Interventional cardiology sees growing role in pulmonary embolism interventions
Pulmonary embolism (PE) treatment is rapidly evolving and becoming a significant area of focus for interventional cardiologists. Peter Monteleone, MD, an interventional cardiologist, director of the interventional cardiology fellowship program at Ascension Texas Cardiovascular, national director of cardiovascular research at Ascension Health, and assistant professor, UT Austin Dell School of Medicine, shared his center's experience with Cardiovascular Business. His department plays a big role in the hospital's pulmonary embolism response team (PERT).
The shift in how pulmonary embolism is treated
Historically, PE was treated with systemic IV thrombolytic therapy, similar to heart attack patients more than 30 years ago. But he said lytic therapy carries significant risks, especially of bleeding. Monteleone explained that over the past decade, advanced interventional, catheter-based technologies have emerged that provide safer and more effective treatments, especially in very acute patients where the PE is life-threatening. These new treatments led to PE therapy involvement by interventional radiologists and cardiologists.
"Oftentimes we're getting involved not just because they do interventional procedures, but also because they would help manage some of the physiology. One of the things that we use to parse out the lower-risk patients versus the higher-risk patients is how a patient's heart is responding to the pulmonary embolism," Monteleone explained.
He said this happened quickly over the past decade, and the partnering led to the creation of PERT teams made of up several multidisciplinary experts to better care for these patients.
"One of the things that's grown out of this last decade of pulmonary embolism work is looking for champions of pulmonary embolism therapies. And in a lot of places, if not most places, pulmonary critical care doctors have really been the champion of caring for these patients. They've been the one making decisions about what to do and how to manage, but the interventional tools that became available were not tools that they used, so then there was this balance between cardiology and pulmonary critical care," Monteleone said.
The role of interventional cardiology
Interventional cardiologists are uniquely positioned to leverage their expertise in advanced catheter-based therapies for PE based on their experience using similar devices in coronary procedures.
"Our classic work has been done in heart arteries, but those technologies are very adaptable to other territories, including the lungs," Monteleone explained. This adaptability is crucial in managing both the physiological and procedural aspects of PE, such as ensuring proper oxygenation and stable blood pressure in patients.
He said introduction of devices like the Ekos catheter and thrombectomy systems for the lungs revolutionized PE treatment. These innovations have allowed for more precise and safer clot management, similar to the evolution of stents and balloon devices in coronary arteries. Monteleone acknowledges the rapid pace of these advancements and also noting that "our goal has been to figure out not just what we can do, but how and when we should do it."
Creation of multidisciplinary teams for PE
Valuable lessons are still being learned in how to best car for various acuity level PE patients, which is why multidisciplinary teams are so important. Pulmonary critical care doctors, interventional radiologists, vascular surgeons, and cardiologists collaborate to optimize treatment strategies.
"The framework of teams has been remarkable. That's one of the things that's helped the field advance so quickly," Monteleone emphasized.
One major innovation that has helped better facilitate these teams to make them much more efficient in emergent cases is the use of artificial intelligence (AI). Several vendors now offer FDA-cleared AI that sits within the scanner or the PACS to scan through CT imaging studies as they come off the scanner before any human reader sees them. If the AI detects a PE requiring immediate intervention, it will send a notification alert to everyone on the PERT team on their cell phones with patient case information and the CT scans for them to review immediately.
His hospital system uses the RapidAI technology, which has helped not only with acute PE cases but also with incidental findings in patients where a PE may otherwise have been missed.
"That condition is not just recognized immediately, but the data is shared immediately. And that helps in a number of ways for the sickest of the sick. That means that our teams that might play a role in every PE. And we can immediately mobilize teams to get to another hospital that maybe does not do ECMO, but we can get them there to take care of those patients urgently. That availability of data also let us avoid missing patients," Monteleone said.
Expanding access to PE care is needed to eliminate disparities
One of the pressing challenges is expanding access to advanced PE treatments to more hospitals and in rural areas. Monteleone said the lack of access means many patients at hospitals without PERT teams, they are still being treat the same way as patients were in the 1990s.
"The most important right now is expanding access to care for this disease state," he said. Monteleone highlights the disparity in treatment availability and advocates for increasing the presence of trained specialists and advanced technologies in more locations. He said this usually starts with finding a champion willing to take on the challenge of putting together a team and improving patient care.
Find more information on the recent REAL-PE trial Monteleone was involved in.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com