Management of Pulmonary
Embolism
Michael Hooper MD MSc
Associate Professor Pulmonary and Critical Care Medicine
Eastern Virginia Medical School
bull I have no conflicts of interest to report
VTE Overview
bull VTE introduction
bull How do we prevent this in
people at risk
bull How do we diagnosis this
bull How do we treat this
VTE Pathogenesis bull Virchowrsquos triad (stasis endothelial injury hypercoagulability)
bull Acute Death (for PE)
bull 10 sudden death
bull untreated -gt 20-30 mortality
bull (DVT) - Clot propogation Embolization 15
bull Recurrence
bull Post-phlebitic syndrome CTEPH
Epidemiology of venous thromboembolism John A Heit Nat Rev Cardiol 2015 Aug 12(8) 464ndash474
World J Gastrointest Oncol 2016 Mar 15 8(3) 258ndash270
Published online 2016 Mar 15 doi 104251wjgov8i3258
PMCID PMC4789611
Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review
Clinical Characteristics of Patients with Acute Pulmonary Embolism Data from PIOPED II
PE Diagnostic Approach
SymptomsHistoryExam
high pre-test low pre-test
no suspicion
Quant D Dimer negative NO
treatment
NO
treatment
consider PVLs
positive
Anticoagulation
negative or
not done
CTA
chest (or
VQ
negative
positive Assess
Hemodynamics
and consider
other therapy
positive
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
bull I have no conflicts of interest to report
VTE Overview
bull VTE introduction
bull How do we prevent this in
people at risk
bull How do we diagnosis this
bull How do we treat this
VTE Pathogenesis bull Virchowrsquos triad (stasis endothelial injury hypercoagulability)
bull Acute Death (for PE)
bull 10 sudden death
bull untreated -gt 20-30 mortality
bull (DVT) - Clot propogation Embolization 15
bull Recurrence
bull Post-phlebitic syndrome CTEPH
Epidemiology of venous thromboembolism John A Heit Nat Rev Cardiol 2015 Aug 12(8) 464ndash474
World J Gastrointest Oncol 2016 Mar 15 8(3) 258ndash270
Published online 2016 Mar 15 doi 104251wjgov8i3258
PMCID PMC4789611
Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review
Clinical Characteristics of Patients with Acute Pulmonary Embolism Data from PIOPED II
PE Diagnostic Approach
SymptomsHistoryExam
high pre-test low pre-test
no suspicion
Quant D Dimer negative NO
treatment
NO
treatment
consider PVLs
positive
Anticoagulation
negative or
not done
CTA
chest (or
VQ
negative
positive Assess
Hemodynamics
and consider
other therapy
positive
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
VTE Overview
bull VTE introduction
bull How do we prevent this in
people at risk
bull How do we diagnosis this
bull How do we treat this
VTE Pathogenesis bull Virchowrsquos triad (stasis endothelial injury hypercoagulability)
bull Acute Death (for PE)
bull 10 sudden death
bull untreated -gt 20-30 mortality
bull (DVT) - Clot propogation Embolization 15
bull Recurrence
bull Post-phlebitic syndrome CTEPH
Epidemiology of venous thromboembolism John A Heit Nat Rev Cardiol 2015 Aug 12(8) 464ndash474
World J Gastrointest Oncol 2016 Mar 15 8(3) 258ndash270
Published online 2016 Mar 15 doi 104251wjgov8i3258
PMCID PMC4789611
Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review
Clinical Characteristics of Patients with Acute Pulmonary Embolism Data from PIOPED II
PE Diagnostic Approach
SymptomsHistoryExam
high pre-test low pre-test
no suspicion
Quant D Dimer negative NO
treatment
NO
treatment
consider PVLs
positive
Anticoagulation
negative or
not done
CTA
chest (or
VQ
negative
positive Assess
Hemodynamics
and consider
other therapy
positive
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
VTE Pathogenesis bull Virchowrsquos triad (stasis endothelial injury hypercoagulability)
bull Acute Death (for PE)
bull 10 sudden death
bull untreated -gt 20-30 mortality
bull (DVT) - Clot propogation Embolization 15
bull Recurrence
bull Post-phlebitic syndrome CTEPH
Epidemiology of venous thromboembolism John A Heit Nat Rev Cardiol 2015 Aug 12(8) 464ndash474
World J Gastrointest Oncol 2016 Mar 15 8(3) 258ndash270
Published online 2016 Mar 15 doi 104251wjgov8i3258
PMCID PMC4789611
Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review
Clinical Characteristics of Patients with Acute Pulmonary Embolism Data from PIOPED II
PE Diagnostic Approach
SymptomsHistoryExam
high pre-test low pre-test
no suspicion
Quant D Dimer negative NO
treatment
NO
treatment
consider PVLs
positive
Anticoagulation
negative or
not done
CTA
chest (or
VQ
negative
positive Assess
Hemodynamics
and consider
other therapy
positive
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Epidemiology of venous thromboembolism John A Heit Nat Rev Cardiol 2015 Aug 12(8) 464ndash474
World J Gastrointest Oncol 2016 Mar 15 8(3) 258ndash270
Published online 2016 Mar 15 doi 104251wjgov8i3258
PMCID PMC4789611
Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review
Clinical Characteristics of Patients with Acute Pulmonary Embolism Data from PIOPED II
PE Diagnostic Approach
SymptomsHistoryExam
high pre-test low pre-test
no suspicion
Quant D Dimer negative NO
treatment
NO
treatment
consider PVLs
positive
Anticoagulation
negative or
not done
CTA
chest (or
VQ
negative
positive Assess
Hemodynamics
and consider
other therapy
positive
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
World J Gastrointest Oncol 2016 Mar 15 8(3) 258ndash270
Published online 2016 Mar 15 doi 104251wjgov8i3258
PMCID PMC4789611
Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review
Clinical Characteristics of Patients with Acute Pulmonary Embolism Data from PIOPED II
PE Diagnostic Approach
SymptomsHistoryExam
high pre-test low pre-test
no suspicion
Quant D Dimer negative NO
treatment
NO
treatment
consider PVLs
positive
Anticoagulation
negative or
not done
CTA
chest (or
VQ
negative
positive Assess
Hemodynamics
and consider
other therapy
positive
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Clinical Characteristics of Patients with Acute Pulmonary Embolism Data from PIOPED II
PE Diagnostic Approach
SymptomsHistoryExam
high pre-test low pre-test
no suspicion
Quant D Dimer negative NO
treatment
NO
treatment
consider PVLs
positive
Anticoagulation
negative or
not done
CTA
chest (or
VQ
negative
positive Assess
Hemodynamics
and consider
other therapy
positive
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
PE Diagnostic Approach
SymptomsHistoryExam
high pre-test low pre-test
no suspicion
Quant D Dimer negative NO
treatment
NO
treatment
consider PVLs
positive
Anticoagulation
negative or
not done
CTA
chest (or
VQ
negative
positive Assess
Hemodynamics
and consider
other therapy
positive
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk
how long
which agent(s)
monitor
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
IVC Filter
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
IVC Filter
Effect of a Retrievable Inferior Vena Cava Filter Plus Anticoagulation vs
Anticoagulation Alone on Risk of Recurrent Pulmonary Embolism A
Randomized Clinical Trial
Patrick Mismetti MD PhD123 Silvy Laporte MS PhD23 Olivier Pellerin MD MSc45
Pierre-Vladimir Ennezat MD PhD6 Francis Couturaud MD PhD7 Antoine Elias MD
PhD8 Nicolas Falvo MD9 Nicolas Meneveau MD PhD10 Isabelle Quere MD PhD11
Pierre-Marie Roy MD PhD1213 Olivier Sanchez MD PhD14 Jeannot Schmidt MD
PhD1516 Christophe Seinturier MD17 Marie-Antoinette Sevestre MD18 Jean-
Paul Beregi MD PhD19 Bernard Tardy MD PhD2021 Philippe Lacroix MD22
Emilie Presles MSc3 Alain Leizorovicz MD23 Herveacute Decousus MD24 Fabrice-
Guy Barral MD2526 Guy Meyer MD13 for the PREPIC2 Study Group
[+] Author Affiliations
JAMA 2015313(16)1627-1635 doi101001jama20153780
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
IVC Filter
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
IVC Filter
bull Consider if you cannot anticoagulate
Severe bleeding diathesis
Platelet count lt50000microL
Recent planned or emergent surgeryprocedure
Major trauma
Active bleeding
History of intracranial hemorrhage
Intracranial or spinal tumors
Large abdominal aortic aneurysm with concurrent severe hypertension
Stable aortic dissection
PE or Proximal DVT - IVC Filter Now
Distal DVT - consider serial US
