pulmonary embolic disease: diagnosis and treatment - web.duke.edu
TRANSCRIPT
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Pulmonary Embolic
Disease:
Caval Filtration and
Other Stuff
Tony P. Smith, M.D.
October 2, 2009
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Controversies in Treatment of Acute Pulmonary Embolic Disease
Scope of the problem
Transcatheter therapy
Inferior vena caval filters
Superior vena caval filters
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Pulmonary Embolism
scope of the problem
• 650,000 patients annually in the U.S.
• Up to 150,000 deaths
• 15% of all in hospital deaths
Where do these numbers come from?
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primary or secondary discharge diagnosis of PE
↑ 126,546 to 229,637 (↑45%)
Nationwide Inpatient Sample
8-year period 1998 and 2005
hospital case-fatality rates
↓ 12.3% to 8.2% (p < 0.001)
length of hospital stay
↓ 9.4 days to 8.6 days (p < 0.001)
total hospital charges
↑ $25,293 to $43,740 (p < 0.001)
health care expenditures related to VTE and PE
> $1.5 billion annually
Chest. Jun 2009
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57 yo male admitted for craniotomy for tumor
On day of surgery filter placed for isolated
peroneal vein thrombus by sonography
D/C 2 days later on LMWH after successful tumor resection
Returned to ED 1 day later with LLE seizure-like activity
While in ED became acutely SOB, poor ABGs,
coded and died
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“Despite having an IVC filter,
our suspicion is that he had a massive saddle embolus”
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PIOPED (I)
Evaluate nuclear scintigraphy for acute PE
Low probability for PE
High probability for PE
Intermediate probability for PE
≤19% (12%)
≥80% (87%)
20-79% (35%)
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Pulmonary EmbolismComputed Tomography
Direct visualization of thrombus
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N Engl J Med June 2006
“The predictive value of either CTA or CTA-CTV
is high with a concordant clinical assessment,
but additional testing is necessary when the
clinical probability is inconsistent
with the imaging results”
PIOPED II
Evaluate multidetector CT for acute PE
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Patients do die from acute pulmonary
embolism but it’s relatively rare
Mechanism is still unknown in many
…if not most
It is probably right heart strain
those are the ones that come to IR
We do know….
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45-year-old male recently diagnosed non-small-cell lung cancer and
lower extremity DVT
Presented to ED with pleuric chest pain and extreme SOB. On warfarin.
87% saturation despite 02.
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Chest CT (below) → massive pulmonary embolism right > left
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The patient was started on heparin,
but began to have increased symptoms
Cardiac echo → right heart strain with increased
pressures
pericardial effusion → no tamponade
Head CT → negative, no mets
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Right pre and post
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Left pre and post
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Pulmonary Embolism
Thrombolytic Therapy
Intravenous administration Intra-arterial administration
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“We cannot conclude whether thrombolytic therapy
is better than heparin for pulmonary embolism based
on the limited evidence found.”
“More double-blind RCTs, with subgroup analysis of
patients presenting with hemodynamically
stable acute pulmonary embolism compared to
those patients with a hemodynamic unstable condition,
are required.”
Cochrane Database Syst Rev. 2006
Contoversy exists for thrombolytic therapy at all
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Pulmonary Embolism
Thrombolytic Therapy
Intravenous Administration
Pre-thrombolysis Post-thrombolysis
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Pulmonary Embolism
Catheter Directed Thrombolytic Therapy
One controlled trial of intravenous
versus intra-arterial pharmacological
thrombolysis using rtPA:
• Small patient numbers (n=34)
19 IA
15 IV
• No significant advantage
to the intra-arterial route
Verstraete et al. Circulation 1988; 77:353
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Pulmonary Embolism
Catheter Directed Thrombolytic Therapy
Only case studies and small series mechanical devices
No randomized controlled trials
• Early results are promising
Mostly limited to patients with
hemodynamic compromise
contraindications to IV thrombolytics
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Pulmonary Embolism
Catheter Directed Thrombolytic Therapy
Pharmacologic
tPA
reteplase
Mechanical
rotating pigtail catheter
Angiojet® Rheolytic System
Intraarterial
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25 patients
Hemodynamic impariment
Rotating pigtail catheter +
Fibrinolysis +
Transcatheter thrombus aspiration
Significantly decreased pulmonary artery pressures
No mention of effect on survival
Nakazawa et al. Br J Radiol. 2008; 81:848
Catheter fragmentation of acute PE
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51 patients
Single center
Treated with AngioJet®
Technical success = 92.2%
Significant improvement in obstruction,
perfusion and Miller indexes (all P < 0.0001)
4 (8%) patients → major bleeding
8 (16%) patients → died in-hospital
Chechi et al. Catheter Cardiovasc Interv. 2009;73:506-13.
