inclusion of pulmonary embolism response in a level i

Download Inclusion of Pulmonary Embolism Response In a Level I of Pulmonary Embolism...Inclusion of Pulmonary Embolism Response ... 24/7/365 MD

Post on 06-Mar-2018




2 download

Embed Size (px)


  • 4/30/2016

    Charles B. Ross, M.D., F.A.C.S.

    Chief, Vascular and Endovascular Services

    Piedmont Heart Institute; Piedmont Atlanta Hospital

    Atlanta, Georgia

    Florida Vascular Society

    2016 Annual Meeting

    Orlando, Florida

    Inclusion of Pulmonary Embolism ResponseIn a

    Level I Vascular Emergency Program

  • FVS: PE 2016


    1. What is a Level I Vascular Emergency Program?How does PE fit in?

    2. Management of Pulmonary Embolism has changed. Whats the rationale?3. How do we intervene for PE? 4. Process and outcomes of PE management in the Piedmont Level I program

  • FVS: PE 2016


    Financial Conflicts: None

    Competition of Interest: Clinical Trial Participation

    OPTALYSE PE EKOS BTG Site Principal Investigator, Piedmont Heart Institute

    Potential Mention of Devices Not In Possession of Specific PE Indication/Off-label Use- Inari Flowtriever- 8F Penumbra Indigo System- Angiodynamics AngioVac

  • Piedmont HealthcarePiedmont Heart InstitutePiedmont Atlanta HospitalPiedmont Healthcare

    2015 Volume Indicators

    455 beds50,211 ED visits1157 CV pump cases1543 PCI cath cases

    116 TAVR43 VAD implants77 ECMO cases

    160 kidney transplants90 liver transplants12 heart transplants

    24/7/365 MD critical careEmory Gen Surg ResidentsMercer PA StudentsPA and Nursing Residents

  • slide 5

    Geographic Reach

    FY15 PHI Patient Origin (white to dark green 1- 3,000+ patients per zip code)

    Piedmont Healthcare and PHI in particular have broad geographic reach with advanced services focused at Piedmont Atlanta

    Affiliate Hospital Locations

    Piedmont Atlanta with Advanced Heart and Vascular Services Including SurgeryPiedmont & Affiliate Hospitals Piedmont Heart ClinicsPiedmont Primary Care ClinicsPiedmont Specialty ClinicsPiedmont Transplant Clinics

  • Level I Vascular Emergency ProgramA natural evolution in emergency cardiovascular care,d.eXY&psig=AFQjCNGxHgHX7kJh1hCimA27fsdPH0Br1A&ust=1414807439175988,d.eXY&psig=AFQjCNGxHgHX7kJh1hCimA27fsdPH0Br1A&ust=1414807439175988

  • FVS: PE 2016

    Level I Vascular Emergency Programs

    Level I Vascular Emergency Programs

    - Natural evolution in cardiovascular emergency care- vascular emergency care is process driven and time dependent- vascular emergency care is resource dependent

    - logistical expertise (CARELINK Call Center)- professional expertise, capability, availability- advanced imaging (CTA, MRA ,ECHO, Vasc Lab and Operating Hybrids)- rapid, precise diagnosis and management- extensive, redundant inventory requirement- critical care required 24/7/365

    - vascular emergency care may benefit from economy of scale

  • FVS: PE 2016

    Level I Vascular Emergency Programs

    - same logistics- similar processes of care- same physicians and teams- same care venues- same coordinator- same outreach and marketing

    Acute Aortic Syndromes Acute Limb Ischemia Catastrophic VTE

    Vascular Emergency Program

  • FVS: PE 2016

    Level I Vascular Emergency Programs

    Level I Vascular Emergency Programs

    Drs. Mark Davies and Alan Lumsden Methodist DeBakey, Houston, Texas- Acute Aortic Treatment Center- Door to intervention time of 90 minutes

