PERTcast: Recent Episodes
PERT Consortium
Welcome to PERTCast, the official podcast of the PERT Consortium! Get an inside look as experts discuss various aspects of caring for patients with Pulmonary Emboli.
Audio from the recent webinar Pulmonary Embolism Decoded: Dissecting Myths with Evidence presented by the PERT Trainee Council on June 23, 2026.
Audio from recent webinar, sponsored by Angiodynamics.
This webinar focuses on optimizing the overall efficiency of the thrombectomy procedure for pulmonary embolism (PE), with an emphasis on the AlphaVac Mechanical Thrombectomy System. Experts will explore strategies for managing blood loss during the procedure, improving patient outcomes, and streamlining workflow for faster, more effective treatment. The session will highlight how the AlphaVac system can enhance these aspects, leading to better recovery and more efficient clinical practices in PE management.
Featuring the following speakers: Dr. Sabah Butty Dr. Peter Monteleone Dr. Brian Stegman
Audio from the recent PERT webinar.
In this virtual program, a multidisciplinary panel of leaders in pulmonary embolism will examine the results and real-world impact of the recent HI-PEITHO data release. This multi-country, multi-center landmark RCT was designed and conducted in partnership between society, industry, and academia to achieve impactful results through robust study design and large patient population to addressthe biggest questions in pulmonary embolism care today.
Join us for a discussion with Soophia Naydenov and Melissa Korn, Deputy Bureau Chief of Media at the Wall Street Journal as she describes her experience with pulmonary embolism, post-spinal surgery.
In this episode, PERT President-Elect Dr. Mahir Elder and PERT Past-President Dr. Robert Lookstein, discuss the STORM-PE trial, from its inception to its impact on the field of pulmonary embolism.
In this episode, a multidisciplinary panel of PE experts take learners on a deep dive into Deep Vein Thrombosis (DVT). Listen as they cover the latest in DVT diagnosis and treatment, exploring both clinical considerations and ever-evolving approaches.
Tune in to this episode of PERTCast to hear Dr. Rachel Rosovsky (PERT Past President) and Brian Shensky (Database Developer and Analysis) explore The PERT Consortium® PERC Database, from onboarding to benchmarking and optimal care.
In this episode, Drs. Vivian Bishay, Wissam Jaber and Dr. Vlad Lakhter review safety, patient selection, and risk stratification related to device selection. They examine the economics of outcomes in PE treatment, including workflow efficiency and the impact of avoiding post-procedure infusion and ICU resource use. Discussion ensues on the role of treatment location, ease of use, and how broader access to technology may influence care delivery.
Join us for an exclusive look inside The PERT Consortium™ as President Dr. John Moriarty and incoming President Dr. Mahir Elder sat down with Communications Committee Chair Dr. James Horowitz. From their personal journeys into leadership, to The Consortium's most impactful initiatives, this episode uncovers the bold vision driving the future of PE care. Get ready to hear how these visionary leaders are setting the stage for innovation, collaboration, and life-saving breakthroughs.
In this episode, we explore considerations in mechanical thrombectomy for pulmonary embolism, with particular emphasis on determining appropriate endpoints for concluding a procedure and the critical role of time and procedural efficiency. Key takeaways cover optimizing procedure duration, achieving meaningful reductions in pulmonary artery pressure and clot burden, and employing strategies to minimize or prevent blood loss throughout the intervention.
In this episode, a multidisciplinary panel of PE key opinion leaders share insights and challenge perceived myths within the landscape of PE real world evidence and care. Listen in for the latest data, contemporary treatment strategies, and preview anticipated future developments in this rapidly evolving field of PE.
In this episode of PERTcast, Trainee Council members present compelling cases, discuss their PERT volunteer experience, and encourage residents and fellows to get involved given the many benefits of doing so.
In this episode, resident and fellow members of The PERT Consortium™ Trainee Council share their volunteerism experience with consortium leaders Drs. Rachel Rosovsky and James Horowitz. From research to mentorship, educational content development to committee appointments, this discussion highlights the tremendous value for trainees serving on the PERT Consortium Trainee Council. The deadline to submit a Trainee Council Application is April 15, 2025.
Join us for a compelling episode as we highlight key insights from our recent webinar, featuring a fascinating complex case of a 75-year-old female patient with a history of Sjogren's syndrome, breast cancer, and chronic thromboembolic disease. Our expert panelists discuss the complexities of diagnosis, the role of advanced imaging techniques, and the lessons learned from this challenging case. Whether you missed the webinar or want to revisit the discussion, this episode is packed with valuable takeaways for healthcare professionals. Tune in now and expand your knowledge with insights from leading experts in the field!
