1. Concerns with Catheter Directed TPA for the Treatment of PEs

2. Concerns Triage / Processes
Parallels with catheter-directed CVA treatments
Review of the catheter-directed PE literature

3. Triage Massive / Shock -> Thrombolysis Submassive
No RV strain -> Routine Anticoagulation

4. (CHEST 2002; 121:877–905)

6. “Golden Hour”
“In fatal cases, it has long been recognized that two thirds of those patients will die within 1 h of presentation and that anatomically massive PE will only account for one half of those deaths, with the remainder attributed to smaller submassive or recurrent emboli.”
(CHEST 2002; 121:877–905)

7. Judgment
“…thrombolytic therapy in this population should be individualized and benefits and risks (of bleeding) should be carefully weighed on a case- by-case basis.”
Tapson. Uptodate.

8. Who is called first matters.

9. Death may decide when doctors disagree

11. Code PE
Why do we have “code stroke” and “code STEMI” protocols?

12. Parallels (

13. Parallels Catheter-directed treatment of CVAs
Cather-directed treatment of PEs

15. “No Better Than IV tPA”

16. Too Slow
“The time from symptom onset to endovascular treatment start was too long (1-3 hours) and this delay places [intra- arterial therapy] at a significant disadvantage.”
Barreto, Endovascular Therapy for Acute Ischemic Stroke -- An Update

17. AHA Stroke Guidelines
“Patients eligible for intravenous rtPA should receive intravenous rtPA even if intra-arterial treatments are being considered (Class I; Level of Evidence A).”
“…thrombectomy devices can be useful in achieving recanalization alone or in combination with pharmacological fibrinolysis in carefully selected patients (Class IIa; Level of Evidence B). Their ability to improve patient outcomes has not yet been established. These devices should continue to be studied in randomized controlled trials to determine the efficacy of such treatments in improving patient outcomes.”

18. Triage Parallel
“We did have one patient several years ago who was sent to the cath lab and did not receive IV t- PA when she was a candidate.”

19. DVT Parallel Catheter-directed treatment of DVT versus anticoagulation
Mortality unchanged
Blood transfusions, PEs, ICH, length of stay, and IVC filter placements all significantly higher
Three times more hospital charges (

20. Systemic Thrombolysis for Submassive PE
No mortality benefit
More bleeding including ICH
Less decompensation
n engl j med 370;15 nejm.org april 10, 2014
Journal of Thrombosis and Haemostasis, 10: 751–759
JAMA. 2014;311(23): doi: /jama

21. ULTIMA
Nonblinded, industry-involved trial 59 patients (out of 304 screened)
Ultrasound Catheter TPA up to 4hrs vs heparin
Required RV/LV ratio > 1.0
Not powered for survival or bleeding complications.
RV/LV ratio improved faster with intervention
Heparin group “caught up” by 90 days

22. Natural PE Course
“Most patients with PE treated with anti-coagulation alone will achieve embolus resolution at 4 weeks.”
“The feared consequence of resultant chronic thromboembolic pulmonary hypertension occurs only 0.1% to 3.8% of patients with PE”
“Mortality after submassive PE is uncommon”
(Circulation. 2014;129: )

23. ULTIMAtely Meh? Small, not blinded, industry-involved
ULTIMA shows that US facilitated TPA compared to heparin rapidly improves RV size.
IVC / RV improvement not significantly different at 90 days.
No survival or bleeding data

24. Seattle-II Industry-funded, not (yet?) published
US Catheter directed TPA
No comparison group
No ICH. Major bleeding 11.3%
Many patients required two catheters.
RV/LV ratio acutely improved
1 death due to PE (0.5%). 3 total deaths (2%).

25. Seattle Pee-eww? Industry-funded. Not published. No comparison group.
Although no ICH reported, major bleeding appears as high as systemic tPA. 11.3% vs 11.5%.
Apparently only shows short-term RV improvement.

26. ACCP Guidelines
“In patients with acute PE when a thrombolytic agent is used, we suggest administration through a peripheral vein over a pulmonary artery catheter.”
“In patients with acute PE associated with hypotension and who have (i) contraindications to thrombolysis, (ii) failed thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (eg, within hours), if appropriate expertise and resources are available, we suggest catheter-assisted thrombus removal over no such intervention.”
“In patients with acute PE who are treated with anticoagulants, we recommend against the use of an IVC filter.”

27. Chronic thromboembolic pulmonary hypertension?
40% never diagnosed with DVT or PE
0.57% incidence in patient’s with PE
Only 10/170 (5.8%) with symptoms actually have CTEPH
“Because of the very low incidence of CTEPH after PE, the implementation of extensive follow-up programs for the detection of CTEPH after acute PE seems to be unnecessary.”
Haematologica. Jun 2010; 95(6): 970–975.

28. Chronic RV Dysfunction?
159 heparin vs 19 TPA
Neither 6 minute walks nor NYHA scores were significantly different between heparin and thrombolysis.
RV hypokinesis no difference between the two groups (7% vs 6%)
Subgroup analysis showed that heparin only group 27% had “increase in RVSP” and 46% had symptoms. However, more tPA patients had RVSP > 40 (11% vs 7%).
(Chest / 136 / 5 / November, 2009)

29. Conclusions
PE with RV strain (like a STEMI) often is an emergency which requires a clear, single pathway. Time consumed trying to tease out who owns these patients is dangerous. Critical care medicine should hold primary responsibility for these patients.

30. Conclusions
Our history with CVAs should be a lesson to us. Despite initial promising studies, large trials of catheter-directed therapy have shown no benefit over standard of care. WakeMed’s premature journey down this pathway last time was wasteful and dangerous.

31. Conclusions
Although catheter directed thrombolysis for submassive PEs may show some promise, these early industry-supported studies have shown no meaningful long term improvement over routine care. Catheter-directed thrombolysis should remain an option in patients who have contraindications or fail systemic therapy.