the world report mortality in the <10% range which would make acute PTE a viable treatment.

 

[Hernandez]

Are you at an institution that is a referral center for pulmonary thromboendarectomy? I am, and our surgeons have a low threshold to go to the OR. The unstable patients get VA ECMO then the OR. We've had surprisingly good results but it takes a surgeon who is comfortable with the operation as it's extremely complex.

I've asked this question before, but how many massive PEs are y'all really seeing? I'm not at a tiny institute and we might give tPa once a month for a PE.

 

[proman]

I've asked this question before, but how many massive PEs are y'all really seeing? I'm not at a tiny institute and we might give tPa once a month for a PE.

Since I'm not on the medicine side, I don't know how many times tPA is given. An informal survey of my colleagues and we do 1-2 thrombectomies for acute PE a month. We do slightly more than that for chronic PE. The survival rate seems to be much better than 50%, closer to 75-80% for us. UCSD does tremendously more.

One surgeon I spoke with made a pretty strong argument for operating on the submassive PE population since a substantial portion develop chronic pulmonary hypertension and the long term survival in those patients is poor. These patients are typically very good surgical candidates.