Systemic thrombolytic and ultrasound-assisted catheter-directed thrombolysis for treatment of acute pulmonary embolism: a 7-year, multicenter experience.

Treatment of acute pulmonary embolism (PE) varies based upon risk stratification and ranges from outpatient oral anticoagulation to emergency surgical embolectomy. Patients with high-risk PE can be considered for systemic thrombolytic (ST) based upon guideline recommendations, but intermediate-risk PE does not currently have strong evidence to guide primary reperfusion strategies via thrombolytic administration. Ultrasound-assisted catheter-directed thrombolysis (USAT) is an alternative reperfusion option to ST but is not currently recommended as first line in any key guidelines due to limited available evidence. This retrospective, multicenter, observational study compares 210 patients treated with USAT (n = 105) or ST (n = 105) for acute high- or intermediate-risk PE in three hospitals. Baseline characteristics were significant in that severity of illness was higher in those that received ST, which limited comparisons of outcomes. The primary outcome of major bleeding in patients receiving USAT was 15.2% and 22.9% in those that received ST. Efficacy of reperfusion strategy was observed to be 86.7% of patients in USAT group and 65.7% in ST group. Reperfusion strategies had no difference in in-hospital death, intensive care length of stay, or hospital length of stay. Predefined subgroup analysis found that high-risk PE had higher mortality (14.7%) than intermediate-risk PE (0%) regardless of reperfusion strategy. Upon multivariate analysis, high-risk PE was the only independent risk factor for major bleeding while USAT therapy and intermediate-risk PE were independent predictors of efficacy. Due to the difference in baseline severity of illness, direct comparisons in primary outcomes to each group was not performed. We have described real world usage of both USAT and ST and which patients were likely to receive each therapy at these institutions.

Estratégia Fármaco-Invasiva no Infarto do Miocárdio: Análise Descritiva, Apresentação de Sintomas Isquêmicos e Preditores de Mortalidade / Pharmaco-invasive Strategy in Myocardial Infarction: Descriptive Analysis, Presentation of Ischemic Symptoms and Mortality Predictors

Resumo Fundamento O infarto do miocárdio com elevação do segmento-ST (IAMCSST) é definido por sintomas acompanhados por alterações típicas do eletrocardiograma. Entretanto, a caracterização dos sintomas isquêmicos não é clara, principalmente em subgrupos, como mulheres e idosos. Objetivos Analisar a tipificação dos sintomas isquêmicos, métricas temporais e observar a ocorrência de desfechos intra-hospitalares, em análise dos escores preditivos, em pacientes com IAMCSST, em estratégia fármaco-invasiva. Métodos Estudo envolvendo 2.290 pacientes. Tipos de apresentações clínicas pré-definidas: dor típica, dor atípica, dispnéia, sincope. Medimos o tempo entre o início dos sintomas à demanda pelo atendimento e o intervalo entre a chegada à unidade-médica e trombólise. Odds-ratios (OR; IC-95%) foram estimadas em modelo de regressão. Curvas ROCs foram construídas para preditores de mortalidade. Nível de significância adotado (alfa) foi de 5%. Resultados Mulheres apresentaram alta prevalência de sintomas atípicos; maior tempo entre o início dos sintomas e a procura por atendimento; atraso entre a chegada ao pronto-socorro e a fibrinólise. A mortalidade hospitalar foi de 5,6%. Predição de risco pela classificação Killip-Kimball: AUC: [0,77 (0,73-0,81)] em classe ≥II. Subgrupos estudados [OR (IC-95%)]: mulheres [2,06 (1,42-2,99); p=0,01]; insuficiência renal crônica [3,39 (2,13-5,42); p<0,001]; idosos [2,09 (1,37-3,19) p<0,001]; diabéticos [1,55 (1,04-2,29); p=0,02]; obesos 1,56 [(1,01-2,40); p=0,04]; acidente vascular cerebral prévio [2,01 (1,02-3,96); p=0,04] correlacionaram-se com maiores taxas de mortalidade. Conclusão Apesar das mais altas taxas de mortalidade em alguns subgrupos, disparidade significativa persiste nas mulheres, com atrasos no reconhecimento dos sintomas e trombólise imediata. Destaca-se a aplicabilidade do escore Killip-Kimball na predição, independentemente da apresentação clínica.

Abstract Background ST-segment elevation myocardial infarction (STEMI) is defined by symptoms accompanied by typical electrocardiogram changes. However, the characterization of ischemic symptoms is unclear, especially in subgroups such as women and the elderly. Objectives To analyze the typification of ischemic symptoms, temporal metrics and observe the occurrence of in-hospital outcomes, in the analysis of predictive scores, in patients with STEMI, in a drug-invasive strategy. Methods Study involving 2,290 patients. Types of predefined clinical presentations: typical pain, atypical pain, dyspnea, syncope. We measured the time between the onset of symptoms and demand for care and the interval between arrival at the medical unit and thrombolysis. Odds-ratios (OR; CI-95%) were estimated in a regression model. ROC curves were constructed for mortality predictors. The adopted significance level (alpha) was 5%. Results Women had a high prevalence of atypical symptoms; longer time between the onset of symptoms and seeking care; delay between arrival at the emergency room and fibrinolysis. Hospital mortality was 5.6%. Risk prediction by Killip-Kimball classification: AUC: [0.77 (0.73-0.81)] in class ≥II. Subgroups studied [OR (CI-95%)]: women [2.06 (1.42-2.99); p=0.01]; chronic renal failure [3.39 (2.13-5.42); p<0.001]; elderly [2.09 (1.37-3.19) p<0.001]; diabetics [1.55 (1.04-2.29); p=0.02]; obese 1.56 [(1.01-2.40); p=0.04]: previous stroke [2.01 (1.02-3.96); p=0.04] correlated with higher mortality rates. Conclusion Despite higher mortality rates in some subgroups, significant disparity persists in women, with delays in symptom recognition and prompt thrombolysis. We highlight the applicability of the Killip-Kimball score in prediction, regardless of the clinical presentation.