Pulmonary Embolism
Rheolytic thrombectomy
Bradycardia
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Thrombolysis/Thrombectomypre
post
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Acute pulmonary embolism: a current surgical approach.
March 1995 to December 2005,
21 patients underwent pulmonary embolectomy
Group A
14 patients → massive PE w/ cardiogenic shock
Group B
7 patients → sub-massive PE/hemodynam stable w/ RV
dysfunction
Group A: 43% survived → d/c from the hospital.
Group B: 100% survived → d/c from the hospital.
Digonnet et al. Interact Cardiovasc Thorac Surg.
2007;6:27-9.
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Why does one place an
inferior vena cava filter?
Prevent pulmonary embolism
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John Hunter
femoral vein ligation 1700’s
IVC ligation prevent pelvic emboli
circa 1940
Open IVC ligation
mortality 14%
venous stasis 33%
Open IVC clipping/suturing
mortality 12%
venous stasis 33%
History
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Caval ligation 1960s
Can’t do a filter talk without a slide showing cava clipping
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Introduced 1967
Mobin-Uddin umbrella
IVC thrombosis rate ≈ 60%
Edwards Laboratories
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1st reported
percutaneous placement 1984
24 F Introducer
≈41% rate of CFV thrombosis
AJR 1987; 149:1065-1066
Greenfield filter
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Greenfield® (Boston Scientific Corp)
Stainless Steel
12 F, 24 F
Titanium
Once the percutaneous route…
more were placed
smaller introducer
Titanium Greenfield® Filter (1991)
Over-the-Wire Stainless Steel Greenfield® Filter (1995)
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Permanent Inferior Vena Cava Filters
5 in United States
Greenfield SS / Titanium
Vena Tech ™
Bird’s Nest®
Simon Nitinol®
TrapEase®
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IVC Filters
Simon Nitinol™
(C.R. Bard)
Nitinol Medical Technologies 1990
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IVC
FiltersVena Tech™
B Braun
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Bird’s Nest®
Cook, Inc.
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IVC Filters TrapEase™
(Cordis Endovascular)
August 2000
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We have a bunch of filters but…
Do they work?
Do they hurt anybody?
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A clinical trial of vena caval filters in the
prevention of pulmonary embolism
in patients with proximal deep-vein thrombosis
PREPIC Study Group
N Engl J Med 1998; 338:409-416
400 patients with proximal DVT
randomly assigned
• vena caval filter (200 patients)
• no filter (200 patients)
all pts were anticoagulated
(unfract heparin 205, LMWH 195)
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12 days
Symptomatic and non-symptomatic PE
filter group 2 pts
non-filter group 9 pts
(1.1% vs 4.8%, p=0.03)
N Engl J Med 1998; 338:409-416
PREPIC Study Group
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2 yearsDVT
Filter group 37 pts
Non-filter group 21 pts
(20.8% vs 11.6% p=0.02)
Mortality
Filter group 43 pts
Non-filter group 40 pts
(21.6% vs 20.1%, p=NS)
Follow up
Visits @ 3 mo, 1 yr
Telephone 2 yrs
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Eight-Year Follow-Up
of Patients With Permanent Vena Cava Filters
in the Prevention of Pulmonary Embolism
Original 400 pts
follow up 396 patients (99%)
1X/year for 8 years by telephone
Circulation 2005; 112:416-422
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Symptomatic PE
9 patients in the filter group
24 patients in the no-filter group
(p=0.008)
DVT
57 patients in the filter group
41 patients in the no-filter group
(p=0.042)
Postthrombotic syndrome (70.3% vs 69.7%)
Mortality
103 patients in the filter group
98 patients in the no-filter group
(p=NS)
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At 8 years, vena cava filters reduced
the risk of pulmonary embolism
but increased that of deep-vein
thrombosis and had no effect
on survival.
