- Email: [email protected]
Catheter-Directed Intervention for Acute Pulmonary Embolism: Response
tPA.6 The estimated risk of major hemorrhagic complications from systemic tPA is 5%.7 If these statistics hold true, then IV thrombolysis may be the true double-edged sword. Thus, a randomized trial comparing systemic tPA to a standardized CDI protocol is warranted. We are pleased that Dr. Goldhaber will assume a leadership role in establishing a global registry for catheter-directed treatment of PE, and we offer our full support from the Stanford Division of Vascular and Interventional Radiology. Although more research is needed, the best available evidence suggests that CDI is a safe and highly effective treatment.5 Indeed, we believe catheter-directed intervention is not a double-edged sword but rather a shining saber in the fight against PE. William T. Kuo, MD Daniel Y. Sze, MD, PhD Lawrence V. Hofmann, MD Stanford University Medical Center Stanford, CA The authors have no conflicts of interest to disclose. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: William T. Kuo, MD, Department of Radiology, Stanford University Medical Center, 300 Pasteur Drive, H-3651, Stanford, CA 94305-5642; e-mail: [email protected] DOI: 10.1378/chest.07-2278
References 1 Goldhaber SZ. Percutaneous mechanical thrombectomy for acute pulmonary embolism: a double-edged sword. Chest 2007; 132:363–364 2 Kumar N, Janjigian Y, Schwartz DR. Paradoxical worsening of shock after the use of percutaneous mechanical thrombectomy (PMT) device in a post partum patient with a massive pulmonary embolism. Chest 2007; 132:677– 679 3 Sharafuddin MJ, Hicks ME, Jenson ML, et al. Rheolytic thrombectomy with use of the AngioJet-F105 catheter: preclinical evaluation of safety. J Vasc Interv Radiol 1997;8:939–945 4 Dwarka D, Schwartz SA, Smyth SH, et al. Bradyarrhythmias during use of the AngioJet system. J Vasc Interv Radiol 2006; 17:1693–1695 5 Skaf E, Beemath A, Siddiqui T, et al. Catheter-tip embolectomy in the management of acute massive pulmonary embolism. Am J Cardiol 2007;99:415– 420 6 Kuo WT, Van den Bosch MA, Hofmann LV, et al. Catheterdirected embolectomy, fragmentation, and thrombolysis for the treatment of massive pulmonary embolism after failure of systemic thrombolysis [abstract]. Presented at CHEST 2007, the American College of Chest Physicians Annual Meeting; October 2007; Chicago, IL 7 Bovill EG, Terrin ML, Stump DC, et al. Hemorrhagic events during therapy with recombinant tissue-type plasminogen activator, heparin, and aspirin for acute myocardial infarction. Ann Intern Med 1991; 115:256 –265
Response To the Editor: Kuo et al write elegantly about percutaneous mechanical thrombectomy (PMT). In my recent editorial,1 I called it a “doubleedged sword,” but they extol the procedure as “a shining saber.” I think they are polishing their equipment, and the reflection is dazzling. That is certainly the situation when PMT does what is intended. Success begets success. However, a dazzling saber sometimes causes glare, which in turn can challenge visibility. 318
The Stanford Group does not like the AngioJet device (Possis Medical; Minneapolis, MN) for PMT. However, many interventionalists do use the AngioJet device because of their familiarity with it and because of sporadic but dramatic “saves” of patients who otherwise appear doomed to succumb to acute pulmonary embolism (PE). Nevertheless, all of us interested in PMT are operating in a data-free zone. For this reason, the Venous Thromboembolism Research Group and the North American Thrombosis Forum (www.NATFonline.org) will join forces with the Stanford Division of Vascular and Interventional Radiology and all who wish to move the field forward. The initial step will be a collaborative international centralized registry. Despite the problems with PMT, thrombolysis for PE may be equally or even more problematic. Thrombolysis is certainly not by itself a panacea for all PE patients who require more aggressive intervention than anticoagulation alone. At Brigham and Women’s Hospital, we found that of 104 patients receiving PE thrombolysis who were not enrolled in a clinical trial, 19% had major hemorrhagic events.2 Therefore, I agree with Kuo et al that, eventually, a randomized trial of PMT vs thrombolysis should be undertaken. But for now, we must teach each other optimal PMT techniques and develop better equipment to facilitate PMT. Samuel Z. Goldhaber, MD, FCCP Boston, MA The author has no conflict of interest to disclose. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Samuel Z. Goldhaber, MD, FCCP, Cardiovascular Division, Brigham and Women’s Hospital, Professor of Medicine, Harvard Medical School, 75 Francis St, Boston, MA 02115-6110; e-mail: [email protected] DOI: 10.1378/chest.07-2409
References 1. Goldhaber SZ. Percutaneous mechanical thrombectomy for acute pulmonary embolism: a double-edged sword. Chest 2007; 132:363–365 2. Fiumara K, Kucher N, Fanikos J, et al. Predictors of major hemorrhage following fibrinolysis for acute pulmonary embolism. Am J Cardiol 2006; 97:127–129