Tune in now as the expert faculty dives into how the AlphaVac System is transforming pulmonary embolism treatment. In this podcast, they highlight key insights from the APEX-AV trial, explore real-world applications, and discuss the future of PE management. Don’t miss this insightful discussion on bridging clinical trials to real-world impact!
Hear from the experts about the transformative benefits of the PE Center of Excellence (PE CoE) Accreditation Program. This session highlights how this innovative program can elevate your institution's standard of care for Pulmonary Embolism. Tune in to discover the blueprint for driving excellence in PE care.
Join us for a recap of The Clinical PE Story: PEERLESS RCT Comparing FlowTriever to CDT, an in-depth discussion on the results of the PEERLESS randomized controlled trial. This session explores the RCT outcomes and offers valuable clinical insights into the future of PE intervention and patient care.
This episode highlights how the Viz.ai solution has improved the efficiency of a PERT team in Cincinnati. Tune in to hear how it started and how it’s going!
Listen to hear our expert panel discuss risk stratification beyond the current guidelines. Topics include normotensive shock, a perspective from radiology, the NEWS Score, and VTI. Faculty discuss interesting cases and address challenging questions regarding how to risk stratify.
Tune in for a multi-disciplinary panel discussion on the latest real-world data and advanced endovascular strategies for PE management
After highlighting a case of a 31-year old with RV failure, the faculty discuss options, considerations, and barriers based on three settings: the community hospital, the hybrid hospital, and the quaternary care center.
With support from our colleagues at Penumbra, learn more about the speed, safety, and simplicity of CAVT for clot detection and removal.
With support from our colleagues at Thrombolex, learn more about how to incorporate pharmaco-mechanical thrombolysis into your practice
With support from our colleagues at Thrombolex, this session provides an overview of pharmaco-mechanical thrombolysis and what the data tell us
Advancing PE Treatment with Computer Aided Thrombectomy CAT & the Latest Clinical Evidence
Hear firsthand from leaders of the Interhospital Transfer Project Dr. Charles Ross, Dr. Michael McDaniel, Dr. Belinda Rivera-Lebron, and Dr. Parth Rali who recap some of the key take aways from studying interhospital transfers of PE patients from across the country.
The Course Directors of The PERT Consortium’s 2021 Annual Scientific Symposium summarize some key take aways from the event.
Speakers Dr. Thomas Tu, Dr. Andrew Klein, Dr. Wissam Jabber, Dr. Ken Rosenfield, Dr. Rachel Rosovsky, Dr. Victor Tapson, and Dr. Catalin Toma highlight the need for randomized controlled trials on treatment of intermediate-high risk pulmonary embolism.
The session features Dr. John Moriarty, Dr. Jaafar Golzar, and Dr. Brent Keeling who provide an overview of the AlphaVac System and provide an introduction to the APEX-AV study.
In this edition of PERTCast, Dr. Lindsay Lief, Professor Fionnuala Ní Áinle, and Professor Beverley Hunt recap important parts of the webinar: sex-specific differences in men and women as it relates to PE-specific events, anticoagulation in women with menstrual periods, and PE diagnosis and treatment during pregnancy.
Listen in as Dr. Terry Bowers, Dr. Ken Rosenfield, and Dr. Eleni Whatley discuss findings from the inaugural PERC meeting.
Join Dr. Frances Mae West, Dr. Charles Grodzin, Dr. Emily Gundert, Dr. Jim Horowitz, & Dr. Alison Witkin as they recap mechanical measures to achieve hemodynamic stability, including ecmo and right ventricular support.
Dr. Jim Horowitz follows up with our speakers Dr. Brent Keeling, Dr. Rich Channick, Dr. Hillary Johnson-Cox, Dr. Sameer Khandar, and Dr. Akhilesh Sista to recap thoughts on burning questions like is clot burden associated with PE severity? Is increased clot removal associated with improved outcomes? Does increased retained clot lead to worsening long-term quality of life or outcomes?
Join us for this PERTcast featuring Dr. Ken Rosenfield, MD co-principal investigator in the latest clinical trial to date, Hi PEITHO. We meet the co-PI and ask clinical questions, trial endpoints, and study design for this new trial. Its a landmark venture you don’t want to miss out on.
