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(1/22) Acute PE treatment. An ever evolving landscape.
How about a #tweetorial on acute pulmonary embolism ( #PE) and how to use mechanical #thombectomy with @InariMedical #FlowTriever?? Lets goooooo!
#InariFellowsEdition #IRad #IC #cardiotwitter
Pic credit @jonathan_paulmd
How about a #tweetorial on acute pulmonary embolism ( #PE) and how to use mechanical #thombectomy with @InariMedical #FlowTriever?? Lets goooooo!
#InariFellowsEdition #IRad #IC #cardiotwitter
Pic credit @jonathan_paulmd
2/ From @CDCgov data one American dies of a blood clot every....? #VTE #PE @PERTConsortium #InariFellowsForum
3/ Acute #PE stats
100,000â180,000 PE-related deaths annually in US
PE is the most preventable cause of death among hospitalized patients
3rd leading cardiovascular cause of death after coronary disease and stroke
1 American dies of a blood clot every 6 seconds
100,000â180,000 PE-related deaths annually in US PE is the most preventable cause of death among hospitalized patients3rd leading cardiovascular cause of death after coronary disease and stroke 1 American dies of a blood clot every 6 seconds
4/ One major thing for all trainees out there in #ER and on the floor to know when dealing with #VTE- how a patients presents will dictate management!
Massive (high risk)- hypotension,
perfusion
Submassive (mod risk)- RV strain, hypoxic
Minor (low risk)- limited sx
Massive (high risk)- hypotension, perfusionSubmassive (mod risk)- RV strain, hypoxic Minor (low risk)- limited sx
5/ For this #tweetorial we will be focusing on submassive #PE and how to treat with mechanical thrombectomy when indicated. As a #cardiologist to me its all about the patients clinical condition and the always forgotten RV! #RVstrain #InariFellowsForum
6/ The RV: Thin muscular structure that is compliant.
GOOD at accommodating change in volume
NOT GOOD at accommodating ACUTE changes in pulmonary pressure  Â
#Cardiotwitter #InariFellowsForum #VTE #Hemodynamics
GOOD at accommodating change in volume NOT GOOD at accommodating ACUTE changes in pulmonary pressure   #Cardiotwitter #InariFellowsForum #VTE #Hemodynamics
7/ People from acute PE are dying from #CARDIAC events!
Patients with RVD defined as RV/LV >0.9 have a greater chance of adverse events within 30 days. Adverse event rate at 30 days:
51.3% if RV/LV ratio ⤠0.9
80.3% if RV/LV ratio > 0.9
#InariFellowsForum
Patients with RVD defined as RV/LV >0.9 have a greater chance of adverse events within 30 days. Adverse event rate at 30 days:
51.3% if RV/LV ratio ⤠0.980.3% if RV/LV ratio > 0.9 #InariFellowsForum
8/ And since #EchoBoards are coming up donât forget to look for McConnellâs Sign! #EchoFirst
#echo #echocardiography #cardiotwitter #VTE @ASE360 @rajdoc2005 @DocStrom @echo_stepbystep @Ivan_Echocardio @ChamsiPash @hatemsoliman @PPibarot @Miroinmi @EchoAshwag #InariFellowsForum
#echo #echocardiography #cardiotwitter #VTE @ASE360 @rajdoc2005 @DocStrom @echo_stepbystep @Ivan_Echocardio @ChamsiPash @hatemsoliman @PPibarot @Miroinmi @EchoAshwag #InariFellowsForum
9/ Are we doing a good job with treatment? NO!
2018 MGH #PERT Data Same As 20 Years Ago!  Residual thrombus
poor outcomes.
90 day mortality:
41.3% for massive
12.3% for intermediate (ICOPER rate 20 yrs ago: 14.7%)
2/3 of intermediate-risk deaths were post discharge
2018 MGH #PERT Data Same As 20 Years Ago!  Residual thrombus
poor outcomes. 90 day mortality:
41.3% for massive12.3% for intermediate (ICOPER rate 20 yrs ago: 14.7%)2/3 of intermediate-risk deaths were post discharge
10/ So lets talk about todayâs player- @InariMedical #FlowTriever
FLAIR trial dem safety and RV/LV
20 F system. Powerful rapid aspiration of the clot ( #Whoosh)â
Storage/retrieval of clotâ. 60 cc large bore syringe
Pic: @rishikumarmd -gotta love Cardiac Anesthesia!
FLAIR trial dem safety and RV/LV20 F system. Powerful rapid aspiration of the clot ( #Whoosh)âStorage/retrieval of clotâ. 60 cc large bore syringePic: @rishikumarmd -gotta love Cardiac Anesthesia!
11/ An underrated and utilized aspect of this device is the ability to deploy disks to mechanically engage the clot to assist with removal.
Keys- let all them deploy and let them dwell! (Significant improvement ages 90 sec)
Crucial for removing chronic clot!
