Scientific Letter
Percutaneous management of massive pulmonary thromboembolism
Tratamiento percutáneo del tromboembolismo pulmonar masivo
J.C. Castro-Garay, A. Uribarri
, I. Cruz-González, J. Martín-Moreiras, P.L. Sánchez
Corresponding author
Servicio de Cardiología, Complejo Asistencial Universitario de Salamanca – Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain
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Castro-Garay, A. Uribarri, I. Cruz-González, J. Martín-Moreiras, P.L. Sánchez" "autores" => array:5 [ 0 => array:2 [ "nombre" => "J.C." "apellidos" => "Castro-Garay" ] 1 => array:4 [ "nombre" => "A." "apellidos" => "Uribarri" "email" => array:1 [ 0 => "auribarrig@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "I." "apellidos" => "Cruz-González" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Martín-Moreiras" ] 4 => array:2 [ "nombre" => "P.L." "apellidos" => "Sánchez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cardiología, Complejo Asistencial Universitario de Salamanca – Instituto de Investigación Biomédica de Salamanca, Salamanca, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento percutáneo del tromboembolismo pulmonar masivo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1337 "Ancho" => 2955 "Tamanyo" => 336057 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) CT-angiography of pulmonary arteries showing thrombotic content in the 2 main pulmonary arteries. (B) Transthoracic echocardiogram, apical four-chamber plane, severe dilation of right ventricle. (C) Basal left pulmonary angiography. (D) Fragmentation using pigtail catheter. (E) Left pulmonary angiography after mechanical thrombectomy. (F) Aspirated thrombotic content (arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pulmonary thromboembolism (PTE) is still one of the leading causes of morbimortality in the world.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The European clinical guidelines stratify this entity into various categories based on the risk of death during the first 30 days.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> High risk PTEs start with shock or maintained blood hypotension (defined as systolic blood pressure<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHg for more than 15<span class="elsevierStyleHsp" style=""></span>min not explained by other causes), and in these cases, mortality rates are 35–58 per cent of the cases.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Even though the treatment with systemic fibrinolysis may reduce mortality, it does not come without serious complications. Registries from daily clinical practices estimate that a low percentage of patients with high risk PTE receive fibrinolytic therapy due to various contraindications to receive such therapy.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> In these situations, both the surgical thrombectomy and the percutaneous pulmonary thrombectomy (PPT) have been reported.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Now we will describe our own experience in the therapeutical management of patients with high risk PTE and contraindications for fibrinolysis from January 2015 through January 2016. During this time 15 patients with high risk PTE were admitted in our unit, of which 4 patients (26.7 per cent) underwent one PPT due to contraindications for fibrinolytic therapy.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Case #1 is that of an eighty-year-old female with reported syncope due to cranioencephalic traumatism (CET) that initiated with subdural hematoma. Bilateral PTE is diagnosed and she develops cardiogenic shock that needs precise vasoactive support. PPT is performed and an immediate hemodynamic improvement is confirmed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Case #2 is that of a fifty-year-old female with one active cerebral oligodendroglioma. She is admitted to the hospital with acute respiratory failure and cardiogenic shock; the CT scan confirms presence of bilateral PTE. PTT was performed but yet despite the extraction of a great amount of thrombus, the hemodynamic improvement was insufficient, so we decided to combine local fibrinolysis with a single bolus of 10<span class="elsevierStyleHsp" style=""></span>mg of rtPA administered directly with the catheter with a good response.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Case #3 is that of an eighty-one-year-old female admitted to the hospital due to an episode of out-of-hospital recovered cardiac arrest (RCA). Upon arrival and while studying the etiology of the RCA, one cerebral CT scan is performed that confirms presence of subdural hematoma due to CET. One emergent echocardiogram is performed in the emergency room that confirms presence of dilation and severe right ventricular dysfunction with high probability of PTE.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Due to the situation of shock refractory to high doses of vasoactive drugs, the patient is referred to the unit of hemodynamics where support using venoarterial extracorporeal membrane oxygenation (VA-ECMO) is implanted, one pulmonary angiography is performed that confirms the diagnostic suspicion, and ultimately one PTT was performed with excellent clinical and hemodynamic response that allows the withdrawal of the VA-ECMO after 3 days. Unfortunately, the patient died due to anoxic encephalopathy secondary to the time of the RCA.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The last case is that of a forty-four year-old female with a history of breast neoplasm who was admitted to the hospital for breast reconstruction surgery with abdominal flap. Six hours after the surgery the patient developed sudden shock and acute respiratory failure, and the echocardiogram showed data suggestive of PTE. PTT was performed with excellent results and clinical progression.