Although their use may be
beneficial in patients at high risk of
pulmonary embolism,
systematic use in the
general population with
venous thromboembolism
is not recommended.
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IVC filters: Cochrane analysis, 2009
11 studies, 1 randomized trial
No firm conclusions regarding filter efficacy in the prevention of
pulmonary embolism can be drawn from the PREPIC study.
The group of people who received filters in the study varied
significantly....notably those patients with DVT or PE and in
whom anticoagulation has failed or cannot be administered.
The PREPIC study used permanent filters.
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The PREPIC study also lacked statistical power to detect a
reduction in the incidence of pulmonary embolism over
shorter and more clinically significant time periods.
The failure of the PREPIC study to demonstrate a survival
advantage was due to its older study population (mean age
73 years) with multiple other co-morbidities; only 7 deaths
from PE
The PREPIC study did show an increasing incidence of
DVT that correlated to the length of time the filter was in
situ.
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Advantages of Retrievable Filters
Offer all the benefits of
permanent filters without
the long-term venous
thrombotic complications
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• Optional filters
• retrievable
• convertible
• Temporary filters (tethered)
Permanent versus Non-permanent Filters
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Retrievable Filters
5 in United States
Günther-Tulip™/Celect™
OptEase®
Recovery® /G2® /G2 ® X
ALN
Option™
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Retrievable filters
• Never sure if you’ll have to remove it
• Works as well as permanent ones
• Cost greater
• Eliminate the one with the “most” data…Greenfield
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Günther Tulip™
Celect™Contraindications for removal
thrombus >25% of cone
pts high risk for PE
Cook Inc.
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Retrospective review of clinical data of
73 patients (22-89 years)
August 2007 and June 2008
66% thrombus (legs/lungs/both)
34% prophylactic
3 pts symptoms of PE
2 (2.7%) diagnosed PE by imaging
Follow-up abdominal CT
18 patients and demonstrated filter-related
problems in 7 (10%/39%) (caval
perforation/fracture)
Celect IVC filter
J Vasc Intervent Radiol Sept 2009
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OptEase® Cordis Endovascular
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G2® Bard Peripheral Vascular
G2®X
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G2® Bard Peripheral Vascular
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ALN optional filterALN implants chirurgicaux
Surgimed solutions
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ALN optional filter
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Option™ Vena Cava Filter
Angiotech
FDA clearance June 2009
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52-year-old gentleman who had an
infected right total knee replacement
Surgery included a right leg free fibular flap
Chemically paralyzed postoperatively
to promote graft success
Triple lumen catheter inadvertently
placed in the right carotid artery post-op
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Paralytic d/c 1.5 days later → hemiparetic L side.
Head CT scan → R MCA stroke → craniectomy
Postoperatively developed extensive DVT
within the R upper extremity
- non-occlusive thrombus RIJ
- no thrombus LEs
Started acutely on heparin
Team requests superior vena cava filter
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Indications for superior vena caval filtration
Questions?
upper extemity DVT the same as lower?
retrievable filters change anything?
unknowns
Same as for IVC filtration?
• Contraindication to anticoagulation
• Progression of DVT or PE despite
adequate anticoagulation
• Massive pulmonary clot burden
• Failure existing filter
• Prophylactic
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Pathophysiology of UE DVT is quite different
from that of LE DVT
UE disease may be more likely to be due to local,
anatomic or mechanical factors than LE disease
The natural history of UE thrombosis and risk of
embolization are still matters of debate
Spyropoulos AC. J Thromb Haemost. 2009; 7:1041-2
Risks of upper extremity DVT?
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154 pts → SVC filter placement
Retrospective analysis
Jan 1994-Aug 2005
TrapEase™ 38 (25%)
Greenfield® 116 (75%)
3 cases (1.9%) of pericardial tamponade
Vascular 2009;17:44-50
1 misplacement into R brachiocephalic vein
No known cases of symptomatic PE, caval occlusion,
pneumothorax, or filter migration.
Concluded: data reaffirmed the
safety and effectiveness of SVC filter placement.
Usoh et al. Ann Vasc Surg 2009; 23: 350-354
SVC filter placement
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Does retrieval change the game?
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Retrieval ≈ 2 months