CatheterBased Options for Treating PE Jay Giri MD

Catheter-Based Options for Treating PE Jay Giri, MD MPH Assistant Professor of Medicine Director, Pulmonary Embolism Response Team Associate Director, Penn Cardiovascular Quality, Outcomes, & Evaluative Research Center Hospital of the University of Pennsylvania 1

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company Names Company Names

Pulmonary Embolism Types MASSIVE Shock / Hypotension SUBMASSIVE Normotensive + RV Strain LOW RISK None of the above 3

Rationale for Advanced Therapy Wood KE. Critical Care Clinics 2011; 27(4): 885 -906 4

Can We Prevent This? 5

PE Therapeutic Options: All Over the Map Anticoagulation IV Thrombolysis Catheter Directed Thrombolysis IVC Filter Pharmaco-Mechanical Catheter Treatment Surgical Embolectomy ECMO 6

Acute MI: Evolution of Standard of Care Open Vessel Theory Late 1990’s - 1970’s - 80’s Supportive Mid 1990’s Pharmacologic Endo. Mechanical Heparin Thrombolytics Primary PCI OPEN superior to OCCLUDED MECHANICAL superior to PHARMACOLOGIC 7

Acute PE: Evolution of Standard of Care Open Vessel Theory 1970’s - 90’s Supportive Mid 1990’s Pharmacologic 2010’s-Future Pharm+Mech CDT Heparin Thrombolytics en bloc ECMO OPEN should be superior to OCCLUDED PHARMACOMECHANICAL possibly superior to PHARMACOLOGIC 8

Weighing Benefits & Risks of PE Intervention • Prevent early mortality • Improve symptoms • Major Bleeding • ICH • Precipitate Decompensation • Prevent CTEPH 9

Theoretical Advantages for Local Lytic w. Higher local concentration w. Lower overall dose w. Ability to fragment clot if desired w. PA pressure monitoring Scmitz-Rode CVIR 1998; 21: 199 -204 10

Options for CDT Cragg-Mc. Namara • 4 -5 F • 100 cm catheter length • 5 -10 cm infusion length • $100 -200 Unifuse • 4 -5 F • 100 cm catheter length • 5 -10 cm infusion length • $100 -200 EKOS • 5 F • 100 cm catheter length • 5 -10 cm infusion length • $2000 -3000 11

Catheter-Directed Thrombolysis 4 -24 hour treatment ↓ lytic dose (12 -24 mg TPA) ? Bleeding impact ? thrombus resolution impact Faster than passive catheter-directed alone (? ) 12

Who Knows? Longer Infusion Reduced Dose 13

Rapidly Evolving Technology for PE 14

Sample Devices for PE Intervention Jaber et al. JACC. 2016; 67(8): 991 -1002 15

Suction Thrombectomy: It Takes A Village… 16

Vortex Suction Thrombectomy in the Cath Lab • Percutaneous placement of a 22 F Vortex catheter right CFV & 17 F (outflow) cannula left CFV • TEE guided to the RA or PA 17

TEE guided Vortex Thrombectomy 18

Extracorporeal membrane oxygenation 19

24 Hour ECMO Availability for PE @ MGH 30 25 20 Surgical embolectomy Catheter-directed therapies Systemic thrombolysis 15 10 Anticoagulation 5 0 ECMO Era (2007 - 2014) Pre-ECMO Era (1994 - 2006) Ain, Abtahian, Giri, et al. In submission. 20

Percutaneous RV Support ? 21

BP less than 90 or on pressors? No Signs of submassive PE? - + Troponin - RV dysfxn Yes No Submassive PE Minor PE Thrombus in transit? Massive PE Yes Percutaneous thrombectomy and anticoagulation Assess bleeding risk Low Elevated No High Risk stratify submassive PE PESI - RV (TAPSE) - Overall cardiopulmonary reserve - HR/BP - Objective vitals with exertion Lower Higher Assess surgical risk Systemic Lytics Assess Surgical Risk High Low-Intermediate Prohibitive Elevated Cathete Open r Embolectom Directe y vs. CDT d Lytics Consider perc thrombectomy if clot-in-transit Low Anticoag +/perc thrombectomy Open Ebolectom y Anticoagulation Assess bleeding risk Low Elevated Systemic lytics Prohibitive Anticoagulation Age < 65 Anticoagulation > 65 Catheter directed lytics 22

Thank You w HUP PERT Founders • • Akaya Smith Barry Fuchs Prashanth Vallabhajosyula Nimesh Desai w PE Research Collaborators • • • Saurav Chatterjee (Mt. Sinai – St. Lukes) Ido Weinberg (MGH) Geoff Barnes (U Mich) Peter Groeneveld (Penn) Sri Adusumalli (Penn) Bram Geller (Penn) 23