Interventional Radiology Plays Key Role on Pulmonary Embolism Response Teams
Multidisciplinary teams provide rapid, expert care for pulmonary embolism management
While the players and practices involved in managing pulmonary embolism (PE) vary, physicians who diagnose and treat this life-threatening condition share a common goal: to deliver the best patient care as soon as possible.
To that end, more hospitals are forming multidisciplinary PE response teams (PERTs) to expedite, optimize and activate treatment decisions.
Modeled after rapid response teams for aortic and cardiac emergencies and stroke, PERTs make multidisciplinary expertise available 24/7.
Each year, deep vein thrombosis (DVT) and PEs affect an estimated 10 million people worldwide. Up to 30% of people with DVT/PE will die within one month of diagnosis, and 1 in 3 people will have a recurrence within 10 years, according to the CDC.
Interventional radiology (IR) plays a critical role on the PERTs, which may also include specialists from cardiac surgery, pulmonary medicine, cardiology, hematology, critical care, vascular medicine, vascular surgery, pharmacy and others.
"The role of interventional radiologists is central to the PERT in that they most commonly provide imaging expertise in assessing evidence of right heart strain or failure and deliver advanced therapies such as local thrombolysis or mechanical thrombectomy,” said Ziv Haskal, MD, professor of radiology and medical imaging in the division of interventional radiology at the University of Virginia (UVA) School of Medicine.
Referring physicians activate the PERT, which reviews and discusses the patient’s clinical information and radiologic images in real time to reach a consensus opinion, and treatment recommendations are communicated back to the referring physician. PERTs also may mobilize resources and staff to deliver advanced treatments.
The collaboration that makes a successful PERT is equally important in getting a team started, physicians say.
“You can’t do it alone,” said Maureen Kohi, MD, who oversaw the creation of a PERT as division chief of vascular and interventional radiology at the University of California, San Francisco, after noticing heterogeneity in the way different faculty were addressing PE.
“In order to successfully develop a robust PERT, you need buy-in and champions from different departments, and ultimately you need buy-in from the hospital for resourcing,” said Dr. Kohi, currently a professor and chair of the Department of Radiology at the University of North Carolina at Chapel Hill.
“Multiple studies have shown the life-saving effects of PERTs.”
ZIV HASKAL, MD
PERTs Show Life-Saving Effects
The PERT at UVA meets on a scheduled basis to review outcomes, protocols, positive and negative events, to create and revise their standard work and define in-house and out-of-hospital education for health care providers.
In a 2020 study in Respiratory Research, researchers compared 554 UVA patients’ six-month survival rates, hospital length-of-stay, type of PE therapy, and in-hospital bleeding before and after the institution of the PERT. The patients were similar in baseline demographics, comorbidities and risk.
According to results, the rates of advanced therapy were 4.5 times higher during the PERT era (9.1% vs. 2%) and all-cause mortality in patients with acute PE significantly decreased.
“Multiple studies have shown the life-saving effects of PERTs,” said Dr. Haskal, a co-author on the study. “After creating our PERT, all-cause mortality in acute PE markedly and durably dropped with the initiation of much more advanced intervention, without increased hospital costs or length of stay. That’s lives saved.”
In 2018, the UVA PERT launched an IR PE ECMO alert, in which the need for potential extracorporeal membrane oxygenation during a catheter-directed intervention for a critically ill and deteriorating PE patient can be assembled in less than 60 minutes. Via an automated paging system and protocol, perfusionists, cardiac anesthesiologists, interventional radiologists, operative nurses, and cardiothoracic surgeons all assemble in the IR suite.
“Inconsistent recognition of gradual deterioration and sudden cardiovascular collapse due to massive PE point to a missed opportunity to identify these patients earlier and provide lifesaving intervention,” Dr. Haskal said. “Our PE ECMO alert is a model for all large centers.”
Other studies suggest PERTs reduce time to therapy, may shorten ICU stays and increase PE awareness and education across an institution, thereby increasing confidence in the identification and treatment of high-risk PE.
“Given the many different approaches to PE treatment, it may be challenging to achieve consensus regarding how best to manage a patient,” Dr. Kohi said.
Other challenges such as turf battles may be circumvented with planning, collaboration and coordination. For example, which department will perform a procedure when there is overlap can be determined by assigning different days of the week in advance.
Dr. Kohi also emphasized the need for long-term data such as prospective, randomized, control trials on the outcomes of different PE therapies, which may motivate the creation of PERTs at some centers.
Still, as the research continues and more institutions form PERTs, Dr. Kohi and many others are optimistic.
“The PERT approach provides the structure for consistent care, constant reappraisal, flexibility and data collection,” said Dr. Haskal, who envisions PERTs across the country so that patients at every hospital can be methodically assessed onsite or quickly transferred if needed. “It’s time for hospitals to get on board.”
For More Information
Access the study, “Adoption of a dedicated multidisciplinary team is associated with improved survival in acute pulmonary embolism,” at respiratory-research.biomedcentral.com.
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