Merren, Michael P.

Pulmonary embolism (PE) is a leading cause of cardiovascular morbidity and mortality. Systemic thrombolysis is recommended for high-risk PE, but risk of major bleeding limits its use despite its efficacy. While mechanical thrombectomy (MT) has emerged as an alternative reperfusion strategy, real-world safety data remains limited. The objective of this single-center retrospective observational cohort study was to characterize the safety profile and procedural complications of MT. Methods Adult patients with intermediate-risk and high-risk PE who underwent MT at a quaternary academic medical center between January 1, 2017, and December 31, 2024, were included. Demographic, clinical, laboratory, imaging, procedural, outcome, and mortality data were collected. Major adverse events and bleeding were defined according to established criteria. Results From a total of 103 screened patients, 65 were included. Of these, 22 (34%) were classified as high-risk and 43 (66%) as intermediate-risk. Baseline demographics were similar between groups. High-risk patients demonstrated greater clinical disease severity, with higher mean Pulmonary Embolism Severity Index (PESI) scores (188.5 vs 122.4). Clinical deterioration prior to MT occurred in 35% of intermediate-risk patients. Extracorporeal membrane oxygenation (ECMO) consultation rate (32% vs 7%), peri-procedural ECMO use (18% vs 2.3%), major bleeding (27% vs 4.7%), and in-hospital mortality (36% vs 11.6%) were higher in the high-risk group. Thrombus removal was achieved in 77% and 88% of high- and intermediate-risk patients, respectively. High-risk patients had longer ICU (mean 4 vs 1.3 days) and hospital stays (mean 21.5 vs 6.4 days), higher thirty-day mortality (36% vs 14%), and lower 90-day survival (59% vs 79%). Conclusions MT achieved high rates of thrombus removal in both groups. In this retrospective cohort, high-risk patients had greater baseline clinical severity and was associated with higher bleeding rates, greater resource utilization, including ECMO consultation and peri-procedural use, prolonged ICU and hospital stays, as well as increased mortality.

Mortality rates from pulmonary embolism (PE) remain significant, highlighting the need for alternative treatment strategies beyond traditional anticoagulation. Percutaneous interventions, including mechanical thrombectomy and catheter-directed thrombolysis, are emerging as promising options. Given the complex pathophysiology and unique risk profiles of these patients, meticulous multidisciplinary planning is essential. Anesthesiologists play a central role in coordinating care and managing perioperative risks to improve outcomes. This article provides insights into best safety practices and shares experiences from a leading quaternary center. It offers guidance for anesthesia providers to proactively engage in comprehensive risk stratification, participate in multidisciplinary discussions, and support robust contingency planning for managing PE patients undergoing percutaneous interventions in non-operating room anesthesia settings.

Highlights Biplane ultrasound imaging reduces need for probe manipulation during procedure. Providers note clinical benefit of biplane ultrasound imaging for vascular access. Biplane disadvantages include probe size, imaging quality, size of the screen. Thorough didactic and practical education is essential for biplane success. Abstract Background: Use of ultrasound guidance for vascular access procedures is commonplace in inpatient and outpatient care settings. Standard ultrasound probes offer the operator a single-plane view, necessitating rotation of probe to attain dual complimentary views. This mechanical probe rotation increases technical difficulty of ultrasound use. The purpose of this study is to evaluate the rate of cannulation success and efficiency of a synchronous biplane ultrasound mode in ultrasound-guided arterial line placement as compared with a standard single-view ultrasound mode in the operating room setting. Methods: Patients scheduled for elective surgery in which a radial arterial catheter would be used for hemodynamic monitoring were approached for consent to this study. Patients were randomized to either undergo placement with single-plane view versus synchronous biplane view; outcomes were recorded. Providers were provided preprocedural ultrasound education as well as the option of a short hands-on experience; their level of experience was noted. Results: Placement time of a peripheral arterial catheter was longer and required more attempts to be successful using synchronous biplane imaging as compared with single-plane imaging across providers of all skill/experience levels. Subjectively, providers noted the benefit of synchronous biplane imaging in vascular access; however, disadvantages including probe size, quality of imaging, and size of the screen were noted. Discussion: Thorough education regarding the use and functionality of biplane synchronous imaging in vascular access is essential. Additional guided-practice time with experienced operators could also be helpful to overcome the challenges observed in this study.

Pulmonary embolism (PE) embodies a large healthcare burden globally and is the third leading cause of morbidity and mortality worldwide. Submassive (intermediate-risk) PE accounts for 40% of this burden. However, the optimal treatment pathway for this population remains complex and ill-defined. Catheter-directed interventions (CDIs) have shown promise in directly impacting morbidity and mortality while demonstrating a favorable success rate, safety profile, and decreased length of stay (LOS) in the intensive care unit and hospital. This retrospective review included 22 patients (50% female) with submassive PE who underwent mechanical thrombectomy (MT). A total of 45% had a contraindication to thrombolytics, the mean pulmonary embolism severity index was 127, 36% had saddle PE, the average decrease in mean pulmonary artery pressure (PAP) was 7.2 mmHg following MT, the average LOS was 6.9 days, the 30-day mortality rate was 9%, the major adverse event (MAE) rate was 9%, and the readmission rate was 13.6%. A total of 82% had successful removal of thrombus during MT with no major bleeding complications, intracranial hemorrhage events, or device-related deaths. Acknowledging the limitation of our small sample size, our data indicate that MT in the intermediate-high-risk submassive pulmonary embolism (PE) cohort resulted in a decreased hospital length of stay (LOS) and in-hospital mortality compared to standard anticoagulation therapy alone.