Chronic Inferior Vena Cava Filter Thrombosis: Endovascular Treatment and One-Year Follow-Up with Intravascular Ultrasonography.

Inferior vena cava (IVC) filter thrombosis can be fatal when it is not detected and treated. Its management can be challenging, because little evidence supports specific treatments. We present the case of a 72-year-old man with a history of deep vein thrombosis in whom IVC filter thrombosis developed 7 years after filter placement. Recanalization with oral anticoagulation had failed. Using intravascular ultrasonography, we performed pharmacomechanical thrombolysis, deploying 2 stents simultaneously through the IVC filter and then 2 more into the iliac veins, with excellent results. One year later, the patient's veins and IVC filter were patent, his symptoms were greatly improved, and only nonobstructive neointimal hyperplasia was seen. This case highlights the usefulness of balloon venoplasty and double-barrel stent placement in restoring blood flow through an occluded IVC, and the value of intravascular ultrasonography during and after such procedures.

Thrombolysis of plasmin-ΔK on photochemically induced branch retinal vein occlusion after intravitreal injection in rats / 中华实验眼科杂志

Background Retinal vein occlusion is a common retinal vascular diseases.Thromblysis and anticoagulation therapies are main approaches.However,systemic thrombolysis is relatively inefficient,and it often enhances the risk of hemorrhage.Objective This study was to investigate the therapeutic effects of PLM-ΔK,a kringle deficiency mutant of plasmin,on photochemically induced branch retinal vein occlusion (BRVO) after intravitreal injection.Methods BRVO models were established by the combination of caudal vein injection of Rose Bengal with argon laser radiation of periphery area of retinal veins in SD rats.Forty model rats were randomized into balance salt solution (BSS) group and 0.01 U,0.02 U,0.03 U PLM-ΔK group,and 10 μl corresponding drug was intravtreally injected 12 hours after modeling.Ophthalmoscopy and fundus fluorescein angiography (FFA) were performed to observe the change of retinal veins.The animals were sacrificed 3 days after intravitreal injection,and hematoxylin and eosin staining was used for the histopathological and ultrastructural examination of retinas.The retina of the rats was isolated for the stretched preparation of retina.The expressions of fibronectin (FN) and laminin (LN) in eyeball wall were assayed by immunofluorescence technology.The use and care of the animals complied with Statement of the Association for Research in Vision and Ophthalmology.Results The revascularization of over 2 retinal veins was found in 0,3,6 and 8 rats in the BBS group and 0.01 U,0.02 U,0.03 U PLM-ΔK group 3 days after intravitreal injection,respectively,showing a significant difference among the groups (x2=9.635,P =0.022),and the rat number with revascularization in 0.01 U PLM-ΔK group was not significantly different from that in BSS group (Z=-1.558,P =0.119),but the difference between 0.03 U PLM-ΔK group and 0.01 U PLM-ΔK group was significant (Z=-2.762,P=0.006).In the third day after intravitreal injection,retinal vein thrombus were found in the BSS group under the light microscope,and angiogenesis was seen on the retinal flatmount nuclear.In the 0.03 U PLM-ΔK group,posterior vitreal detachment was exhibited under the light microcope,and no retinal new vessel and cell damage were seen.FN was strongly expressed in the inner limiting membrane (ILM) layer,photocyte layer,outer limiting membrane (OLM) layer,choroid and scleral layer,and LN was expressed mainly in the ILM,OLM and scleral layer in the BSS group.However,the expression intensities of FN and LN were obviously weakened in the 0.03 U PLM-ΔK group.Conclusions Intravitreal injection of PLM-ΔK can enhance the reperfusion of occluded branch retinal vein and serve as a potential therapeutic drug for BRVO.Also it can permeate into choroid after intravitreal injection to degradate FN and LN.

Life-saving systemic thrombolysis in a patient with massive pulmonary embolism and a recent hemorrhagic cerebrovascular accident.

Massive pulmonary embolism is associated with mortality rates exceeding 50%. Current practice guidelines include the immediate administration of thrombolytic therapy in the absence of contraindications. However, thrombolysis for pulmonary embolism is said to be absolutely contraindicated in the presence of recent hemorrhagic stroke and other conditions. The current contraindications to thrombolytic therapy have been extrapolated from data on acute coronary syndrome and are not specific for venous thromboembolic disease. Some investigators have proposed that the current contraindications be viewed as relative, rather than absolute, in cases of high-risk pulmonary embolism. We present the case of a 60-year-old woman in whom massive pulmonary embolism led to cardiac arrest with pulseless electrical activity. Eight weeks earlier, she had sustained a hemorrhagic cerebrovascular accident-a classic absolute contraindication to thrombolytic therapy. Despite this practice guideline, we administered tissue plasminogen activator systemically in order to save the patient's life. This therapy did not evoke intracranial bleeding, and the patient was eventually discharged from the hospital. Until guidelines specific to venous thromboembolic disease are developed, we think that the current contraindications to thrombolysis should be considered on an individual basis in patients who are at high risk of death from massive pulmonary embolism.