Lack of Vascular representation in Catheter based PE therapy.

[deleted745951]

As more PERT (Pulmonary Embolism response teams) are forming around the country, there is little to no Vascular Surgery involvement in most of the institutions with these initiatives. Vascular surgeons, in general, do not treat PE's here in Canada based on the practice patterns I've seen. It's mainly IC and IR, they also make the majority of the PERT members in the US.

I was curious as to why there is only little representation of VS in wire-based PE treatments? Is it cause of a general lack of interest/ too many arterial cases already or political reasons? The procedures seem like something well within the specialty's skillset and "territory". It also seems like it would make rewarding cases with cool new tech (Flowtriever). Paging @Jolie South @TypeADissection @LucidSplash

The PERT Movement – Vascular surgeons must answer the call

Rapid communication between frontline physicians who diagnose PE and those who can offer definitive management is the hallmark of the PERT approach.

www.mdedge.com

The above is an article by Dr Ross written in 2017 briefly discussing the issue.

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[TypeADissection]

I think a lot of it falls along political lines and interest. Where I did my residency, IR/IC/VS rotated taking PERT call and so I did a fair number of PE lysis cases +/- EKOS catheters. Where I am currently for fellowship, we play no role in the PERT team and mostly because we are so busy as it is with everything else that feeds into our institution from the entire state. Next year in practice the PERT call is split between IR and IC, and to be honest, I don't have a huge interest to insert myself into that call pool. It's not that the cases are technically challenging per se, for me it's more about how much I want to do when I get out into the real world. I would love to hear what others who are in practice think about this though. Cheers.

 

[LucidSplash]

I think regional referral patterns vary widely. Where I trained for fellowship, we had no involvement, IR handled it all. Volume there was such that no one really cared about missing those cases. Where I am now, ED calls vascular for these cases, but there is a PERT that encompasses IC and IR and pulm as well. My partner has put in lysis catheters for PE before but so have IR and IC. I have yet to but will if necessary and have been familiarizing myself with the data and recommendations (such as they are but not great all around) accordingly since I didn’t really pay attention to it in training. I’m happy to help out but also would be fine if IR and IC and pulm managed it all.

 

[LucidSplash]

Also Flowtriever/Clotriever is pretty neat but currently the price point on the device is a bit too high IMHO to use it except in cases where other therapy has failed and the risk/benefit ratio meets a certain minimum.

 

[Jolie South]

As more PERT (Pulmonary Embolism response teams) are forming around the country, there is little to no Vascular Surgery involvement in most of the institutions with these initiatives. Vascular surgeons, in general, do not treat PE's here in Canada based on the practice patterns I've seen. It's mainly IC and IR, they also make the majority of the PERT members in the US.

I was curious as to why there is only little representation of VS in wire-based PE treatments? Is it cause of a general lack of interest/ too many arterial cases already or political reasons? The procedures seem like something well within the specialty's skillset and "territory". It also seems like it would make rewarding cases with cool new tech (Flowtriever). Paging @Jolie South @TypeADissection @LucidSplash

The PERT Movement – Vascular surgeons must answer the call

Rapid communication between frontline physicians who diagnose PE and those who can offer definitive management is the hallmark of the PERT approach.

www.mdedge.com

The above is an article by Dr Ross written in 2017 briefly discussing the issue.

We did not do lysis very much at all in fellowship because we had so much other volume on call. Not that we couldn’t do it, but it just requires a time commitment that logistically is easier for IR to manage than vascular surgery. I actually really like lysis cases. But say surgeon A has a million elective cases in hybrid 1 and cardiology doing TAVRs in hybrid 2, it would cause a huge delay in care for surgeon B to do the call lysis case after waiting for everyone else to be done. Then, when you have to bring the patient back the next day, it’s the same scenario again to find the time.

I do think flowtriever has advantages in that you are not having to bring the patient back multiple days, keep them in the ICU, and you don’t expose them to bleeding risk. If we did lysis in fellowship, we always did flowtriever or angiojet bc of the time constraints on my private practice attendings.

 

[coldleg]

PP guy here, my group is the sole "PE response team" for about 6 suburban hospitals. We have relatively low competition from IR/IC in terms of anything non-coronary or non-piss/puss. It started when word spread about PE intervention, and we were already doing most of the peripheral endo anyway. We were early adopters, and have been able to hold our turf so far. It's not something we were necessarily exposed to in training, but we were all willing to learn.

Nothing terribly exciting, but the Triever does make for some crazy cool specimen. Easy to use yourself when you're in an OR after hours, and your surgical tech only really does hips or gallbladders. Tried it recently when all of our EKOS machines were in use, and a guy came in looking terrible.

