William Tom Kuo MD, Presenter: Nothing to Disclose

1) Recognize the role of modern catheter-directed therapy (CDT) for massive PE. 2) Understand expert recommendations for PE thrombolysis. 3) Identify the potential complications from CDT and how they might be avoided. 4) Appreciate limitations of existing data and the need for further prospective studies.

PURPOSE Systemic thrombolysis for treatment of acute pulmonary embolism (PE) carries a 20% risk of major hemorrhage including a 3-5% risk of hemorrhagic stroke [1] [2]. We used evidence-based methods to evaluate the safety and efficacy of modern catheter-directed therapy (CDT) as an alternative treatment for massive PE. MATERIALS AND METHODS The systematic review was initiated by electronic literature searches (MEDLINE, EMBASE) from January 1990 through September 2008. Inclusion criteria were applied to select patients with acute massive PE treated with modern CDT. Modern techniques were defined as the use of low-profile devices (≤ 10-French), mechanical fragmentation and/or aspiration of emboli including rheolytic thrombectomy, and intra-clot thrombolytic injection if local drug was infused. Relevant non-English language manuscripts were translated into English. Paired reviewers assessed study quality and abstracted data. Meta-analysis was performed using random effects models to calculate pooled estimates for complications and clinical success rates across studies. Clinical success was defined as stabilization of hemodynamics, resolution of hypoxia, and survival to hospital discharge. RESULTS 594 patients from 35 studies (6 prospective, 29 retrospective) met criteria for inclusion. The pooled clinical success rate from CDT was 86.5% (95% CI, 82.1%-90.2%). Pooled risks of minor and major procedural complications were 7.9% (95% CI, 5.0%-11.3%) and 2.4% (95% CI, 1.9%-4.3%), respectively. Approximately 96% (546/571) were treated with CDT as the first adjunct to heparin without prior intravenous thrombolysis. CONCLUSION Modern CDT is a relatively safe and effective treatment for acute massive pulmonary embolism. At experienced centers, CDT should be considered as first-line treatment for patients with massive PE.

Kuo, W, Pulmonary Embolus: Endovascular Treatment.  Radiological Society of North America 2009 Scientific Assembly and Annual Meeting, November 29 - December 4, 2009 ,Chicago IL. http://archive.rsna.org/2009/8001310.html