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The Modern Algorithm For Management Of Massive And Submassive Pulmonary Embolism
Date:11/21/2013

 Engelhardt said, "Ultrasound-accelerated thrombolysis (USAT), enabled by the EkoSonic® Endovascular System is an advanced catheter-directed modality that facilitates localized delivery of rtPA into the pulmonary thrombus. The ultrasonic energy increases thrombus permeability and facilitates deep penetration of the drug into the thrombus, which accelerates clot dissolution using only a fraction the standard IV rtPA dose."

In his presentation Engelhardt cited his institutional approach for acute PE, employs USAT as the primary therapy for both massive and submassive patients. Upon identification of signs/symptoms consistent with PE and confirmation of PE by computer tomographic angiography (CTA) of the chest, the patient is referred to Cardiovascular and Thoracic Surgery. Based on presence of RV strain defined as the right-ventricle-to-left-ventricle diameter (RV/LV) ratio at end-diastole exceeding 0.9, the patient undergoes USAT using a low-dose rtPA infusion protocol.  The early experience with USAT examined varied doses and infusion durations.  He went on to report that the current protocol has been standardized to a total dose of 24 mg rtPA infused at 1.0 mg/hour/catheter (12 hours in bilateral; 24 hours in unilateral PE) with no bolus.  

Engelhardt emphasized, "We retrospectively evaluated PE patients treated with USAT with follow-up chest CTA at 48±6 hours post infusion.  57 patients (age 58±15 yrs) have been included during the study period from 2009-2013, with 15 new patients enrolled since last reported in 2012. There were 7 massive and 50 submassive PE cases.  52 patients (91%) presented with bilateral PE. Overall, a rtPA dose of 29.5±14.8 mg was infused over 17.2±6.6 hours. Following USAT, the RV/LV ratio was reduced from 1.5±0.4 at baseline to 1.0±0.2 at follow-up CTA (p<0.001). 30-day follow-up CTA availabl
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