 

[TypeADissection]

PP guy here, my group is the sole "PE response team" for about 6 suburban hospitals. We have relatively low competition from IR/IC in terms of anything non-coronary or non-piss/puss. It started when word spread about PE intervention, and we were already doing most of the peripheral endo anyway. We were early adopters, and have been able to hold our turf so far. It's not something we were necessarily exposed to in training, but we were all willing to learn.

Nothing terribly exciting, but the Triever does make for some crazy cool specimen. Easy to use yourself when you're in an OR after hours, and your surgical tech only really does hips or gallbladders. Tried it recently when all of our EKOS machines were in use, and a guy came in looking terrible.

As someone heading into PP, I will definitely be stealing our institution's IR/IC protocol when placing EKOS catheters in regards to TPA and hep infusion rate (usually just through the side port). Our place also performs a TTE beforehand to assess RV strain along with troponins serialized and then gets another one 12-24H after lysis catheter is removed at bedside. +/- repeating CT PE protocol. I definitely have to take a closer look. Any other pearls, points of wisdom or lessons learned to share? Cheers.

 

[coldleg]

As someone heading into PP, I will definitely be stealing our institution's IR/IC protocol when placing EKOS catheters in regards to TPA and hep infusion rate (usually just through the side port). Our place also performs a TTE beforehand to assess RV strain along with troponins serialized and then gets another one 12-24H after lysis catheter is removed at bedside. +/- repeating CT PE protocol. I definitely have to take a closer look. Any other pearls, points of wisdom or lessons learned to share? Cheers.

I typically don't use echo unless its an on the fence call and need some convincing. I mostly go off of RV:LV ratio on CT.

Private practice tips: Can use different protocols depending on type of day. You'll likely be the one pulling the catheters yourself, so save yourself from having to come in late at night. Depending on the time of day, can do a 12, 6, or 4 hour protocol

Assuming 2 catheters, 0.5mg(x2) for 12 hours, 1mg (x2) for 6, or 2mg (x2) for 4 hours. These are from the OPTALYSE study

From a technical standpoint, my go to is a C2 cobra and floppy glide. Sometimes you need a long angled pigtail to get into the right PA.

 

[XCdude]

PP guy here, my group is the sole "PE response team" for about 6 suburban hospitals. We have relatively low competition from IR/IC in terms of anything non-coronary or non-piss/puss. It started when word spread about PE intervention, and we were already doing most of the peripheral endo anyway. We were early adopters, and have been able to hold our turf so far. It's not something we were necessarily exposed to in training, but we were all willing to learn.

Nothing terribly exciting, but the Triever does make for some crazy cool specimen. Easy to use yourself when you're in an OR after hours, and your surgical tech only really does hips or gallbladders. Tried it recently when all of our EKOS machines were in use, and a guy came in looking terrible.

Pus has one s in it...

 

[droliver]

Just curious, is this really something vascular surgeons are clamoring to do? Unless this paid a ridiculous amount of money the unpredictable nature of those would seem like something they avoid like the plague, like a shunt declot for example

 

[LucidSplash]

Just curious, is this really something vascular surgeons are clamoring to do? Unless this paid a ridiculous amount of money the unpredictable nature of those would seem like something they avoid like the plague, like a shunt declot for example

I just think it depends on your training and the regional variation of who is involved. Personally I’m not dying to do it but I have plenty on my plate.

“Unpredictable nature” isn’t what is keeping Vascular from this... that describes most of our patient population and half our interventions.

 

[Jolie South]

Just curious, is this really something vascular surgeons are clamoring to do? Unless this paid a ridiculous amount of money the unpredictable nature of those would seem like something they avoid like the plague, like a shunt declot for example

I think as lucidsplash said depends on training and regional market. I did not do that much lysis in fellowship, but I actually really find these cases satisfying. Now, I also have no skilled IR to defer to, so if a case comes in I would do it.

 

[coldleg]

Just curious, is this really something vascular surgeons are clamoring to do? Unless this paid a ridiculous amount of money the unpredictable nature of those would seem like something they avoid like the plague, like a shunt declot for example

It'll never be on the top ten list of why any of us chose vascular. It's something to add to our repertoire that uses skills we already have. I actually like being involved because our ability as VS to say NO to a patient or a referral is something IC/IR has a hard time doing. We do the cases we see as appropriate. As for unpredictability, that's the nature of our entire specialty. Most of my day is spent managing unpredictable schedule disruptions. 52

Not sure where you work, but every vascular surgeon in my geographic location does his or her own declots.

 

[badasshairday]

Shunt declot while unpredictable does not require you to get out of bed urgently to come in and do. Can wait til morning. In fact even a lot of this PE work can wait since lysis usually is on submassive PE anyways. Just 2 cents from an IR who does PE cases. I suspect many vascular surgeons aren't in to it as seen on this thread because they already have a lot of other things on there plates..... ruptured aortic aneurysm anyone?!