tetano
Editor, Senior Moderator
Crit Care Explor
. 2022 Mar 29;4(4):e0670.
doi: 10.1097/CCE.0000000000000670. eCollection 2022 Apr.
In Situ Pulmonary Thrombolysis and Perfusion Lung Angiography in Severe COVID-19 Respiratory Failure
Angel Augusto Pérez-Calatayud[SUP] 1 [/SUP], Rocío Enriquez-García[SUP] 2 [/SUP], Christian Fareli-González[SUP] 3 [/SUP], Christopher D Barrett[SUP] 4 5 [/SUP], Carlos Alberto Saldivar-Rodea[SUP] 2 [/SUP], Jorge Perulles-Marin[SUP] 2 [/SUP], Miguel Angel Reyes-Caldelas[SUP] 2 [/SUP], Carlos Ivan Rosenberg-Contreras[SUP] 2 [/SUP], Julieta Berenice Gómez-Moreno[SUP] 2 [/SUP], Guadalupe Guerrero-Avendaño[SUP] 1 [/SUP], Raúl Serrano-Loyola[SUP] 1 [/SUP], Raúl Carrillo-Esper[SUP] 1 [/SUP], Ernest E Moore[SUP] 6 7 [/SUP]
Affiliations
Abstract
A proof-of-concept study using thrombolysis with catheter-directed tissue plasminogen activator (tPA) and pulmonary angiography imaging was performed to visualize perfusion deficits and reperfusion/therapeutic effects of tPA.
Design: A prospective, open-label, compassionate study. Descriptive statistics were presented for categorical variables and as means with sds for continuous variables. The Wilcoxon test was used to determine the differences between the two-related samples and a t test for continuous variables. Statistical significance was set at p value of less than 0.05. Agreement between observations was evaluated using the Kappa Cohen index and overall agreement using the Fleiss Kappa coefficient.
Setting: A single COVID-19 ICU of Mexico´s General Hospital Dr Eduardo Liceaga.
Subjects: Fifteen patients with severe Delta variant severe acute respiratory syndrome coronavirus 2 infection, 18-75 years old, requiring mechanical ventilation with a persistent Fio[SUB]2[/SUB] requirement of 70% or higher and Pao[SUB]2[/SUB]/Fio[SUB]2[/SUB] ratio (or imputed ratio) less than 150 for more than 4 hours. The coagulation inclusion criteria were International Society on Thrombosis and Haemostasis score greater than 5, and presence of a d-dimer greater than 1,200, with viscoelastic testing using rotational thromboelastometry (Instrumentation Laboratories, Mexico City, Mexico) showing both hypercoagulability (EXTEM amplitude at 5 min > 65 FIBTEM > 30) and hypofibrinolysis (EXTEM maximum lysis < 8%).
Interventions: Catheter-directed tPA angiography and iFlow system analysis to assess pre-tPA baseline pulmonary perfusion and changes in response to thrombolysis.
Results: Nine patients had microvascular filling defects demonstrated by angiography, and good agreement was found with iFlow analysis (ƙ = 0.714). Statistically significant differences were identified in the area under the curve (AUC) region of interest/AUC reference tissue with and without filling defects in phase 2 DM -0.09206 (sd ± 0.16684) (p = 0.003). The Pao[SUB]2[/SUB]/Fio[SUB]2[/SUB] values measured immediately and 48 hours after the procedure were significantly higher (p = 0.001 and p = 0.005, respectively). Statistically significant differences were found in d-dimer values (p = 0.007), Fio[SUB]2[/SUB] (p = 0.002), and oxygen saturation in arterial blood/Fio[SUB]2[/SUB] (p = 0.045), as well as in the number of patients who required prone positioning before, immediately after the procedure, and at 48 hours after the procedure (p = 0.002).
Conclusions: Thrombolysis with catheter-directed tPA resulted in imaging evidence via pulmonary angiography and iFlow technology of improved lung perfusion in COVID-19 patients with severe respiratory failure.
Keywords: COVID 19; microvascular thrombosis; thrombolysis.
