Evaluation of the Benefit of Extended Catheter-Directed Thrombolysis with Serial Angiography for Acute Pulmonary Embolism

Purpose: To evaluate whether extended catheter-directed thromholysis (CDT) with repeat visits to the angiography suite provide added benefit in treatment of acute pulmonary embolism (PE).Materials and Methods: This was a retrospective review of CDT procedures performed for acute PE in 156 patients (age 56.1 y +/- 15.3, 46.2% women) between 2009 and 2019. All patients underwent at least 1 follow-up visit to the angiography suite for evaluation of pulmonary artery pressure (PAP) and thrombus burden (Miller score) before termination (111/156, 71.2%) or continuation of CDT (45/156, 28.8%).Results: Patients who had CDT extended beyond the first follow-up visit required a higher total dose of tissue plasminogen activator (40.7 mg +/- 14.3 vs 22.6 mg +/- 9.9, P < .001) to achieve a similar final Miller score (6.4 +/- 3.8 vs 7.6 +/- 3.9, P = .1) and a similar reduction in systolic PAP (-14.4 mm Hg +/- 10.2 vs -12.6 mm Hg +/- 11.9, P = .6). The initial Miller scores were similar in both groups (19.7 +/- 5.8 vs 19 +/- 4, P = .4) but were significantly higher during the first follow-up visit (after 18 hours +/- 5.5 vs 20 hours +/- 4.8, P = .06) in patients requiring multiple follow-up visits (12.2 +/- 5 vs 7.6 +/- 3.9, P < .001). Multiple regression analyses identified heart rate > 100 beats/min and systolic PAP > 55 min Hg as associated with the need for extended CDT. Extended CDT did not result in a higher hemorrhagic complication rate (1/45 vs 6/111, P = .7).Conclusions: Patients presenting with higher art rates and systolic PAP may benefit from extended CDT to achieve similar reductions in PAP and thrombus burden, without clear added risk of hemorrhage.