Catheter-directed Thrombolysis for Severe Pulmonary Embolism in Pediatric Patients

doi:10.1016/j.avsg.2014.03.016

Annals of Vascular Surgery

Volume 28, Issue 7, October 2014, Pages 1794.e1-1794.e7

https://doi.org/10.1016/j.avsg.2014.03.016 Get rights and content

Background

Catheter-directed thrombolytic (CDT) therapies for severe pulmonary embolism (PE) have been shown to be effective and safe when compared with systemic thrombolysis in adults. Pediatric studies assessing efficacy and safety of CDT for PE are lacking. Hence, our aim was to review CDT as a therapy for pediatric PE.

Methods

We retrospectively reviewed charts of patients aged <18 years, who underwent CDT for main or major branch pulmonary artery occlusion associated with hypotension or right ventricular dysfunction secondary to PE during a 3-year period, in our tertiary care academic Pediatric Intensive Care Unit.

Results

Six CDT interventions were performed on 5 patients with PE (median age: 16.5 years). All patients presented with chest pain and dyspnea. The predisposing factors for thrombogenesis differed in all patients, and all had multiple risk factors. Five of six procedures (83%) were accompanied by ultrasound agitation with EKOS endowave infusion system (ultrasound-accelerated CDT [UCDT]), whereas 1 had CDT without ultrasound agitation. Complete resolution of PE occurred in 4 instances (67%) at 24 hr, whereas in 2 cases (33%), there was partial resolution. One patient with complete resolution underwent another successful UCDT after 4 months for recurrence. Clinical parameters (heart rate, respiratory rate, blood pressure, and oxygen saturations) and echocardiographic findings improved after treatment in all the patients. Median duration of hospital stay was 9 days with no mortality and treatment-related complications. All patients were discharged with long-term anticoagulation.

Conclusions

Our case series is the first that describes CDT/UCDT as an effective and safe therapy for pediatric patients with severe PE. CDT is known to accelerate fibrinolysis via focused delivery of thrombolytic agent to the thrombus site. For carefully selected patients, CDT/UCDT provides a useful treatment option for severe PE irrespective of the etiology, predisposing conditions, and associated comorbidities.

Section snippets

Setting

We conducted a retrospective study during a 3-year period (December 2009–December 2012) after approval from the Institutional Review Board of Baylor College of Medicine. In pediatric patients aged <18 years, treated at Texas Children's Hospital, Houston, TX with CDT or UCDT for submassive or massive PE, etiologic factors for PE and clinical parameters were reviewed.

Intervention

The indication for CDT was massive or submassive PE as defined by the presence of either hypotension or severe right ventricular

Patient Demography and Predisposing Factors

Five patients with PE confirmed by computed tomography or conventional angiography underwent 6 CDT interventions during this study period. The median age of patients treated was 16.5 years (range: 11–17). Five of six (83%) interventions were carried out in women. All patients presented with chest pain and dyspnea. All patients had 2 or more predisposing factors for thrombogenesis present at diagnosis. Coexisting lower extremity venous thrombosis and obesity were the most common risk factors and

Discussion

Acute massive or submassive PE featuring or leading to hemodynamic compromise is a serious life-threatening condition requiring prompt intervention. Standard therapy in adults includes anticoagulation with concurrent thrombolytic therapy in patients who have hemodynamic instability.¹⁸ Studies have shown that patients with RV dysfunction have poor outcomes because of the potential for developing RV failure and cardiogenic shock.¹⁹ Emergent systemic thrombolysis facilitates thrombus reduction and

Conclusions

In our case series of pediatric patients with submassive or massive PE, CDT and UCDT led to partial or complete resolution in each case. These interventional treatment strategies may allow for faster resolution of thrombi with decreased bleeding risk. In the event of recurrence, CDT can be successfully reinitiated. Thus, pediatric patients can be treated with CDT provided that practitioners take into account the variations needed in the treatment from the adult population.

