Patients with massive or sub-massive pulmonary embolisms (PEs) often face poor survival odds—not necessarily due to the severity of their disease, but because their treatment is often suboptimal or treated too conservatively. This patient population is critically ill but often misdiagnosed as having acute myocardial infarction (MI). These factors may contribute to PE being one of the most common causes of death in the United States.
In order to reverse high mortality rates associated with PE, the Detroit Medical Center created a PE Response Team (PERT) in 2014. The team was designed to treat PE patients as quickly as possible using advanced modalities, including ultrasound-accelerated, catheter-directed thrombolysis. For a study published in Cath Lab Digest, Mahir Elder, MD, and colleagues assessed more than 1,500 cases of patients hospitalized with acute PE.
“We found that patients who were treated with standard systemic thrombolysis had higher in-hospital mortality and intracranial hemorrhage than those who were treated with catheter-directed thrombolysis,” says Dr. Elder. “To date, the 250 patients who have been treated by our PERT team—called Clotbusters—have a 10% mortality rate, whereas patients at our institution with massive or sub-massive PE who received systemic tPA or heparin have a 60% mortality rate.”
All About PERT
The Detroit Medical Center PERT includes interventional cardiologists, nurses, cardiovascular technologists, and radiation therapists. Initially, referrals to Clotbusters came from emergency physicians with hypotensive patients who needed immediate treatment. “Now, pulmonologists, oncologists, and surgeons with ICU patients who develop PEs activate the pager that mobilizes our team 24 hours per day, 7 days per week,” says Dr. Elder. “We also get referrals from many emergency departments in southeastern Michigan; a radio ad we aired to inform the public about the warning signs of PE also spread the word that we have the expertise and resources to treat these patients.”
Dr. Elder hopes that PERTs eventually will become standard for the treatment of PE. However, before creating a PERT, three essential elements must be in place:
- The multispecialty team has to be inclusive and collaborative. “At one hospital, interventional radiologists saw the PERT as encroaching on their turf and they refused to participate, which killed the program,” Dr. Elder explains.
- Operators must have the skill and clinical judgment to treat hemodynamically unstable patients. Such experience comes from having performed at least 50 successful cases.
- Staff needs a protocol in place so that all equipment is on standby, saving valuable time.
Making a Difference
Clotbusters follows patients after their clots have resolved, educating them on the importance of hydration, exercise, and what to do during prolonged periods of sitting. “About 90% of our patients make changes in their behavior, which significantly reduces the recurrence rates,” adds Dr. Elder. “Many physicians treating patients with massive or sub-massive PE aren’t yet aware of the aggressive and effective advanced technologies to treat these critically ill, unstable patients. Clotbusters is a viable option to significantly improve outcomes for patients with PE. Our goal is to reach every patient with PE who needs life-saving treatment.”
Patel N, Patel N, Agnihotri K, Panaich S, Thakkar B, Patel A, et al. Catheter Cardiovasc Interv. 2015;86:1219-1227. Available at http://onlinelibrary.wiley.com/doi/10.1002/ccd.26108/full.
Cath Lab Digest. Clot busters: the pulmonary embolism program at Detroit Medical Center. Available at www.cathlabdigest.com/article/Clot-Busters-Pulmonary-Embolism-Program-Detroit-Medical-Center
Alhasan R, Qaqi O, Elder M. Saddle embolus and right atrial clot: using catheter-directed thrombolysis for management of massive pulmonary emboli. Cath Lab Digest. 2015;23. Available at www.cathlabdigest.com/article/Saddle-Embolus-Right-Atrial-Clot-Using-Catheter-Directed-Thrombolysis-Management-Massive.
Detroit Medical Center. Racing to save a life. Available at www.dmc.org/mary.
Detroit Medical Center. Close to death, lung clot patient survived after high-tech “catheterization” at DMC. Available at www.dmc.org/?id=2487&sid=1.
Detroit Medical Center. With her life in danger, every second counted. Available at www.dmc.org/colleen.
Detroit Medical Center. Struggling with a deadly pulmonary embolism, he was rescued by the DMC “Clotbuster” team. Available at www.dmc.org/?id=2585&sid=1.