The PERT consortium invites you to listen to a podcast moderated by Geoff Barnes, MD, and joined by Rachel Rosovsky, MD, and Scott Kaatz, DO, as they discuss extended VTE treatment and the American Society of Hematology (ASH) 2020 guidelines.
These podcasts were developed by the featured Pulmonary Embolism Response Team (PERT) Consortium speakers through a sponsorship from Janssen Pharmaceuticals, Inc. Doctors are also paid consultants of Janssen Pharmaceuticals, Inc.
© Janssen Pharmaceuticals, Inc. June 2021 cp-173153v3
Debrief: EndoWars: Aspirate vs. Dissolve. If you missed the webinar, do not worry. James Horowitz, MD follows up with our speakers and moderator Geoff Barnes, MD, MSc, Carin Gonsalves, MD, FSIR, Jay Giri, MD, MPH, Maya Serhal, MD, and Keith Sterling, MD, FSIR.
Debrief from the PERT Webinar: Cancer and PE: A Growing Problem. If you missed the webinar, do not worry. Jim Horowitz, MD followed-up with our moderator - Rachel Rosovsky, MD, MPH and speakers - Marc Carrier, MD, Lisa Baumann Kreuziger, MD, MS, Alok A. Khorana, MD, FACP, FASCO and Tzu-Fei Wang, MD.
The PERT Consortium® kindly invites you to the webinar “Cancer and PE: A Growing Problem”. Patients with cancer are at increased risk of developing pulmonary emboli. Join us to hear from world leading experts in cancer and thrombosis on the prevention, treatment, and adverse events that affect this vulnerable population.
Our speakers are Marc Carrier, MD, Lisa Baumann Kreuziger, MD, MS, Alok A. Khorana, MD, FACP, FASCO and Tzu-Fei Wang, MD. This webinar will be moderated by Rachel Rosovsky, MD, MPH.
CTEPH, the rare yet increasing complication of pulmonary embolism. We discuss the surgical management of CTEPH, when to refer, evaluation timeline, and key points which you should not miss.
Dr. Jon Haft, MD, is an Associate Professor of Cardiothoracic Surgery at University of Michigan Medical Center.
The PERT Consortium invites you to listen to a podcast moderated by Victor Tapson, MD, and joined by Alex Spyropoulos, MD, and Greg Piazza, MD, as they discuss the VTE risk for hospitalized acutely ill medical patients, risk stratification tools, and the population health impact.
These podcasts were developed by the featured Pulmonary Embolism Response Team (PERT) Consortium speakers through a sponsorship from Janssen Pharmaceuticals, Inc. Doctors are also paid consultants of Janssen Pharmaceuticals, Inc.
© Janssen Pharmaceuticals, Inc. June 2021 cp-173153v3
Patient PERTspective: 8 Time Jeopardy Champion Jennifer Quail didn’t let her new diagnosis of pulmonary embolism and antiphospholipid syndrome stop her from competing in the tournament of champions. Her impressive comeback from a serious medical condition.
Debrief: Home management of PE. If you missed the webinar, do not worry. We spoke with Rachel Rosovsky, President Elect, Hematologist at Massachusetts General Hospital on home management of VTE, appropriate patient selection, and role for follow up once discharged.
The PERT Consortium® kindly invites you to listen to the audio from our webinar entitled, “Endo Wars: Aspirate vs. Dissolve”.
Experts will debate the optimal management for two patients with intermediate-high risk pulmonary embolism. In these two debates, we will explore the evidence and practice patterns supporting the use of anticoagulation alone vs. catheter-directed therapies. We will also compare catheter-directed thrombolysis to catheter-directed thrombectomy as a means of managing patients with acute pulmonary embolism.
This webinar will be moderated by Geoff Barnes, MD, MSc. Our speakers are Carin Gonsalves, MD, FSIR, Jay Giri, MD, MPH, Maya Serhal, MD, and Keith Sterling, MD, FSIR.
Episode 8: Our guest, Dr. Robert Lookstein, MD, MHCDL is a Professor of Radiology and Surgery at Mt Sinai as well as the Executive Vice Chairman of Radiology and the current President of the PERT Consortium.
#PERTprez speaks!
Episode 7: Our guest, John Moriarty MD FSIR is an interventional radiologist and an Associate Professor at UCLA with appointments in both the Departments of Radiology and Internal Medicine.