    Dr. Michael Dalsing at Indiana University - Methodist Hospital in Indianapolis 2009- model statewide referral system for vascular emergencies- Tera Recon system for transfer of imaging data prior to patient arrival- extended the AATC concept to all vascular emergencies

    Piedmont Atlanta Hospital- program build-out: August 2012-June 2014- sites visits IU-Methodist; Mehta-Albany- program live July 2014- multidisciplinary- our program incorporates PE rapid response

    INNOVATIONCare plans and transfer protocols

    Remote image transmittalahead of the patientRapid definitive plan

  • Level I Vascular Emergency Program

    M.D. Groups Impacted by the Level I Program

    Cardiothoracic SurgeryVascular Surgery

    CV Anesthesiology

    CTS Critical Care

    GLA Critical Care

    Fuqua CV/Radiology Imaging

    PHI Cardiology Critical Care

    Emergency Department


    FVS: PE 2016

  • CTA-PE Protocol

    CTA Large Thrombus Burden PE

    Hemodynamically Unstable

    Massive PE

    Hemodynamically Stable

    Submassive PE

    Institute hemodynamic and respiratory


    Check BNP and troponin

    Evaluate echocardiogram

    LE Venous Duplex to identify source

    Immediate consultation through Carelink:

    Cardiothoracic Surgery

    Vascular Surgery

    Shock Team

    Vascular Surgery Consult



    to lytic therapy


    Consider IVC Filter



    Consider IVC Filter


    to lytic therapy

    Piedmont Healthcare Clinical PathwayAcute Venous Thromboembolism: Large Thrombus Burden PE Treatment Pathway

    (+) Right heart


    (-) Right heart



    Piedmont Heart Venous ProgramNovember 2013

    *Clinical pathways and guidelines are evidence-based tools that have been developed by a multidisciplinary team to assist clinicians in making appropriate health care decisions. They are not intended to replace individual clinicians judgment.

    GLA Pulmonary Critical Care Consult

    FVS: PE 2016

  • Level I Vascular Emergency Program

    Level I Activity: July 2014 March 2016

    PE- Contributes 33% of Level I volume

    Downstream intangibles.- Maintains vascular surgical leadership

    in major venous interventions- iliofemoral venous thrombosis- vena cava thrombosis- filter decision-making

    - Maintains high-profile vascular visibilityin the critical care units

    - Platform for collaboration

    FVS: PE 2016

  • FVS: PE 2016

    900,000 cases annually 7.9 39 billion dollars U.S. Healthcare Costs

    Incidence 133/100,000 people/yr increases with age

    PE - 3rd leading cause of cardiovascular mortalityLeading cause of preventable in-hospital death in the United States100,000 to 180,000 deaths/year 25-33% present as sudden death

    4 % incidence of CTPH

    DVT at least 350,000 cases annually 29 79% Post-thrombotic Syndrome- develops slowly- progressively debilitating- 6 to 7 million patients today- 400,000 500,000 venous ulcers

    All practicing physicians interface with patients with or at risk for VTE

    Venous Thromboembolism Scope of the problem

  • FVS: PE 2016

    Venous Thromboembolism Scope of the problem

    VTE PE- different population compared to traditional VS- unmet need for interventional care- incredibly rewarding

  • FVS: PE 2016

    Level I Vascular Emergency Programs

    PE and the evolution from relative noninterventional care to safe intervention

    its all about the RV

    its all about the RV

    its all about the RV

  • Pulmonary Embolism Pathophysiology

    Thrombus travels from legs to the right heart and lungs

    Acutely obstructs pulmonary arteriesIncreases PVR

    Right ventricular strain and failure

    Hypotension, HypoxemiaDecreased coronary artery


    Cardiac output/shock DEATH

    FVS: PE 2016

  • 1. Stratify Risk for Adverse Outcome- identify RV strain

    2. Relieve PA Obstruction- facilitate rapid RV recovery- Possibly prevent lat