Body Mass Index in COPD Mortality Is It All in the Water? To the Editor: The article in a recent issue of CHEST (June 2007) by Budweiser et al1 addressed the ability of body mass index (BMI) to predict mortality. Indeed, in a related study2 in a population of cirrhotic patients BMI was found to be a good predictor of malnutrition, although peripheral edema and removal of ascites did not affect the outcome. However, the authors did not address some factors that might account for the positive association of BMI and survival. First, it is possible that the cohort with a BMI ⬎ 25 kg/m2 might not have been at baseline weight (ie, they might have had volume overload), given that patients with advanced COPD often have volume retention.3 Thus, the results might reflect the benefit of diuresis. Indeed, 74% of patients were receiving therapy with diuretics at hospital admission. This hypothesis could be checked by recalculating the BMI on a daily basis or at hospital discharge. Second, it is unclear why confidence intervals are given for Correspondence
References 1 Goldhaber SZ. Percutaneous mechanical thrombectomy for acute pulmonary embolism: a double-edged sword. Chest 2007; 132:363–364 2 Kumar N, Janjigian Y, Schwartz DR. Paradoxical worsening of shock after the use of percutaneous mechanical thrombectomy (PMT) device in a post partum patient with a massive pulmonary embolism. Chest 2007; 132:677– 679 3 Sharafuddin MJ, Hicks ME, Jenson ML, et al. Rheolytic thrombectomy with use of the AngioJet-F105 catheter: preclinical evaluation of safety. J Vasc Interv Radiol 1997;8:939–945 4 Dwarka D, Schwartz SA, Smyth SH, et al. Bradyarrhythmias during use of the AngioJet system. J Vasc Interv Radiol 2006; 17:1693–1695 5 Skaf E, Beemath A, Siddiqui T, et al. Catheter-tip embolectomy in the management of acute massive pulmonary embolism. Am J Cardiol 2007;99:415– 420 6 Kuo WT, Van den Bosch MA, Hofmann LV, et al. Catheterdirected embolectomy, fragmentation, and thrombolysis for the treatment of massive pulmonary embolism after failure of systemic thrombolysis [abstract]. Presented at CHEST 2007, the American College of Chest Physicians Annual Meeting; October 2007; Chicago, IL 7 Bovill EG, Terrin ML, Stump DC, et al. Hemorrhagic events during therapy with recombinant tissue-type plasminogen activator, heparin, and aspirin for acute myocardial infarction. Ann Intern Med 1991; 115:256 –265
Response To the Editor: Kuo et al write elegantly about percutaneous mechanical thrombectomy (PMT). In my recent editorial,1 I called it a “doubleedged sword,” but they extol the procedure as “a shining saber.” I think they are polishing their equipment, and the reflection is dazzling. That is certainly the situation when PMT does what is intended. Success begets success. However, a dazzling saber sometimes causes glare, which in turn can challenge visibility. 318
The Stanford Group does not like the AngioJet device (Possis Medical; Minneapolis, MN) for PMT. However, many interventionalists do use the AngioJet device because of their familiarity with it and because of sporadic but dramatic “saves” of patients who otherwise appear doomed to succumb to acute pulmonary embolism (PE). Nevertheless, all of us interested in PMT are operating in a data-free zone. For this reason, the Venous Thromboembolism Research Group and the North American Thrombosis Forum (www.NATFonline.org) will join forces with the Stanford Division of Vascular and Interventional Radiology and all who wish to move the field forward. The initial step will be a collaborative international centralized registry. Despite the problems with PMT, thrombolysis for PE may be equally or even more problematic. Thrombolysis is certainly not by itself a panacea for all PE patients who require more aggressive intervention than anticoagulation alone. At Brigham and Women’s Hospital, we found that of 104 patients receiving PE thrombolysis who were not enrolled in a clinical trial, 19% had major hemorrhagic events.2 Therefore, I agree with Kuo et al that, eventually, a randomized trial of PMT vs thrombolysis should be undertaken. But for now, we must teach each other optimal PMT techniques and develop better equipment to facilitate PMT. Samuel Z. Goldhaber, MD, FCCP Boston, MA The author has no conflict of interest to disclose. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Samuel Z. Goldhaber, MD, FCCP, Cardiovascular Division, Brigham and Women’s Hospital, Professor of Medicine, Harvard Medical School, 75 Francis St, Boston, MA 02115-6110; e-mail: [email protected] DOI: 10.1378/chest.07-2409
References 1. Goldhaber SZ. Percutaneous mechanical thrombectomy for acute pulmonary embolism: a double-edged sword. Chest 2007; 132:363–365 2. Fiumara K, Kucher N, Fanikos J, et al. Predictors of major hemorrhage following fibrinolysis for acute pulmonary embolism. Am J Cardiol 2006; 97:127–129
Body Mass Index in COPD Mortality Is It All in the Water? To the Editor: The article in a recent issue of CHEST (June 2007) by Budweiser et al1 addressed the ability of body mass index (BMI) to predict mortality. Indeed, in a related study2 in a population of cirrhotic patients BMI was found to be a good predictor of malnutrition, although peripheral edema and removal of ascites did not affect the outcome. However, the authors did not address some factors that might account for the positive association of BMI and survival. First, it is possible that the cohort with a BMI ⬎ 25 kg/m2 might not have been at baseline weight (ie, they might have had volume overload), given that patients with advanced COPD often have volume retention.3 Thus, the results might reflect the benefit of diuresis. Indeed, 74% of patients were receiving therapy with diuretics at hospital admission. This hypothesis could be checked by recalculating the BMI on a daily basis or at hospital discharge. Second, it is unclear why confidence intervals are given for Correspondence