Acute Management of Pulmonary Embolism Dr Alex West Respiratory Consultant Guy’s and St Thomas’ Hospital London
Acute Management of
Pulmonary Embolism
Dr Alex West
Respiratory Consultant
Guy’s and St Thomas’ Hospital
London
Declarations - none
Order of Play
• Up date in Diagnostic Imaging
- CTPA and V:Q SPECT
• Sub-massive PE
- How to assess
- Pragmatic approach to decision thrombolysis
- Catheter directed thrombolysis
Up date in Diagnostic Imaging
Get the diagnosis right at the
start…
Standard V/Q scan
• Planar images
• Camera is stationary over the patient
• Acquires an image from this one angle,
like an x-ray
Planar image
SPECT
• Single Photon Emission Computed
Tomography
• Camera rotates around the patient, gets
images from a variety of angles
• Can then reconstruct 3-dimensional view
SPECT – how it works
• Camera head rotates around patient
Normal SPECT image
PERF
PERF
PERF
VENT
VENT
VENT
A
X
I
A
L
C
O
R
O
N
S
A
G
I
T
Abnormal
PERF
PERF
PERF
VENT
VENT
VENT
False positives?
False positives
Consolidation
Dose of Radiation
• Worst case scenario:-
• Perfusion (technetium): 2.2mSv
• Ventilation (krypton): 0.29mSv
• Ventilation (technetium): 1mSv
• 1mSv: 1 in 20,000 chance of fatal cancer
• 1 year in London: 2 mSv
• 1 year in Cornwall: 8 mSv
CTPA… Plus
• New Scanners – dual tubes & “voltages”
• Can detect specific – eg calcium, iodine
• Measure volume of iodine per pixel –
shown in colour
• Dose of radiation same or even less….
• Need less contrast (eg renal failure)
Iodine map= perfusion map
- marked decreased perfusion in
left lung
Dual energy CTPA- CTPA image
only- left pulm art filling defect
Fused iodine and CT
Virtual non-contrast CT- allows us
to remove iodine and we can
therefore see if an intravascular
mass virtually “enhances”
Definitions of PE
Massive PE
• SBP < 90 mmHg or drop of >40 mmHg
• >15 mins
• with no other cause
• Up to 5-10% of patients
• Mortality – high (15-58%)
Massive PE - Treatment
• Resuscitation
• “Full Dose” systemic thrombolysis
• tPA – 10mg bolus, 90mg / 2 hours
• Risk of major bleeding (6-20%)
• Intracranial Haemorrhage (2-6%)
• ….But outweighs risk of death from PE
Sub-massive PE
• Not hypotensive but…
• Evidence of right heart dysfunction
• Evidence of myocardial injury
– elevated Troponin , BNP
• Confirmed large clot burden – CTPA (V:Q)
• Mortality or “Adverse Events” 3-25%?
So why not thrombolyse too?
(Excellent Pro/Con Debate at this meeting 2 years ago… Overwhelming NO!)
And Thorax Pro/Con Debate
So why not thrombolyse too?
(Excellent Pro/Con Debate at this meeting 2 years ago… Overwhelming NO!)
And Thorax Pro/Con Debate
“Adverse Events” from
Sub-Massive PE
American Guidelines – Chest 2016
• Sub-massive PE
*23. In selected patients with acute PE who deteriorate
after starting anticoagulant therapy but have
yet to develop hypotension and who have a low
bleeding risk, we suggest systemically administered
thrombolytic therapy over no such therapy
(Grade 2C).
American Guidelines – Chest 2016
*23. In selected patients with acute PE who deteriorate
after starting anticoagulant therapy but have
yet to develop hypotension and who have a low
bleeding risk, we suggest systemically administered
thrombolytic therapy over no such therapy
(Grade 2C).
….Dose not suggested
American Guidelines – Chest 2016
MOPETT Trial
• Concept of “Safe Dose Thrombolysis”? • Cardiac output – Brain 15%, Heart 5%, Pulmonary 100%
• tPA - 10mg bolus
• tPA - 40mg/2 hours (0.5mg/kg if <50kg)
MOPETT Trail
MOPETT Trail
“PERT”
A Pragmatic British
Alternative…
And applicable to DGH as
teaching hospitals alike…
PE Lysis Team- “PELT”
• Chest Physicians
• Critical Care
• Haematologists
• Interventional Radiology
• (Obstetric Physician)
PE Lysis Team- “PELT”
• Chest Physicians
• Critical Care
• Haematologists
• Interventional Radiology (pt bleeding risk)
• (Obstetric Physician)
Sub-massive PE
• Not shocked but…
• Evidence of right heart dysfunction
• Evidence of myocardial injury
– elevated Troponin , BNP
• Confirmed large clot burden – CTPA (V:Q)
• Mortality or “Adverse Events” 3-15%?
Sub-massive PE
• Not shocked but…
• Evidence of right heart dysfunction*
• Evidence of myocardial injury
– elevated Troponin*, BNP*
• Confirmed large clot burden* - CTPA (V:Q)
• Mortality or “Adverse Events” 3-15%....
• Predictors* – both +ve and -ve
PE Lysis Team- “PELT”
• Initial Clinical Assessment
• ECHO
• Bilateral leg Dopplers
• Bleeding risk (NB age, Pulmonary infarction)
PE Lysis Team- “PELT”
• Initial Clinical Assessment
• ECHO
• Bilateral leg Dopplers
• Bleeding risk (NB age, Pulmonary infarction)
• Serial Assessment – review progress
• Patient involvement in decisions/consent
• …..then you make a TEAM judgement
Local Protocol for Sub-Massive PE
• Team decision
• Done in level 2 or 3
• Systemic “half dose” first line
• Catheter direct Thrombolysis for
- bleeding risk (eg post surgery)
- Second line (post systemic, including massive PE)
- “Older Clot”?
• (Local outcome very good… thus far)
Catheter Directed Thrombolysis
• Interventional Radiology
• Time is situ 12-24 hours
• Infuse tPA 0.5-1mg per hour
• Lower total dose
• Can be bilateral (and each side “adjusted”)
• Still risk of bleeding and arrhythmia
50
EKOS™ Endovascular System Features
―
―
―
51
Acoustic Pulse Thrombolysis™
treatment Mechanism of action
Fibrin Separation Ultrasound separates fibrin
without fragmentation of emboli
Active Drug Delivery Drug is actively driven into clot by
“Acoustic Streaming”
EKOS™ Acoustic Pulse Thrombolysis™ treatment is a minimally invasive
system for accelerating thrombus dissolution.
Question?
• 34yo lady, 33/40
pregnant. V:Q –
Significant bilateral
PEs. BP 115/78.
Tachy 110, 60% O2,
RR24, sats 91%. Has
had 2/7 full dose
LMWH, no better,
moved to ICU for
“closer monitoring”
• A: Continue Fragmin
• B: iv heparin
• C: Cather Directed
Thrombolysis
• D: 100mg tPA
• E: 50mg tPA
• F: Give all info to
patient and let her
decide
Question?
• 34yo lady, 33/40
pregnant. V:Q –
Significant bilateral
PEs. BP 115/78.
Tachy 110, 60% O2,
RR24, sats 91%. Has
had 2/7 full dose
LMWH, no better,
moved to ICU for
“closer monitoring”
• A: Continue Fragmin
• B: iv heparin
• C: Cather Directed
Thrombolysis
• D: 100mg tPA
• E: 50mg tPA
• F: Give all info to
patient and let her
decide
Summary
• Advances in diagnostics to enable correct
diagnosis at the start
• Advances in TEAM decisions for the more
severe PEs to enable improved morbidity
and mortality