James Horowitz MD FACC FAHA is a cardiac intensivist and is the director of the Cardiac ICU and NYU Langone Health.
Links:
Endovascular Removal of Thrombus and Right Heart Masses Using the AngioVac System: Results of 234 Patients from the Prospective, Multicenter Registry of AngioVac Procedures in Detail (RAPID).
Moriarty J, et al. JVIR. 2021. PMID: 33526346
https://pubmed.ncbi.nlm.nih.gov/33526346/
The AngioVac system as a bail out option in infective endocarditis
Starck CT, et al. Ann Cardiothoracic Surg. 2019. PMID: 31832358
https://pubmed.ncbi.nlm.nih.gov/31832358/
The Role of Percutaneous Vacuum-Assisted Thrombectomy for Intracardiac and Intravascular Pathology
Basman C, et al. J of Cardiac Surg. 2018. PMID: 30187515
https://pubmed.ncbi.nlm.nih.gov/30187515
Factors Associated with Successful Thrombus Extraction with the AngioVac Device: An Institutional Experience
D'Ayala et al. Annals of Vascular Surgery. 2017. PMID: 27521826
https://pubmed.ncbi.nlm.nih.gov/27521826/
Percutaneous Retrieval of an Embolized Vegetation from Pulmonary Artery After ICD Lead Extraction
Bhansal HM et al JACC 2020 Supplement
https://www.jacc.org/doi/pdf/10.1016/S0735-1097%2820%2933256-3
The PERT Consortium® kindly invites you to listen to the aiudio from our webinar entitled “What Would You Do? Real Life Cases.” This webinar is moderated by Ken Rosenfield, MD. Speakers are Amir Darki, MD and Abdul Haseeb Qazi, MD. Panelists include Andrew Klein, MD, Jana Montgomery, MD, ScM, FACC, Hamid Mojibian, MD and Frances Mae West, MD.
Episode 6: Our guest, Scott Cameron MD, PhD is a cardiology and vascular medicine specialist and is the Section Head of Vascular Medicine at Cleveland Clinic
James Horowitz MD is a cardiac intensivist and is the director of the Cardiac ICU and NYU Langone Health.
Links:
The lung is a site of platelet biogenesis and a reservoir for haematopoietic progenitors.
Lefrançais E, et al. Nature. 2017. PMID: 28329764
https://pubmed.ncbi.nlm.nih.gov/28329764/
Lung megakaryocytes are immune modulatory cells.
Pariser D, et al. J Clin Invest. 2021. PMID: 33079726
https://pubmed.ncbi.nlm.nih.gov/33079726/
Megacaryocytes and platelet clumps as the cause of finger clubbing.
Dickinson CJ, Martin JF. Lancet 1987. PMID: 2891996
https://pubmed.ncbi.nlm.nih.gov/2891996/
Histopathologic analysis of extracted thrombi from deep venous thrombosis and pulmonary embolism: Mechanisms and timing.
Silver MJ et al. Catheter Cardiovasc Interv 2021. PMID: 33522027
https://pubmed.ncbi.nlm.nih.gov/2891996/
PERT Podcast
A VTE Discussion With a Focus on ESC Guidelines and Treatment Duration
The PERT consortium invites you to listen to a podcast moderated by Geoff Barnes, MD, and joined by Greg Piazza, MD, Rachel Rosovsky, MD, and George Davis, PharmD, as they discuss extended VTE treatment and the ESC 2019 guidelines.
These podcasts were developed by the featured Pulmonary Embolism Response Team (PERT) Consortium speakers through a sponsorship from Janssen Pharmaceuticals, Inc. Doctors are also paid consultants of Janssen Pharmaceuticals, Inc.
© Janssen Pharmaceuticals, Inc. June 2021 cp-173153v3
PERT Podcast
Management Pathways for PE
The PERT consortium invites you to listen to a podcast moderated by Emily Gundert, MD, and joined by Geno Merli, MD, and Jeff Kline, MD, as they discuss the management of pathways for the treatment and management of pulmonary embolism.
These podcasts were developed by the featured Pulmonary Embolism Response Team (PERT) Consortium speakers through a sponsorship from Janssen Pharmaceuticals, Inc.