. 2022 Mar 29;4(4):e0670.
doi: 10.1097/CCE.0000000000000670. eCollection 2022 Apr.
In Situ Pulmonary Thrombolysis and Perfusion Lung Angiography in Severe COVID-19 Respiratory Failure
Angel Augusto Pérez-Calatayud[SUP] 1 [/SUP], Rocío Enriquez-García[SUP] 2 [/SUP], Christian Fareli-González[SUP] 3 [/SUP], Christopher D Barrett[SUP] 4 5 [/SUP], Carlos Alberto Saldivar-Rodea[SUP] 2 [/SUP], Jorge Perulles-Marin[SUP] 2 [/SUP], Miguel Angel Reyes-Caldelas[SUP] 2 [/SUP], Carlos Ivan Rosenberg-Contreras[SUP] 2 [/SUP], Julieta Berenice Gómez-Moreno[SUP] 2 [/SUP], Guadalupe Guerrero-Avendaño[SUP] 1 [/SUP], Raúl Serrano-Loyola[SUP] 1 [/SUP], Raúl Carrillo-Esper[SUP] 1 [/SUP], Ernest E Moore[SUP] 6 7 [/SUP]
Affiliations
- PMID: 35372845
- PMCID: PMC8966962
- DOI: 10.1097/CCE.0000000000000670
Abstract
A proof-of-concept study using thrombolysis with catheter-directed tissue plasminogen activator (tPA) and pulmonary angiography imaging was performed to visualize perfusion deficits and reperfusion/therapeutic effects of tPA.
Design: A prospective, open-label, compassionate study. Descriptive statistics were presented for categorical variables and as means with sds for continuous variables. The Wilcoxon test was used to determine the differences between the two-related samples and a t test for continuous variables. Statistical significance was set at p value of less than 0.05. Agreement between observations was evaluated using the Kappa Cohen index and overall agreement using the Fleiss Kappa coefficient.
Setting: A single COVID-19 ICU of Mexico´s General Hospital Dr Eduardo Liceaga.
Subjects: Fifteen patients with severe Delta variant severe acute respiratory syndrome coronavirus 2 infection, 18-75 years old, requiring mechanical ventilation with a persistent Fio[SUB]2[/SUB] requirement of 70% or higher and Pao[SUB]2[/SUB]/Fio[SUB]2[/SUB] ratio (or imputed ratio) less than 150 for more than 4 hours. The coagulation inclusion criteria were International Society on Thrombosis and Haemostasis score greater than 5, and presence of a d-dimer greater than 1,200, with viscoelastic testing using rotational thromboelastometry (Instrumentation Laboratories, Mexico City, Mexico) showing both hypercoagulability (EXTEM amplitude at 5 min > 65 FIBTEM > 30) and hypofibrinolysis (EXTEM maximum lysis < 8%).
Interventions: Catheter-directed tPA angiography and iFlow system analysis to assess pre-tPA baseline pulmonary perfusion and changes in response to thrombolysis.
Results: Nine patients had microvascular filling defects demonstrated by angiography, and good agreement was found with iFlow analysis (ƙ = 0.714). Statistically significant differences were identified in the area under the curve (AUC) region of interest/AUC reference tissue with and without filling defects in phase 2 DM -0.09206 (sd ± 0.16684) (p = 0.003). The Pao[SUB]2[/SUB]/Fio[SUB]2[/SUB] values measured immediately and 48 hours after the procedure were significantly higher (p = 0.001 and p = 0.005, respectively). Statistically significant differences were found in d-dimer values (p = 0.007), Fio[SUB]2[/SUB] (p = 0.002), and oxygen saturation in arterial blood/Fio[SUB]2[/SUB] (p = 0.045), as well as in the number of patients who required prone positioning before, immediately after the procedure, and at 48 hours after the procedure (p = 0.002).
Conclusions: Thrombolysis with catheter-directed tPA resulted in imaging evidence via pulmonary angiography and iFlow technology of improved lung perfusion in COVID-19 patients with severe respiratory failure.
Keywords: COVID 19; microvascular thrombosis; thrombolysis.