</p><p id="par0065" class="elsevierStylePara elsevierViewall">All our cases were women of an average age of 63.75 years old. Four women were in shock due to severe right ventricular dysfunction and needed vasoactive support with dobutamine and noradrenaline, plus one of the patients needed support with VA-ECMO. The characteristics of patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Affectation in all cases was proximal and bilateral in both pulmonary arteries.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Once the diagnosis of PTE was confirmed, the indication of immediate perfusion due to its high risk was established and the patients were referred to the unit of hemodynamics to perform one PTT since the systemic fibrinolytic treatment was contraindicated. The percutaneous technique used was the same one in all the cases and consisted of obtaining right femoral venous access, make one pigtail catheter advance through both pulmonary arteries and inject contrast in order to identify the occluded branch. Once the branch to be treated was identified an interchange was tried from extra support guide-wire to catheter-guide-wire or 8F sheath (e.g., Torq Vue<span class="elsevierStyleSup">®</span>, St Jude Medical) that was placed proximal to the thrombus. Fragmentation was accomplished using one pigtail catheter and introducing it through the 8F sheath; then aspiration was attempted through such sheath with support from multipurpose catheters (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). During the PTT all patients received treatment with IV sodium heparin with one dose adjusted to activated coagulation time values of 200<span class="elsevierStyleHsp" style=""></span>s, being the infusion continued when completing the proceeding adjusted to APPT-ratio values of 1.5–2. In all the cases, one variable amount of thrombus was extracted that would lead to significant clinical and hemodynamic improvement.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Before and after the proceeding, pulmonary pressures were measured invasively and an average reduction of the mean pulmonary pressure of 17.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>14.8<span class="elsevierStyleHsp" style=""></span>mmHg was observed. In the patient with VA-ECMO support no measurements of the pulmonary pressure were taken since such measurements cannot be assessed with this kind of support. Improvement of the right ventricular function in the echocardiogram performed 72<span class="elsevierStyleHsp" style=""></span>h after the proceeding was confirmed. The telediastolic diameters of the basal, medial, and longitudinal right ventricle were reduced an average of 16.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.8<span class="elsevierStyleHsp" style=""></span>mm, 10.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.3<span class="elsevierStyleHsp" style=""></span>mm, and 2.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5<span class="elsevierStyleHsp" style=""></span>mm, respectively. Also, the right ventricular function measured using the tricuspid annular plane systolic excursion (TAPSE) was increased an average of 10.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.4<span class="elsevierStyleHsp" style=""></span>mm. After 6 months, the subjects from cases #1, #2 and #4 are still alive with no signs of developing pulmonary hypertension in the control echocardiogram.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The PPT technique includes the mechanical fragmentation of the thrombus and may be completed with the different protocols of local fibrinolysis. Although today there is no unanimous consensus on what the indications and optimal technique are, it is widely accepted that the PPT technique may be assessed in patients with contraindications for fibrinolysis or fibrinolytic failure. Based on our initial experience, we should avoid the combined treatment with local fibrinolysis in patients with contraindications for systemic fibrinolysis, yet despite the fact that the dose of the fibrinolytic agent is lower. In this sense, there are many studies that show that isolated PTT is a feasible and safe technique.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6–9</span></a> Also, an immediate improvement of pulmonary pressures has been reported – something that may be useful in patients with shocks and severe right ventricular failure.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> During the last years, there were also several studies on the use of this technique in patients with sub-massive PTEs with good results.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> The advances of technology with the development of new devices that facilitate the extraction of thrombi together with the growing experience with this type of techniques may, in the coming years, generalize the use of the PPT technique for the management of patients with PTEs.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The goal of this paper is to show our own initial experience in the implementation of an urgent PTT program while benefiting from the presence of one on-call interventional cardiologist 24<span class="elsevierStyleHsp" style=""></span>h/day and 365 days/year, within the recommendations established for the management of ST-segment elevation acute coronary syndrome (STACS). In Spain this type of program would be easier and cheaper to generalize to the large majority of centers with programs of primary angioplasty. To that end, the creation of multidisciplinary teams (ER, ICU, cardiology, radiology, etc.) may improve the management and prognosis of this type of patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have received no funding while conducting this study.