© Janssen Pharmaceuticals, Inc. June 2021 cp-173153v3
PERT Podcast
The PERT Approach to the Treatment and Management of Pulmonary Embolism
The PERT consortium invites you to listen to a podcast moderated by Immediate Past President of PERT Consortium, Richard Channick, MD, and joined by Chris Kabrhel, MD, Kenneth Rosenfield, MD, Brent Keeling, MD, Robert Lookstein, MD MHCDL, and Christina Fanola, MD as they discuss the PERT approach to PE management.
These podcasts were developed by the featured Pulmonary Embolism Response Team (PERT) Consortium speakers through a sponsorship from Janssen Pharmaceuticals, Inc. Some Doctors are also paid consultants of Janssen Pharmaceuticals, Inc.
© Janssen Pharmaceuticals, Inc. June 2021 cp-173153v3
PERT Webinar - Cases Over Cocktails
Hear How Experts Are Treating Challenging PE Cases
The PERT Consortium invites you to join our next webinar, Cases over Cocktails, with our current and past presidents, Richard Channick, MD and Victor Tapson, MD, FCCP, FRCP and moderated by PERTs’ first president, Kenneth Rosenfield, MD, MHCDS, FACC, MSCAI. Hear how experts are treating challenging PE cases.
PERT Webinar - PE And the Covid Pandemic
Expert Opinions from European and US Hot Spots
The PERT Consortium invites you to join another ground breaking webinar with our colleagues from Spain, the Netherlands, and New York- David Jimenez, MD, Erik Klok, MD, and Matt Langston, MD. Learn how international and U.S. clinicians face the challenges surrounding PE and the COVID-19 Pandemic. This will be a 2 hour webinar-including case presentations, and Q & A. Our expert panelists include: James Horowitz, MD, Brent Keeling, MD, Robert Lookstein, MD, MHCDL, Seth Sokol, MD, Victor Tapson, MD.
PERT Webinar - COVID-19 and Pulmonary Embolism
Perspectives from China and the United States
The PERT Consortium invites you to join this ground breaking webinar with Charles Grodzin, MD, and our Chinese colleague, Shaoping Nie, MD, PhD, FESC, FSCAI to learn about how US and international clinicians are facing the challenges surrounding PE care in the COVID-19 epidemic. This will be a 2 hour webinar-including a case presentation, and time for Q&A. Our expert panelists include: Geoffrey Barnes, MD, MSC, James Horowitz, MD, Andrew J.P. Klein, MD, FACC, FSCAI, Rachel Rosovsky, MD, MPH and Vic Tapson, MD.
Episode 5: Dr. Rosovsky interviews Dr. Robert Lookstein about the new PERT Consortium Database!!
Dr. Lookstein is a Professor of Radiology and Surgery at the Icahn School of Medicine at Mount Sinai.
Dr. Rosovsky is the Director of Thrombosis Research within the Division of Hematology at Mass General Hospital.
Episode 4: Dr. Rosenfield interviews Dr. Richard Channick on Post PE care!
Dr Channick is the current PERT Consortium president and is the Director of the Acute and Chronic Thromboembolic Disease Program within the David Geffen School of Medicine at UCLA.
Dr. Rosenfield is Section Head of Vascular Medicine and Intervention at Mass General Hospital and past PERT president and founder.
What happens after a PE?
- Following acute pulmonary embolism some patients do not return to their baseline and may suffer from what is called post PE syndrome.
- Some of these unfortunate patients develop chronic thromboembolic disease or chronic thromboembolic pulmonary hypertension
Follow Up Clinic
- In clinic it's important to assess if patients have returned to their baseline of physical acitivity. If the answer is no, then go for objective testing
- First step may be getting a follow-up echocardiogram or repeat imaging
- CTA is extremely helpful for acute pulmonary embolism. CTA is less revealing for chronic pulmonary embolism. VQ scan is the most sensitive test for the chronic pulmonary embolism. If VQ scan is normal 8 to 10 weeks following acute PE rhythm you do not have any chronic pulmonary embolism
- Following an abnormal VQ scan next steps should be --> evaluated for CTED or CTEPH.
Define chronic thromboembolic pulmonary hypertension and its characteristics?
- CTED or CTEPH is a scar tissue forming in pulmonary vessels is not an acute clot. à higher degree of such vascular obstruction will lead to increase in PVR and eventually PHTN and RV dysfunction.
- CTED or CTEPH has distinct appearance on imaging: Chronic clot may have appearance of fibrous bands, webs or bands. Appearance is quite different than acute clot.
- Extremely high pulmonary artery pressure of about 80 or 90 millimeters of Hg suggest chronic right ventricular pressure overload.
