Massive PE management

  • A Cochrane review from last month concluded that there is some evidence that thrombolytics improve hemodynamics, TTE findings, and survival time, the data we have overall is heterogenous and of varying quality. The reviewers concluded it is uncertain whether the benefits clearly outweigh the risks, as TPA improves outcomes but is associated with significant major bleeding risk.
    • Contraindications to TPA include:
      • Intracranial neoplasm, recent (<2 months) CNS or spinal surgery or trauma, history of hemorrhagic stroke, active bleeding. Relative contradindications include SBP>200 DBP >110, ischemia CVA within 3 months, surgery in previous 10 days, pregnancy, and several other very specific situations.
    • Catheter-directed interventions (CDI) remain controversial, since most techniques are not FDA approved and have no standard algorithm to use for large RCTs yet.
      • In a review of 35 studies on CDI for massive PE, survival ranged from 40-100%, and success was higher if local thrombolytics were given rather than just aspiration of clot. The major complication risk of 8% was lower than for systemic thrombolytics.
    • Only about 10-30% of patients who have an IVC filter placed have them retrieved at some point, mainly because they are never scheduled for removal or are lost to follow up
    • Current literature supports IVC filter placement in PE patients with anti-coag contraindications. However, placement of prophylactic IVC filters (in those at high risk for DVT but no known DVT) in those who can be anti-coagulated has not been shown to have any effect on mortality and is associated with increased DVT risk

Gyang E, Zayed M, Harris EJ, et al. Factors impacting follow-up care after placement of temporary inferior vena cava filters. J Vasc Surg 2013; 58:440.

Haut ER, Garcia LJ, Shihab HM, et al. The effectiveness of prophylactic inferior vena cava filters in trauma patients: a systematic review and meta-analysis. JAMA Surg 2014; 149:194.

Hao Q, et al. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev. 2015 Sep 30;9:CD004437.

W.T. Kuo, M.K. Gould, J.D. Louie, J.K. Rosenberg, D.Y. Sze, L.V. Hofmann. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol, 20 (2009), pp. 1431–1440

American College of Chest Physicians. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S.


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