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In a meta-analysis of CBT, outcomes were reported for 945 adults with intermediate-risk PE with a clinical success rate (defined as prevention of decompensation) of 97.5% (95% CI, 95.3%-99.1%) and 30-day mortality rate of 0% (95% CI, 0%-0.5%); major bleeding and strokes were rare.35 Small pediatric case series also have reported favorable outcomes for CBT in intermediate-risk PE.54-56,70 In addition to short-term outcomes, therapies used in the acute phase may reduce morbidities subsequent to PE such as CTEPH.
Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.
Pediatric Pulmonary Embolism: Imaging Guidelines and Recommendations
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It is important to note that conventional angiography may be insensitive to the detection of subsegmental PE, with a sensitivity of only 32%,14 compared with CTPA (which was used as the gold standard). Conventional angiography still plays a crucial role in the diagnosis and treatment of acute massive and submassive PE (hemodynamic instability) with therapeutic and catheter-directed modalities, such as ultrasound-assisted thrombolysis and mechanical embolectomy.33,34,40,41 The incidence of PE in the pediatric population has traditionally been considered low, ranging from 0.73% to 4.20%.42,43
Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Thrombosis: Phlegmasia Cerulea Dolens Presenting with Venous Gangrene in a Child
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Therapeutic hypothermia likely contributed to her complete neurologic recovery. A staged EkoSonic UCDT for bilateral PE facilitated early ECMO decannulation.33 UCDT has been shown to decrease the burden of pulmonary embolus, decrease pulmonary pressures and facilitate early RV recovery.9,34
A 12-year-old girl with severe acute respiratory syndrome coronavirus 2 infection presented as phlegmasia cerulea dolens with venous gangrene. Emergent mechanical thrombectomy was complicated by a massive pulmonary embolism and cardiac arrest, for which extracorporeal cardiopulmonary resuscitation and therapeutic hypothermia were used. Staged ultrasound-assisted catheter-directed thrombolysis was used for treatment of bilateral pulmonary emboli and the extensive lower extremity deep vein thrombosis while the patient received extracorporeal membrane oxygenation support. We highlight the need for heightened suspicion for occult severe acute respiratory syndrome coronavirus 2 infection among children presenting with unusual thrombotic complications.
Rare Cardiac Emergencies: Aortic Dissection, Pulmonary Hypertensive Crisis, and Pulmonary Embolism
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There are a few very rare pediatric cardiac problems not clearly related to the heart in which the cardiologist is usually called to make the diagnosis and help in management. Aortic dissection and pulmonary embolism are so rare in children that many providers have not encountered these problems. Pulmonary hypertension shares pathophysiology with pulmonary embolism, although emergency presentations are also extremely rare. In this review, we describe the presentation and latest practices in the evaluation, triage, and emergency department management strategies.
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Thrombolytic Therapy of Acute Massive Pulmonary Embolism Using Swan-Ganz Pulmonary Artery Catheter
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The patient was doing well without any respiratory symptoms at 1-year follow-up. Catheter-directed thrombolytic therapy has gained increased acceptance as a life-saving therapeutic armamentarium in patients with acute massive PE, as numerous studies have demonstrated its therapeutic clinical efficacy.2–7 The outcome of this case is notable as this is the first report highlighting the utility of a Swan-Ganz catheter for pulmonary artery thrombolytic infusion in a patient who was unable to undergo the conventional catheter-directed thrombolytic therapy for acute massive PE.
Acute massive pulmonary embolism (PE) is associated with high fatality, and catheter-directed thrombolytic therapy has been shown to be an efficacious treatment for this condition. We herein report a patient who developed acute massive PE but could not undergo the conventional catheter-directed thrombolytic therapy. A Swan-Ganz pulmonary artery catheter was placed at bedside to initiate immediate thrombolytic infusion, which resulted in dramatic clinical improvement. This report underscores a potential role of thrombolytic therapy via a transjugular pulmonary artery catheter in patients with acute massive PE who could not undergo the conventional catheter-based thrombolytic intervention.

View all citing articles on Scopus

: The work was carried out in the Section of Critical Care Medicine and Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine and in Texas Children's Hospital, Houston, TX.

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Case ReportCatheter-directed Thrombolysis for Severe Pulmonary Embolism in Pediatric Patients

Background

Methods

Results

Conclusions

Section snippets

Setting

Intervention

Patient Demography and Predisposing Factors

Discussion

Conclusions

J Pediatr Surg

J Pediatr

J Pediatr

Blood

J Emerg Med

J Pediatr

Prog Cardiovascular Dis

Chest

Lancet

Am J Cardiol

Ann Thorac Surg

J Vasc Interv Radiol

Am J Cardiol

Pulmonary embolism in the pediatric emergency department

Pediatrics

Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007

Pediatrics

Case Report
Catheter-directed Thrombolysis for Severe Pulmonary Embolism in Pediatric Patients