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Anticoagulation
bull If high suspicion of PE in a sick patient
anticoagulate while figuring it out
bull For lobar or gt PEs all patients who can be anti-
coagulated should be
bull If hemodynamically stable (no RV strain) and no
clot in transition then anticoagulation alone is
sufficient
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
PE - stable 55
Massive 5
Submassive
40
PE with stable hemodynamics
Good Prognosis
PE with shock
Mortality gt 50
PE normal BP RV strain
Increased mortality morbidity
Jaff et al Circulation 2011123(16)1788-1830 Goldhaber et al Lancet 1999353(9162)1386-9 Quiroz et al Circulation (2004)1092401-2404 Freacutemont Chest 2008 133558-362 Schoef Circ 2004 1103276-3280 Kucher Arch Intern Med 2005 1651777-1781
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Should we treat Submassive PE
differently
bull RVLV ratio gt 09 is an independent risk factor for
mortality
bull Persistent RV dysfunction at dc
bull 8 fold risk of recurrent symptomatic PE
bull 4 fold risk of mortality
Quiroz Circ 2004 1092401-2404 Freacutemont Chest 2008 133558-362
Schoef Circ 2004 1103276-3280
Kucher Arch Intern Med 2005 1651777-1781
Grifoni Arch Intern Med 2006 Oct 23166(19)2151-6
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Systemic Thrombolysis bull Obstructive Shock is a widely accepted indication for systemic
thrombolysis (ACCP Guidelines)
bull Has been proposed for
bull RV dysfunction
bull Respiratory Failure
bull Extensive Clot Burden
bull RA or RV thrombus
bull Patent Foramen Ovale
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
PEITHO bull Not in shock
bull AND RV dysfunction RV ED diameter gt 30mm RL
ED diameter gt 09 RV hypokinesis Tricuspid Sys
Velocity gt 26 ms
bull AND positive troponin (trop T gt 001)
bull Tenectoplase 30 to 50mg vs placebo
bull 7 day composite outcome of hemodynamic
compromise or death
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Thrombolytics
bull Accepted as therapy in massive PE with shock
bull 12 systemic dose tPA appears to have similar
efficacy
bull higher bleeding rates may result from TNKase
andor elevated PTTs in setting of thrombolytic use
bull Patient selection is critical
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Catheter Directed Thrombolysis
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
SWAN
EKOS EKOS
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
PA Systolic 76
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
PA Systolic 34
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
POD 1
bull TPA administered at 1mghrcatheter
bull Low dose heparin in each sheath
bull Swan PA pressures monitored until resolution of PA
hypertension
bull Fibrinogen PTT CBC and hemodynamics
monitored for signssymptoms of bleeding
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Ultima Trial
bull Low dose (lt20mg tpa)
bull Multicenter randomized controlled trial
bull Ultrasound assisted catheter-directed thrombolysis
bull Acute symptomatic PE confirmed by CT
bull RVLV ratio gt1 on echo (normal is 06)
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Catheter Directed Thrombolysis
bull Superior hemodynamic response versus
anticoagulation alone
bull Significantly lower dose of TPA (15mg to 40mg versus
50mg-100mg) over a longer period of time (12 hours
versus 2 hours)
bull Potential for lower risk of adverse events and improved
efficacy
bull Based on safety data and theoretical benefit may see
this performed more frequently at capable centers
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
PE Acute Therapeutic Approach
filter
stable
RV dys
dying
surgicalmech
thrombectomy
Anticoagulation
Anticoagulation +
CDT
Anticoag
+Systemic
Thrombolysis
elevated bleeding risk monitor
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
Summary
bull Anticoagulation alone in most cases NOACs are
preferred in many cases
bull Lytics appear to have a role in submassivemassive
PE Patient selection is critical The agent dose
mode of delivery and overall anticoagulation
protocol may influence patient outcomes