- Bronchial collaterals on CTA may suggest a chronic process.
Acute Vs Chronic Clot on Imaging:
- Acute clot will have a central occlusive appearance.
- Sometimes it is hard to differentiate. If patient has not been anticoagulated in the past you anticoagulate and do a follow-up in 8 to 10 weeks.
- Signs of RV hypertrophy on the echocardiogram also suggests a chronic process
Treatment of chronic thromboembolic pulmonary hypertension
- First-line of treatment is surgical. [It is complicated cardiac surgery that involves expert surgical team. It involves cardiopulmonary bypass, deep hypothermic arrest and needs and expertise.]
- Balloon pulmonary angioplasty growing evidence.
- RIOCIGUAT is the only approved drug for CTEPH. Macitentan has been studied but not approved. PDE inhibitors also have been tried
- Upfront medical therapy should not delay the referral for the patients who potentially are surgical candidates.
Types of chronic thromboembolic pulmonary disease and surgical classification
- Four levels depend on whether the disease starts
- If the disease starts proximally it is easier for the surgeon to dissect. It depends where the chronic clots are involving the pulmonary vasculature.
Level 1 disease: Proximal disease
Level 2 disease: Lobar disease
Level 3 disease segmental disease
Level 4 disease sub-segmental disease
Basics Concepts of Balloon Pulmonary Angioplasty (BPA)
- It involves dilating the narrowed pulmonary segments and improve with the primary pulmonary perfusion and reducing the pulmonary hypertension.
- First step is to do the pulmonary angiogram. Then match the perfusion defects with the VQ scan. Work as a team.
- Goal is not to over distend the pulmonary vasculature. Goal is just to break up the scar or the fibrous tissue and increase distal perfusion. Vascular stenting is not performed usually.
- BPA is a staged procedure. The session can last anywhere between 2-3 to 12-13 sessions.
- Each session is 2 to 3 hours involves fair amount of radiation and the contrast.
- Pulmonary hemorrhage is a very serious complication; BPA has a learning curve.
Episode 3: James Horowitz interviews Rachel Rosovsky on DOACs.
Dr. Rosovsky is the Director of Thrombosis Research in the Division of Hematology at Mass General Hospital. She is also an Assistant Professor at Harvard and a member of the Board of Directors of the PERT Consortium.
Dr. Horowitz is the Director of the CCU at NYU Langone Health and the Co-Chair of the Interdisciplinary Resuscitation Committee. He is also an Assistant Professor or Medicine and a member of the Board of Directors of the PERT Consortium.
Directly acting oral anticoagulants.
- FDA approved DOACS: Xarelto (rivaroxaban), Eliquis (apixaban), Savasya (edoxaban), Pradaxa (dabigatran).
- All DOACs have similar efficacy in terms of VTE occurrence and better safety profile compared compared to Coumadin.
MOA:
- Dabigatran: directthrombin inhibitor.
- Rest of the DOACs: factor X inhibitors.
- DOACS usually do not need monitoring. Most common interaction noted with drugs like ketoconazole (CYP3A4).
Dosing:
- Dabigatran and Edoxaban: Overlap with parenteral enoxaparin for 5 to 10 days is needed.
- Apixaban and Rivoraxaban: Need loading dose. For apixaban it is 10 mg 2 times a day for 7 days followed by 5 mg 2 times a day. Rivaroxaban: 15 mg 2 times a day for 21 days followed by 20 mg once a day. (Xarelto need to be taken with food)
- Only 55% of the patients with Coumadin remain in therapeutic range.
Drug reversal agents for DOACs
- Dabigatran reversal: Idarucizumab
- Xarelto and Eliquis reversal: Andexenat Alpha.
Factors in deciding candidacy for DOACs:
- DOACs in patients with Child-Pugh score B/C cirrhosis should not be used.
- Renal failure with CrCl <30: either low dose DOACs (i.e. edoxaban) or avoid DOACs.
- No DOACs for weight >120 kg, based on ISTH guidelines. (higher the BMI may have increased risk of bleeding with better efficacy, potentially due to absorption issues-- levels can fluctuate)
Drug monitoring for DOACs:
- No standardized methods. Not routinely done.
- It should be considered in patients with extremes of weight and patients who have gone gastric/bariatric surgeries, because all DOACs are absorbed get into upper GI tract.
Pregnancy and Venous thromboembolism:
- No DOACs in pregnancy.
