Faculty Bibliography

Acute pulmonary embolism (PE) is a major public health problem and accounts for 100,000-180,000 deaths per year in the United States. Current prognostic stratification separates acute PE into massive, submassive, and low-risk by the presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive and low-risk PE have mortality rates of 25-65%, 3%, and < 1%, respectively. In this review we will focus on therapies currently available to manage acute massive and submassive PE.

Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high-risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.

Background: Current evidence suggests short-term right heart hemodynamic benefits of catheter directed thrombolysis (CDT) in patients treated with severe pulmonary embolism (PE). However, functional outcomes after CDT are lacking. We used 6-minute walk test (6MWT) as a marker of functional capacity after CDT and determined which factors were associated with 6MWT outcomes.
Method(s): This was a single-center retrospective study conducted from 2014-2018. Charts for patients who underwent 6MWT after CDT were reviewed. Three components of 6MWT, including distance walked, oxygen saturation during the test, and symptoms of dyspnea (Borg scale) were analyzed.
Result(s): 57 patients (mean age: 60 +/- 13 y, female/male: 27/57) underwent CDT; 56 patients had intermediate-risk PE, and 1 patient had high-risk PE. Total thrombolytic dose used was 19.66 +/- 8.27 mg. The right ventricular (RV) diameter decreased from 5.04 +/- 0.79 pre-CDT to 2.86 +/- 0.80 post-CDT echocardiogram (p < 0.001, n = 32), RV/left ventricular (LV) ratio decreased from 1.39 +/- 0.27 to 0.92 +/- 0.26 (p < 0.001, n = 32), pulmonary artery systolic pressure (PASP) decreased from 39.52 +/- 21.35 to 29.83 +/- 11.99 (p = 0.026, n = 23). 6MWT was performed 132.91 +/- 108.89 days after the procedure. The mean distance walked was 310 +/- 113.8 m. Multiple variables significantly correlated with 6MWT outcome, as shown in the Poster 15 Table. Multivariable regression analysis showed total thrombolytic dose (r² = 0.084, p = 0.032) and troponin (r² = 0.069, p = 0.04) as independent predictors of dyspnea scores before 6MWT.
Conclusion(s): Exercise capacity in patients with submassive PE treated with CDT is poor despite improvement in right heart hemodynamics. Total thrombolytic dose and troponin level are independent predictors for dyspnea scores before 6MWT

Objective: Pulmonary embolism response teams (PERTs)have become increasingly popular at institutions around the country, although only anecdotal evidence is available to support their efficacy. PERTs are mechanisms for rapid involvement of a multidisciplinary team in the management of a time-sensitive condition with many treatment options spanning multiple specialties. We aimed to evaluate time to management of pulmonary embolisms and outcomes since 2016 under our institution's PERT. Method(s): We retrospectively reviewed 151 patients with PERT activations since inception, collecting data on demographics, time to treatment, treatment modality, and in-hospital outcomes. Result(s): The average age was 62.4 years (range, 30-95 years), and 54% of patients were male; 39.4% of patients had normal echocardiographic recordings, with 27% showing right ventricular (RV)hypokinesis, 9.1% showing elevated pulmonary artery pressures, and 6.1% showing RV enlargement. Anticoagulation alone was received by 91.4% of patients; 4.5% had catheter-directed therapy (CDL), and 3.0% had systemic administration of tissue plasminogen activator (tPA). The average time to invasive intervention was 665 minutes (95% confidence interval [CI], 249-1080 minutes)for CDL and 22 minutes (95% CI, 0-456 minutes)for systemic tPA. Average time to anticoagulation was 3 minutes (95% CI, 154-160 minutes). For patients with echocardiographic findings suggestive of RV strain, 21.4% (95% CI, 0.04-0.51)had tPA or an invasive intervention. Of patients with echocardiographic findings consistent with RV strain who underwent conservative management, 80% were discharged home after an average length of stay of 6.0 days (95% CI, 4.5-7.5). Twenty (14.1%; 95% CI, 5.5-22.5)patients receiving anticoagulation alone had bleeding events, whereas none of the patients undergoing CDL or tPA had bleeding. Sixteen (11.2%; 95% CI, 5.7-16.3)patients who had anticoagulation died in the hospital or were discharged to hospice, and none of the patients receiving CDL or tPA died or were discharged to hospice. The odds of in-hospital death were lower for patients receiving anticoagulation than for those without (odds ratio, 0.29), suggesting appropriate identification of high-risk patients. Average hospital stay was 6.5 days (95% CI, 4.9-8.5)for patients who received anticoagulation, 5.3 days for CDL (95% CI, 0-11.2), and 8 days for tPA (95% CI, 2.6-13.4). Conclusion(s): We found that a dedicated PERT team leads to efficient delivery of care and excellent outcomes. The majority of pulmonary embolisms can be managed with anticoagulation alone. CDT and systemic tPA are safe adjunctive treatments for select patients.

