1. Catheter-Based Options for Treating PE
Jay Giri, MD MPH
Assistant Professor of Medicine
Director, Pulmonary Embolism Response Team
Associate Director, Penn Cardiovascular Quality, Outcomes, & Evaluative Research Center
Hospital of the University of Pennsylvania

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Company
Grant/Research Support
Consulting Fees/Honoraria
Major Stock Shareholder/Equity
Royalty Income
Ownership/Founder
Intellectual Property Rights
Other Financial Benefit
Company Names

3. Pulmonary Embolism Types
MASSIVE
Shock / Hypotension
SUBMASSIVE
Normotensive + RV Strain
LOW RISK
None of the above

4. Rationale for Advanced Therapy
Wood KE. Critical Care Clinics 2011;27(4):

5. Can We Prevent This?

6. PE Therapeutic Options: All Over the Map
Anticoagulation
IV Thrombolysis
IVC Filter
Catheter Directed
Thrombolysis
Surgical
Embolectomy
Pharmaco-Mechanical
Catheter Treatment
ECMO

7. Acute MI: Evolution of Standard of Care
Open Vessel Theory
1970’s - 80’s
Supportive
Heparin
Mid 1990’s -
Pharmacologic
Thrombolytics
Late 1990’s -EndoMechanical
Primary PCI
Open superior to Occluded
Mechanical superior to Pharmacologic

8. Acute PE: Evolution of Standard of Care
Open Vessel Theory
1970’s - 90’s
Supportive
Heparin
Mid 1990’s -
Pharmacologic
Thrombolytics
2010’s-Future
Pharm+Mech
CDT
en bloc ECMO
Open should be superior to Occluded
PHARMACOMechanical possibly superior to Pharmacologic

9. Weighing Benefits & Risks of PE Intervention
Prevent early mortality
Improve symptoms
Prevent CTEPH
Major Bleeding
ICH
Precipitate Decompensation

10. Theoretical Advantages for Local Lytic
Higher local concentration
Lower overall dose
Ability to fragment clot if desired
PA pressure monitoring
Scmitz-Rode CVIR 1998;21:

11. Options for CDT Cragg-McNamara Unifuse EKOS 4-5 F
100 cm catheter length
5-10 cm infusion length $
Unifuse
EKOS 5F $

12. Catheter-Directed Thrombolysis
4-24 hour treatment ↓ lytic dose (12-24 mg TPA) ? Bleeding impact ? thrombus resolution impact Faster than passive catheter-directed alone (?)

13. Who Knows?
Reduced Dose
Longer Infusion

14. Rapidly Evolving Technology for PE

15. Sample Devices for PE Intervention
Jaber et al. JACC. 2016; 67(8):

16. Suction Thrombectomy: It Takes A Village…

17. Vortex Suction Thrombectomy in the Cath Lab
Percutaneous placement of a 22 F Vortex catheter right CFV & 17F (outflow) cannula left CFV
TEE guided to the RA or PA

18. TEE guided Vortex Thrombectomy

19. Extracorporeal membrane oxygenation

20. 24 Hour ECMO Availability for PE @ MGH
Ain, Abtahian, Giri, et al. In submission.

21. Percutaneous RV Support?

22. BP less than 90 or on pressors?
Signs of submassive PE?
- + Troponin
- RV dysfxn
Yes
Yes No
Submassive PE
Minor PE
Thrombus in transit?
Massive PE
Yes No
Anticoagulation
Percutaneous
thrombectomy
and anticoagulation
Assess bleeding risk
Risk stratify submassive PE
PESI
- RV (TAPSE)
- Overall cardiopulmonary reserve
- HR/BP
- Objective vitals with exertion
Low
High
Elevated
Assess surgical risk
Systemic Lytics
Assess Surgical Risk
High
Given high NNT and high bleeding risk, our approach is a conservative one. How to prevent submassive PE from progressing to massive PE cuasing hemodynamic collapse and death.
PE severity index
Lower
Low-Intermediate
Higher
Anticoagulation
Prohibitive
Elevated
Low
Anticoag +/- perc thrombectomy
Open Ebolectomy
Assess bleeding risk
Low
Elevated
Prohibitive
Catheter Directed
Lytics
Open Embolectomy vs. CDT
Open Ebolectomy
Age
Anticoagulation
< 65
> 65
Consider perc thrombectomy
if clot-in-transit
Systemic lytics
Catheter directed lytics

23. Thank You HUP PERT Founders PE Research Collaborators Akaya Smith
Barry Fuchs
Prashanth Vallabhajosyula
Nimesh Desai
PE Research Collaborators
Saurav Chatterjee (Mt. Sinai – St. Lukes)
Ido Weinberg (MGH)
Geoff Barnes (U Mich)
Peter Groeneveld (Penn)
Sri Adusumalli (Penn)
Bram Geller (Penn)