#VTE
Keys- let all them deploy and let them dwell! (Significant improvement ages 90 sec) Crucial for removing chronic clot! #VTE
12/ Factors favoring Mechanical #Thrombectomy
Large clot burden
Submassive/massive PE
#Lytic ineligible/actively bleeding
Need for more urgent relief
Able to tolerate large venous sheath insertion
Able to tolerate 1-2 hour catheter procedure
#InariFellowsForum
Large clot burdenSubmassive/massive PE #Lytic ineligible/actively bleedingNeed for more urgent reliefAble to tolerate large venous sheath insertionAble to tolerate 1-2 hour catheter procedure #InariFellowsForum
13/ List of @InariMedical tools needed! Keep this cheat sheet handy! Alright itâs #GAMETIME lets get to the steps! #InariFellowsForum #VTE
14/ STEP 1: ACCESS
Fem or IJ (typically femoral)
Critical to use micropuncture and U/S with large bore catheter (22 Fr)
Master U/S technique. Vein usually collapses, if not use landmarks (mickey mouse view) and Doppler (vein should have continuous flow)
Be wary of prox DVT!
Fem or IJ (typically femoral)Critical to use micropuncture and U/S with large bore catheter (22 Fr)Master U/S technique. Vein usually collapses, if not use landmarks (mickey mouse view) and Doppler (vein should have continuous flow)
Be wary of prox DVT!
15/ STEP 2: Crossing the tricuspid- AVOID the Chordae
Special care must be taken given the size (20 Fr) of the FlowTriever System
Recommended:
Swan or Baim Turi Catheter (PWP)- nice as allows 0.035 wire
Alt:Â Â formed PIG
Monitor hemodynamics and EKG
#InariFellowsForum
Special care must be taken given the size (20 Fr) of the FlowTriever SystemRecommended:
Swan or Baim Turi Catheter (PWP)- nice as allows 0.035 wire Alt:Â Â formed PIGMonitor hemodynamics and EKG#InariFellowsForum
16/ STEP 3: Wiring and Angio
Exchange for PIG and take PA pressure and angio
If pt can hold breath, perform DSA
If unable to hold, cine angiography
Use images to plan landing zone of device
Two strategies for wire navigation: 0.035â or 0.018â
#InariFellowsForum
Exchange for PIG and take PA pressure and angioIf pt can hold breath, perform DSAIf unable to hold, cine angiography Use images to plan landing zone of deviceTwo strategies for wire navigation: 0.035â or 0.018â #InariFellowsForum
17/ STEP 4: ADVANCING
Pay attention to your wire!
Loop is good!
Do not advance triever without the dilator!
Consider buddy wire.
Consider telescope technique with T16 inside T20
#InariFellowsForum #VTR @InariMedical @HadyLichaaMD @AntoniousAttall @DrAmirKaki
Pay attention to your wire! Loop is good! Do not advance triever without the dilator! Consider buddy wire. Consider telescope technique with T16 inside T20 #InariFellowsForum #VTR @InariMedical @HadyLichaaMD @AntoniousAttall @DrAmirKaki
18) STEP 5: WHOOSH!
Perhaps the most important variable in max clot retrieval is: POSITION of T20 relative to the clot.
Optimal is 1-5 mm prox to clot for whoosh.
Consider âDouble whooshâ if needed. Â
Keep wire and catheter position! 
Treat prox to distal.
#VTE
Perhaps the most important variable in max clot retrieval is: POSITION of T20 relative to the clot.
Optimal is 1-5 mm prox to clot for whoosh. Consider âDouble whooshâ if needed.  Keep wire and catheter position! Treat prox to distal. #VTE
19/ STEP 6: check out the HAUL! @InariMedical @JayMathewsMD @HadyLichaaMD @DrNikkiMit @PradeepYadavMD @yuripridemd @datsunian @vcard108 @fady_iskander @t_intheleadcoat #InariFellowsForum #VTE
21/ Overall as a new IC attending and someone that admires the advancement of our field I am very excited to see what the next few years bring in regards to the tx of #VTE. There are many nuances to this procedure I couldnât cover here but please reach out with any questions!
22/ I hope you enjoyed this #Tweetorial ! Thank you @InariMedical for putting on this free fellows course and thank you to Herman Kado and @Thomas_TuMD for sharing many of the pictures and data youâve seen today! Have a great weekend!
@NadeenFaza @bcostelloMD @CMichaelGibson @DocSavageTJU @pravinp8 @ChiznerRyan @onco_cardiology @DocStrom @venkmurthy @SureshSharmaMD @MusaSharkawi @Rahul2282Sharma @NirmanBhatia @ekgpdx @RezaEmaminia @echocardiac @AnwarZaitoun @ChinnaiyanMD @purviparwani @ziadalinyc