Purpose: To evaluate the effect of free-text versus structured reporting on coding for interventional radiology procedures. Materials: Coding data from 2356 interventional radiology procedures performed in 2017 was retrospectively reviewed. Mandatory structured reports were implemented on July 1, 2017. Coding data from 1086 procedure reports from the six months prior to implementation and 1270 procedure reports from the six months after implementation were reviewed to assess changes in code usage. Result(s): Structured reporting increased the number of CPT codes per procedure (2.93 vs 3.90, p<0.01). Structured reporting increased the use of codes for fluoroscopic guidance for central venous catheter placement, ultrasound guidance for vascular access, time-based moderate sedation, and 3D rendering with interpretation (165 vs 343, 442 vs 1326, 273 vs 460, and 0 vs 10; p<0.01). Structured reporting had no significant impact on the usage of other codes like selective catheterization (120 vs 128). Conclusion(s): Implementation of mandatory structured reports for interventional radiology procedures increases the number of codes per report and increases usage of codes requiring documentation of specific criteria.

Keywords: pulmonary embolism; submassive; survey.

Limited evidence is available to guide periprocedural management of oral anticoagulants in the setting of interventional radiology (IR) procedures. For direct oral anticoagulants, therapy interruption (TI) is based on medication half-life and procedural bleeding risk. Periprocedural management of warfarin includes INR monitoring, and possible bridging with parenteral anticoagulants. It is unknown if these recommendations apply to IR procedures. To evaluate bleeding complications and thromboembolic events following periprocedural management of the factor Xa (FXa) inhibitors or warfarin in patients undergoing IR procedures. We performed a retrospective, observational study at NYU Langone Health (NYULH) of all adult patients who underwent an IR procedure from January 2015 to July 2017 and were receiving apixaban, rivaroxaban, or warfarin. Patients who were pregnant or who had a mechanical heart valve were excluded. At NYULH, TI is not required for FXa inhibitors, and an INR < 3 is recommended for patients on warfarin undergoing low risk procedures. For moderate/high risk procedures, TI for 48 h or 72 h with reduced renal function, is recommended for FXa inhibitors, and an INR < 1.5 is recommended for patients on warfarin. We evaluated 350 IR procedures, with a total of 174 low bleeding risk and 176 moderate/high bleeding risk. The 30-day major bleeding rate was 0.9%, clinically relevant non-major bleeding rate was 3%, minor bleeding rate was 1% and thromboembolic event rate was 1%. The periprocedural oral anticoagulation management strategy at NYULH appears safe given the low 30-day incidence of bleeding and thromboembolic events.

PURPOSE OF REVIEW/OBJECTIVE:Patients suffering from acute lower extremity deep vein thrombosis (DVT) are at risk for developing chronic limb pain, heaviness, and fatigue, known as the post-thrombotic syndrome (PTS). RECENT FINDINGS/RESULTS:Although several studies have shown that catheter-directed therapy reduces clot burden and may improve clinical outcomes, the multicenter randomized controlled ATTRACT trial showed no difference in PTS or quality of life at 2 years between patients treated with pharmacomechanical catheter-directed thrombolysis (PCDT) and those treated with anticoagulation alone, and a higher major bleeding rate in the PCDT group. PCDT is not indicated for most patients diagnosed with lower extremity DVT. Since PCDT may benefit patients with iliofemoral DVT, intervention can be considered in this subset of patients if they are at low risk of bleeding.