- Enoxaparin is the treatment of choice -1 mg/kg every 12 hours up to week 36 followed by changing them to unfractionated heparin. (subcutaneous calculated dose).
- Patients who had prior DVTs/PEs and become pregnant may need prophylactic dose of enoxaparin (40 mg subcutaneous once a day)
Cancer and VTE:
- VTE is a second leading cause of death in cancer patients.
- Drug of choice was enoxaparin over warfarin.
- Edoxaban Vs Enoxaparin: Edoxaban with less recurrent VTE, but worse bleeding profile (most bleeds in gastric cancer patients)
- Rivaroxaban Vs Enoxaparin: Rivaroxaban with less recurrent VTE, but worse bleeding profile (most bleeds in gastric cancer)
- Cancer patients who may not be good candidate: a) GI cancer b) needing many procedures c) liver/renal failure d)brain mets.
Provoked vs Unprovoked and extended a/c:
- Unprovoked PE: Two-year risk of recurrence 25% or higher.
- Provoked by surgery [mainly orthopedic surgery, pregnancy, long hospital stay]: risk of recurrence 1% at one year, 3% at 5 years.
- Flying is a weak risk factor to be considered as provoked.
- Amplify-Ext trial: 70% decrease risk of recurrence with low dose apixaban without an increased risk of bleeding in unprovoked VTE.
- Einstein Choice trial: 70% decrease risk of recurrence with low dose rivaroxaban without an increased risk of bleeding. 60% of patients had provoked VTE with ongoing risk factors. (i.e. Obese patients, patients who are immobile, and are still immobile).
Cancer screening following PE:
- 5-10% of patients with VTE would be diagnosed with malignancy in next 5 years. Recommendation is to do age appropriate cancer screening.
Valves and DOACS:
- (increase risk of ischemic events)
Reference:
Rali P, Gangemi A Moores A et al. Direct-Acting Oral Anticoagulants in Critically Ill Patients. Chest. 2019 Sep;156(3):604-618.
Episode 2: Oren Friedman interviews Ken Rosenfield on catheter directed lytics.
Oren Friedman MD
Associate Director, Cardiac Surgery ICU
Pulmonary Critical Care
Cedars-Sinai Medical Center
Ken Rosenfield, MD, MHCDS
Section Head, Vascular Medicine and Intervention
Division of Cardiology
Mass General Hospital
What is catheter directed thrombolysis (CDT)?
- Placing a catheter via femoral or IJs into pulmonary arteries and infusing low dose thrombolytic over extended period.
- Percutaneous mechanical thrombectomy differs as it involves extracting thrombus from pulmonary artery. (mostly from proximal pulmonary arteries, and no thrombolytic regimen used in this method)
MOA of CDT compared to peripheral systemic thrombolysis
- More clot bound thrombolytic directly into the clot compared to around the clot with systemic tPA.
- Increased local thrombolytic concentration.
- Reduced tPA and longer duration of infusion—reason for increased safety profile for ICH and major bleeding compared to full dose systemic tPA. (dose is 100 mg, ICH rates 3-5%)
- CDT also allows improve tPA infusion to into distal pulmonary circulation bed. (Vs percutaneous mechanical embolectomy)
Technical aspects of CDT:
- Pulmonary angiogram is not always needed at time of CDT or post CDT.
- Decision to place unilateral or bilateral catheters (right, left or both branches of pulmonary artery) depends on location of clot based on CTA.
- Patient are usually monitored in ICU while drugs are infusing, close monitoring and experienced clinical nursing staff should be involved.
- Heparin during CDT: fix dose 300-500 unit/per catheter sheaths. Hard to achieve targeted aPTT (40-60) given very short duration of infusion. Fibrinogen to guide tPA duration- limited to no data
- Catheter directed thrombolysis with (EKOS) ultrasound or without ultrasound: We just don’t know. The available data stems from prospective clinical trials with ultrasound catheters.
- Sedation: be careful with sedation. Use minimum. Avoid intubation for procedure itself.
What is successful CDT?
- Goal is to improve hemodynamics, not to remove all thrombus. Drop in pulmonary artery pressures (if monitoring available) or improved RV/LV ratio in pre-vs Post intervention imaging. [Echo or CTA]
Data on CDT
-
Impact on RV/LV ratio, as primary goal of improvement in many trials (see Table below)
-
- ULTIMA trial: Heparin Vs CDT, with EKOS catheters. Rapid normalization of RV/LV ratio compared to heparin alone in immediate period. No difference at 90 days. Small numbers to show impact on mortality.
