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