Peripheral interventions

A nationwide analysis of reperfusion therapies for pulmonary embolism in older patients with frailty

EuroIntervention 2023;19:772-781. DOI: 10.4244/EIJ-D-23-00399

Ioannis  T. Farmakis
Ioannis T. Farmakis1, MD; Stefano Barco1,2, MD; George Giannakoulas3, MD; Karsten Keller1,4,5, MD; Luca Valerio1,4, MD; Tobias Tichelbäcker6, MD; Sasan Partovi7, MD; Ingo Ahrens8, MD; Stavros V Konstantinides1,9, MD; Lukas Hobohm1,4, MD
1. Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; 2. Department of Angiology, University Hospital Zurich, Zurich, Switzerland; 3. Department of Cardiology, AHEPA University General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece; 4. Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; 5. Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany; 6. Clinic III for Internal Medicine, Heart Centre of University Hospital of Cologne, Cologne, Germany; 7. Interventional Radiology Section, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA; 8. Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Cologne, Germany; 9. Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece

Background: Reperfusion therapy is challenging in the elderly. Catheter-directed therapies are an alternative for higher-risk pulmonary embolism (PE) patients if systemic thrombolysis (ST) is contraindicated or has failed. Their safety has not been evaluated in specific vulnerable populations.

Aims: We aimed to assess the safety of reperfusion therapies in elderly and frail patients in the real world.

Methods: In the US Nationwide Inpatient Sample from 2016 to 2020, we identified hospitalisations of patients ≥65 years with PE and defined a frailty subgroup using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. We investigated reperfusion therapies (ST, catheter-directed thrombolysis [CDT], catheter-based thrombectomy [CBT], surgical embolectomy [SE]) and their associated safety outcomes (overall and major bleeding).

Results: Among 980,245 hospitalisations of patients ≥65 years with PE (28.0% frail), reperfusion therapies were used in 4.9% (17.6% among high-risk PE). ST utilisation remained stable, while the use of catheter-directed therapies increased from 1.7% in 2016 to 3.2% in 2020. Among all hospitalisations with reperfusion, CDT, compared to ST, was associated with reduced major bleeding (5.8% vs 12.2%, odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.49-0.70); these results also applied to frail patients. CBT, compared to SE, was also associated with reduced major bleeding (11.0% vs 22.4%, OR 0.63, 95% CI: 0.43-0.91), but not among frail patients. These differences were particularly significant in patients with non-high-risk PE. Differences persisted for overall bleeding as well.

Conclusions: Catheter-directed therapies may be a safer alternative to classical reperfusion therapies for elderly and frail patients with PE requiring reperfusion treatment.

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catheter-directed therapieselderly (>75 years)frailtymiscellaneouspulmonary embolismreperfusionthrombolysis
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