- SEATTLE II trial -- also included massive PE patients.
- PERFECT registry: prospective registry showing safety and efficacy of CDT.
- OPTALYSE trial: compared different CDT dosing regimens.
-
Impact on long term disability like CTED or CTEPH remains to be seen.
Dosing regimens for of CDT: (See Table below)
- Higher risk bleeding patients: use as low as dose possible.
- OPTALYSE trial: Lower dose (as low as 4-8 mg) and shorter duration are effective for hemodynamic improvement. Higher doses were associated with better Miller clot burden improvement with increased risk of bleeding. (2 ICH incidents)
Rali P, Criner J. Am J Respir Crit Care Med. 2018 Sep 1;198(5):588-598
Welcome to the first episode of PERTCast, the official podcast of the PERT Consortium!
Episode 1: Oren Friedman interviews Vic Tapson about risk stratification of the pulmonary embolism patient.
Oren Friedman MD
Associate Director, Cardiac Surgery ICU
Pulmonary Critical Care
Cedars-Sinai Medical Center
Victor Tapson MD
Professor of Medicine
Director, Venous Thromboembolism and Pulmonary Vascular Disease Research Program
Associate Director, Pulmonary and Critical Care Section
Cedars-Sinai Medical Center
PE risk stratification Pearls: history and classifications.
- Patient’s appearance and vitals (initial and trend) are most important parts of risk stratification algorithm.
- Syncope can have a wide differential. Syncope in setting of PE can have significant consequences.
- Patient resting comfortably can be reassuring, but at the same time ask- what happens on exertion, to gauge the severity of symptoms (i.e. dizziness, near syncope etc.)
- Profound hypoxemia is under recognized in PE classification.
- European Society of Cardiology (ESC) integrates PESI, and sPESI score that is much more practical way of PE classification.
- ESC classification divide PE into Intermediate PE (Submassive PE) in to two categories- Intermediate high risk (positive sPESI score, RV dysfunction and biomarker positivity) or Intermediate low risk (Positive sPESI score, and RV dysfunction or biomarker positivity).
- PE classification is heterogeneous, patient’s hemodynamics can evolve, so will be their risk stratification score.
Biomarkers in PE risk stratification:
- Troponin more sensitive than BNP. Be careful for false positives (elevated BNP in chronic heart failure)
- Lactic acid can provide prognostic information in setting of PE.
CTA based risk stratification:
- Contrast reflux into IVC/Liver
- RV/LV ratio >0.9
- Clot burden, 40% occlusion of pulmonary circulation can be associated with high PE related mortality.
Echo based risk stratification:
- Normal RV can’t generate systolic pressure in the excess of 50-60 mm Hg.
- Elevated PA systolic pressure >70-80 mm HG suggest chronic component of RV failure
- RV need to have good systolic function to generate high PA pressure
- TAPSE is not the holy grail of RV dysfunction, interpret with caution.
Residual DVT
- Extensive DVT (above knee) with higher risk PE have worse outcomes.
- Patient activity (few days to weeks) should be restricted.
- IVC filter should not be considered in every case of PE with DVT.
Treatment Pearls:
- Every patient with acute PE should be promptly anticoagulated.
- Change in vital trends or persistently abnormal vital signs may help in consideration of advance reperfusion strategies in same PE category.
Take home message:
- Look at patient’s appearance + Vitals (HR, RR) and add other objective measures (sPESI, Biomarkers, imaging) + Residual clot burden in risk stratification.
- Activate the multidisciplinary PERT to leverage input from local experts.
References:
- Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014;35(43):3033-69, 3069a-3069k.
- Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-9.
- Van der meer RW, Pattynama PM, Van strijen MJ, et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology. 2005;235(3):798-803.
- Prandoni P, Lensing AW, Prins MH, et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. N Engl J Med. 2016;375(16):1524-1531.
- Becattini C, Cohen AT, Agnelli G, et al. Risk Stratification of Patients With Acute Symptomatic Pulmonary Embolism Based on Presence or Absence of Lower Extremity DVT: Systematic Review and Meta-analysis. Chest. 2016;149(1):192-200.
- Grau E, Tenías JM, Soto MJ, et al. D-dimer levels correlate with mortality in patients with acute pulmonary embolism: Findings from the RIETE registry. Crit Care Med. 2007;35(8):1937-41.