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-06-19" "fechaAceptado" => "2016-07-10" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Castro-Garay JC, Uribarri A, Cruz-González I, Martín-Moreiras J, Sánchez PL. Tratamiento percutáneo del tromboembolismo pulmonar masivo. Med Intensiva. 2017;41:437–439.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1337 "Ancho" => 2955 "Tamanyo" => 336057 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) CT-angiography of pulmonary arteries showing thrombotic content in the 2 main pulmonary arteries. (B) Transthoracic echocardiogram, apical four-chamber plane, severe dilation of right ventricle. (C) Basal left pulmonary angiography. (D) Fragmentation using pigtail catheter. (E) Left pulmonary angiography after mechanical thrombectomy. (F) Aspirated thrombotic content (arrows).</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">B RVTD: basal right ventricular telediastolic diameter; L RVTD: longitudinal right ventricular telediastolic diameter; M RVTD: medial right ventricular telediastolic diameter; ECG: echocardiogram; mPASP: mean pulmonary artery systolic pressure; pre: pre-interventional; post: post-interventional; prox: proximal; PASP: pulmonary artery systolic pressure through echocardiogram; TAPSE: tricuspid annular plane systolic excursion (mm); CT: computed tomography; CET: cranioencephalic traumatism; DVT: deep venous thrombosis.</p>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cause of PTE \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic test \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Contraindicated fibrinolysis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre mPASP (mmHg) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post mPASP (mmHg) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6-Month follow-up \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CET (subdural hematoma) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">DVT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cerebral neoplasm (oligodendroglioma) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Not established \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ECG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CET (subdural hematoma) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Exitus</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immobilization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ECG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Major surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1520384.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre mPASP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post mPASP \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre B RVTD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre M RVTD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre L RVTD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post B RVTD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post M RVTD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post L RVTD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre TAPSE \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post TAPSE \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td 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\t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1520385.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Clinical data, hemodynamic and echocardiographic characteristics, and clinical progression.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epidemiology of venous thromboembolism in the community" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.A. Heit" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/ATVBAHA.108.162545" "Revista" => array:6 [ "tituloSerie" => "Arterioscler Thromb Vasc Biol" "fecha" => "2008" "volumen" => "28" "paginaInicial" => "370" "paginaFinal" => "372" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18296591" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.V. Konstantinides" 1 => "A. Torbicki" 2 => "G. Agnelli" 3 => "N. Danchin" 4 => "D. Fitzmaurice" 5 => "N. Galié" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehu283" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2014" "volumen" => "35" "paginaInicial" => "3033" "paginaFinal" => "3069" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25173341" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recent advances in the management of pulmonary embolism: focus on the critically ill patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Meyer" 1 => "A. Vieillard-Baron" 2 => "B. Planquette" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13613-016-0122-z" "Revista" => array:5 [ "tituloSerie" => "Ann Intensive Care" "fecha" => "2016" "volumen" => "6" "paginaInicial" => "19" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26934891" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0065" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.V. Pollack" 1 => "D. Schreiber" 2 => "S.Z. Goldhaber" 3 => "D. Slattery" 4 => "J. Fanikos" 5 => "B.J. O’Neil" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2010.05.071" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2011" "volumen" => "57" "paginaInicial" => "700" "paginaFinal" => "706" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21292129" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0070" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catheter therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "W.T. Kuo" 1 => "M.K. Gould" 2 => "J.D. Louie" 3 => "J.K. Rosenberg" 4 => "D.Y. Sze" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jvir.2009.08.002" "Revista" => array:6 [ "tituloSerie" => "J Vasc Interv Radiol" "fecha" => "2009" "volumen" => "20" "paginaInicial" => "1431" "paginaFinal" => "1440" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19875060" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0075" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Catheter-directed therapy in acute pulmonary embolism with right ventricular dysfunction: a promising modality to provide early hemodynamic recovery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.G. Dilektasli" 1 => "E. Demirdogen Cetinoglu" 2 => "N.A. Acet" 3 => "C. Erdogan" 4 => "A. Ursavas" 5 => "G. Ozkaya" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Sci Monit" "fecha" => "2016" "volumen" => "22" "paginaInicial" => "1265" "paginaFinal" => "1273" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27081754" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mechanical breakdown and thrombolysis in subacute massive pulmonary embolism: a prospective trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Mohan" 1 => "S.T. Chhabra" 2 => "N. Aslam" 3 => "C. Mohan Mittal" 4 => "G. Mohan" 5 => "R. Tandon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4330/wjc.v5.i5.141" "Revista" => array:6 [ "tituloSerie" => "World J Cardiol" "fecha" => "2013" "volumen" => "5" "paginaInicial" => "141" "paginaFinal" => "147" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23710301" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0085" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous aspiration thrombectomy in treatment of massive pulmonary embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Bayiz" 1 => "M. Dumantepe" 2 => "B. Teymen" 3 => "I. Uyar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.hlc.2014.06.014" "Revista" => array:6 [ "tituloSerie" => "Heart Lung Circ" "fecha" => "2015" "volumen" => "24" "paginaInicial" => "46" "paginaFinal" => "54" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25060976" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Efficacy of rotational thrombectomy on the mortality of patients with massive and submassive pulmonary embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Dumantepe" 1 => "B. Teymen" 2 => "U. Akturk" 3 => "M. Seren" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/jocs.12521" "Revista" => array:6 [ "tituloSerie" => "J Card Surg" "fecha" => "2015" "volumen" => "30" "paginaInicial" => "324" "paginaFinal" => "332" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25683156" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004100000007/v1_201709220119/S217357271730125X/v1_201709220119/en/main.assets" "Apartado" => array:4 [ "identificador" => "15647" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004100000007/v1_201709220119/S217357271730125X/v1_201709220119/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217357271730125X?idApp=WMIE" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 3 | 4 |
| 2024 October | 55 | 63 | 118 |
| 2024 September | 53 | 27 | 80 |
| 2024 August | 74 | 48 | 122 |
| 2024 July | 56 | 29 | 85 |
| 2024 June | 59 | 49 | 108 |
| 2024 May | 86 | 25 | 111 |
| 2024 April | 66 | 38 | 104 |
| 2024 March | 65 | 21 | 86 |
| 2024 February | 60 | 39 | 99 |
| 2024 January | 56 | 34 | 90 |
| 2023 December | 46 | 40 | 86 |
| 2023 November | 45 | 38 | 83 |
| 2023 October | 41 | 32 | 73 |
| 2023 September | 32 | 37 | 69 |
| 2023 August | 35 | 15 | 50 |
| 2023 July | 33 | 21 | 54 |
| 2023 June | 22 | 24 | 46 |
| 2023 May | 43 | 29 | 72 |
| 2023 April | 41 | 19 | 60 |
| 2023 March | 42 | 23 | 65 |
| 2023 February | 33 | 30 | 63 |
| 2023 January | 36 | 17 | 53 |
| 2022 December | 44 | 33 | 77 |
| 2022 November | 66 | 28 | 94 |
| 2022 October | 45 | 43 | 88 |
| 2022 September | 36 | 41 | 77 |
| 2022 August | 53 | 39 | 92 |
| 2022 July | 32 | 38 | 70 |
| 2022 June | 39 | 18 | 57 |
| 2022 May | 52 | 29 | 81 |
| 2022 April | 65 | 51 | 116 |
| 2022 March | 50 | 50 | 100 |
| 2022 February | 48 | 29 | 77 |
| 2022 January | 37 | 39 | 76 |
| 2021 December | 57 | 42 | 99 |
| 2021 November | 50 | 47 | 97 |
| 2021 October | 38 | 63 | 101 |
| 2021 September | 42 | 28 | 70 |
| 2021 August | 32 | 41 | 73 |
| 2021 July | 30 | 29 | 59 |
| 2021 June | 22 | 22 | 44 |
| 2021 May | 45 | 47 | 92 |
| 2021 April | 58 | 91 | 149 |
| 2021 March | 50 | 27 | 77 |
| 2021 February | 38 | 24 | 62 |
| 2021 January | 37 | 18 | 55 |
| 2020 December | 31 | 14 | 45 |
| 2020 November | 40 | 24 | 64 |
| 2020 October | 32 | 22 | 54 |
| 2020 September | 32 | 29 | 61 |
| 2020 August | 32 | 21 | 53 |
| 2020 July | 42 | 28 | 70 |
| 2020 June | 28 | 19 | 47 |
| 2020 May | 17 | 4 | 21 |
| 2020 April | 36 | 12 | 48 |
| 2020 March | 15 | 5 | 20 |
| 2020 February | 45 | 22 | 67 |
| 2020 January | 29 | 26 | 55 |
| 2019 December | 34 | 11 | 45 |
| 2019 November | 31 | 31 | 62 |
| 2019 October | 30 | 26 | 56 |
| 2019 September | 21 | 29 | 50 |
| 2019 August | 19 | 22 | 41 |
| 2019 July | 32 | 25 | 57 |
| 2019 June | 12 | 22 | 34 |
| 2019 May | 40 | 33 | 73 |
| 2019 April | 14 | 28 | 42 |
| 2019 March | 15 | 31 | 46 |
| 2019 February | 34 | 42 | 76 |
| 2019 January | 26 | 31 | 57 |
| 2018 December | 36 | 36 | 72 |
| 2018 November | 79 | 37 | 116 |
| 2018 October | 117 | 16 | 133 |
| 2018 September | 57 | 12 | 69 |
| 2018 August | 42 | 13 | 55 |
| 2018 July | 52 | 21 | 73 |
| 2018 June | 43 | 11 | 54 |
| 2018 May | 31 | 8 | 39 |
| 2018 April | 42 | 12 | 54 |
| 2018 March | 64 | 25 | 89 |
| 2018 February | 32 | 7 | 39 |
| 2018 January | 1 | 0 | 1 |
| 2017 November | 0 | 1 | 1 |
| 2017 October | 0 | 1 | 1 |
| 2017 September | 2 | 0 | 2 |
| 2017 August | 0 | 1 | 1 |
| 2017 July | 0 | 1 | 1 |
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