All right, good morning, everyone. So my name is Kachi Ijeoma. I'm a fellow trainee at Mass General Hospital. And thank you for coming for this 10-minute presentation on mechanical thrombectomy. Our objectives are threefold. We're going to review a case that illustrates the use of mechanical thrombectomy for acute PE. We're going to discuss the role of mechanical thrombectomy and the management of acute PE. And then we're going to briefly review mechanical thrombectomy devices which can be used for acute PE. So here's our case. We have a 71-year-old woman with chronic half-path and newly diagnosed metastatic peritoneal carcinomatosis. And she presents with chest pain. Her blood pressure is a little bit soft, 97 over 64. She's tachycardic, tachypneic, and O2 sats 95% of room air. Pertinent labs, her troponin is elevated at 215, hemoglobin 9.7, and her NT-proBNP is elevated just above 4,000. She's put an IV on fraction heparin drip, and imaging is obtained. And you can see on the far left image, her CTP protocol shows that there is a clot that extends from the, in the saddle PE, extending all the way to the lower pulmonary arteries. There's evidence of RV enlargement, RV strain on CT. The RV to LV ratio is greater than one. And in the still frame images in the middle, I'll show you that clot burden, both main PAs. And on the far right, you can see the echo that shows that the RV is enlarged and this RV systolic dysfunction. So my clinical criteria, she is deemed intermediate high-risk PE. Her SPSC score is greater than one. There's elevated troponin, RV dysfunction. So in addition to anticoagulation, how would you manage your acute PE? We do systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, surgical embolactomy, or VA ECMO. And here's what we did. We had a PERT call. You've heard about the PERT team and its relevance this morning. And the recommendation by the PERT team was to proceed with mechanical thrombectomy in addition to her anticoagulation. So our results, the far left image, you can see our baseline hemodynamics, her PA pressure. The mean was about 28 millimeters of mercury in this filling defects in both main PAs. After we did, we used the flowcheaver device to do a mechanical thrombectomy. And her mean PA pressure dropped about eight millimeters of mercury from 28 to 20. And you can see the improved flow in both my arteries. And the far right image shows the aspirated thrombus. And she was transitioned out of the ICU and was eventually sent home on systemic and oral anticoagulation. So percutaneous mechanical thrombectomy. What, how, the big question we ask is when should these devices be used? And the ESC guidelines published in 2019 give us a kind of a algorithm as to when we should use these devices. For high-risk patients with PE, the recommendation by the ESC guideline is these patients will put on hemodynamic support and reperfusion therapy in the shaded. And for those who are deemed to be intermediate high-risk patients, the recommendation is while you treat them in the hospital, you should consider rescue reperfusion if they deteriorate on systemic anticoagulation. Per the ESC guidelines, the ESC guidelines, the ESC guidelines, ESC guidelines, the intermediate high-risk PE patients, the class 2A recommendation to use as an alternative to rescue thrombolytic therapy, you can do surgical embolectomy or use percutaneous catheter-directed therapies for these patients who deteriorate on systemic anticoagulation. So class 2A recommendation. As well as for the high-risk PE patients, also class 2A recommendation that you could do catheter-directed therapy in patients who have failed thrombolysis, systemic thrombolysis, or in whom systemic thrombolysis is contraindicated. We don't have our own AHA, ACC guidelines yet for acute PE, and hopefully these will be coming out shortly regarding these devices. But for catheter-directed therapies for PE, there's three main arms that you can think about these devices. We heard about from Dr. Weinberg, catheter-directed thrombolysis. But initially, we did thrombectomy for these patients using balloon masturbations where you use a pigtail catheter, put it up into the pulmonary arteries, and then just dislodge the clots. This is how we started off in this space. And also, in this space, we also use balloon angioplasty where you use the 7 French balloon and then open it up in the pulmonary arteries and then kind of dislodge the clots. But now we have devices which we hear about, and also on the hands-on station, you can see these devices, how they're used for thrombectomy. We have the flow-treatment device. We have the Lightning 12, as well as the flash devices. These are FDA-approved. And then we also have the AlphaVac, which is an investigational device for acute PE. So for thrombectomy with indigo system, the Lightning 12 and flash systems use a pressure differential or flow-based algorithm that is designed to detect clots. And this helps the operator to reduce the amount of blood loss during the procedure. Few words about the techniques. And once again, the hands-on station encourages us all to go there. Venus axis can be either thermal or IJ. You want to start off getting your baseline PA angiogram, as well as hemodynamics. And then you introduce the lightning catheter to the axis sheet over an O35 wire. The flow switch should be off while you're doing this and advance it all the way up to the clots that you want to, the PA that you want to target. And then when you're about two to three millimeters proximal to the clot, then you can turn your flow switch on. Well, the flow-treatment device is indicated, FDA-indicated, for acute PE management. And there are two modes of action, aspiration suction using a 60-mil large bore syringe, as well as using a nitinol mesh to also help to dislodge or liberate clot from the vessel wall. And I'm just going to skip over this for the interest of time. For the AlphaVac, it's an investigational device. You have a handle that serves as the engine. And you can regulate the amount of blood that you suck out through each suction maneuver, either it's 10 cc or 30 cc, by using the switches that are on the device. And you'll see that on the hands-on station. And the cannula tips, you have a 20-degree or 180-degree tip option for this device. So in summary, catheter-based therapies, as we learned from the guidelines for ESC guidelines, these are adjunctive tools that you can use for the management of high-risk or intermediate high-risk PE. We prefer mechanical thrombectomy for patients who are deemed to be high-risk of bleeding. And that's what's illustrated in our case, patient with metastatic cancer. But other patients who are deemed to be high-risk for bleeding, mechanical thrombectomy is preferred for those patients. And the type of mechanical thrombectomy device, there's no guideline that says one is preferred over the other. We are waiting for clinical trials to help us with that. But your type that you use is predicated by what's available at your local institution, as well as the patient profile and expertise of the provider. And we definitely need more trials to help guide our recommendations regarding catheter-based therapies. The PERC Consortium developed an algorithm, I'll leave that up for you, regarding which pathway to use catheter-directed lysis versus PMT, and it's there for your reference. And thank you so much for listening. And I want to acknowledge the panelists and everyone for this opportunity. Thank you.

mechanical thrombectomy

acute pulmonary embolism

PE management

mechanical thrombectomy devices

catheter-based therapies