Contemporary Trends in Pulmonary Embolism Management and The Value of Intervention in Massive Unstable Embolism
Clancy W. Mullan1, Joshua S. Newman2, Merideth Geib3, Matthew D. Pichert1, Stevan S. Pupovac2, Alan Hartman2, Brian Lima2.
1Yale University School of Medicine, New Haven, CT, USA, 2Northwell health, Manhasset, NY, USA, 3Long School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
Pulmonary embolectomy is a high-risk procedure offered to critical patients. Short-term outcomes from the National Inpatient Sample (NIS) were described as of 2008, but recent data is lacking. This study characterizes the national trends in incidence, management, and outcomes of pulmonary embolism, along with population-level outcomes.
NIS records from 2005 to 2014 were identified by ICD-9 as having pulmonary embolism. Saddle embolisms, shock, and interventions (systemic thrombolysis, catheter-directed therapy, ECMO, and pulmonary embolectomy) were similarly identified. Regression analysis was performed to identify predictors of in-hospital mortality. Saddle embolism records with shock undergoing embolectomy were propensity matched to records without surgical embolectomy by patient- and hospital-level characteristics, producing 189 weighted matched pairs.
2,913,015 pulmonary embolisms - 34,040 with saddle embolism (1.2%) - were identified. 54,698 (1.9%) had shock. Embolectomy and catheter-directed therapies were associated with reduced mortality in saddle embolism with shock (n=1,768, odds ratios (OR) 0.31 [95% CI, 0.20-0.49] and OR 0.68 [0.48-0.95], respectively). Systemic thrombolytic did not affect mortality (1.08 [0.86-1.37]). ECMO utilization increased mortality (2.17 [1.05-4.47]). Propensity matching, embolectomy records had lower rates of systemic thrombolysis (12.5% vs 44.8%, p<0.001) and catheter directed intervention (10.0% vs 20.4%, p=0.004), higher ECMO utilization (2.5% vs 0.0%, p= 0.026), and lower mortality (17.6% vs 30.6%, p<0.001). The number needed to treat for in-hospital mortality of saddle embolisms with shock is 4.8 (95% CI 4.0-7.1).
In this study of nationally representative data, surgical embolectomy was associated significantly reduced in-hospital mortality for patients with saddle pulmonary embolism and shock.
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