Sedation with Propofol During Catheter-Directed Thrombolysis for Acute Submassive Pulmonary Embolism Is Associated with Increased Mortality

Clinical Question
Does the type of sedation used during catheter directed thrombolysis for patients with acute submassive pulmonary embolism (PE) impact survival?

Reference
Manchec, B. et al. Sedation with Propofol During Catheter-Directed Thrombolysis for Acute Submassive Pulmonary Embolism Is Associated with Increased Mortality. J. Vasc. Interv. Radiol. 30, 1719–1724 (2019).

Study Design
Single-institution, retrospective study with 136 patients from 2011-2017 who underwent catheter directed thrombolysis for submassive PE. Primary endpoint was in-hospital mortality.

Funding Source
None

Setting
AdventHealth Medical Group, Orlando, Florida

Summary

Most catheter directed thrombolysis (CDT) is performed with the use of intravenous anesthetics such as propofol and benzodiazepines often combined with opioids such as fentanyl for analgesia. The authors describe that propofol has been shown to decrease blood pressure and dampen baroreceptor reflex among other cardiovascular/cardiopulmonary side effects. Coupled with altered hemodynamics in patients with submassive PE (right heart failure, which may progress to left heart failure and systemic hypotension) selection of sedation must be carefully considered.

This study explores whether the type of sedation (propofol versus midazolam/fentanyl) used during CDT for patients with submassive PE impacts in-hospital mortality.

Inclusion criteria were right to left ventricular (RV/LV) ratio > 0.9, symptom onset within 14 days, CDT during hospitalization, and sedation with propofol or midazolam and/or fentanyl during CDT. Exclusion criteria were acute massive PE, procedure performed without sedation or sedation was not clearly recorded. Of the 136 patients who met inclusion criteria, 25 received propofol and 111 received midazolam/fentanyl. In-hospital mortality was 28% in the propofol group compared to 3% in the midazolam/fentanyl group (P=0.0003). Patients sedated with propofol had 10.4 times the risk of cardiopulmonary arrest or dying during hospitalization compared with patients receiving fentanyl and/or midazolam (95% confidence interval, 2.9-37.3, P=0.0003).

There was no significant difference in comorbidities such as malignancy, heart failure and chronic obstructive pulmonary disease between groups. While patients in the propofol group were younger, with more ASA IV classification and were more likely to be intubated prior to the procedure, propensity-matched analysis showed a persistent statistically significant increase in mortality (P=0.01). Logistic regression showed that PESI score, RV/LV ratio and age were not predictive of mortality (P=0.19). The number needed to harm was 4 (95% confidence interval, 2.8-6.8).

Similar results have been described with other procedures outside IR (such as with bronchoscopy and endoscopy); however, the reason why patients sedated with propofol have worse outcomes is unknown. Nonetheless, these preliminary results prompted the authors to recommend against the use of propofol during CDT for submassive PE until further studies can establish clear guidelines.

Commentary 

Increased use of CDT for acute submassive pulmonary embolism has led to important questions regarding all aspects of treatment to optimize patient outcomes and to minimize risks. However, lack of standardization of CDT in practice (type of catheter used, tPA dose, duration of infusion) makes the establishment of guidelines difficult. Similarly, these variables in practice patterns were not elucidated in this retrospective review. Additionally, it would be interesting to identify what percentage of patients did not require sedation or anesthesia support and to document those outcomes. This preliminary data will undoubtedly prompt meaningful discussion prior to CDT when sedation is required.

Post AuthorTeodora Bochnakova MD
Assistant Professor
Department of Interventional Radiology
Oregon Health and Science University, Portland, OR
@T_bochnakova