What are the guidelines for Ekos (ultrasound-accelerated) catheter ablation for Pulmonary Embolism (PE)?

From the Guidelines

Ekos catheter-directed thrombolysis (CDT) is recommended for intermediate to high-risk pulmonary embolism patients with significant clot burden, right ventricular strain, and hemodynamic compromise who cannot receive systemic thrombolysis due to bleeding risks. The procedure involves placing an ultrasound-assisted catheter directly into the pulmonary artery thrombus under imaging guidance, typically via femoral vein access. The standard regimen uses recombinant tissue plasminogen activator (tPA, alteplase) at a dose of 0.5-1 mg/hour per catheter for 12-24 hours, with a total dose typically not exceeding 24 mg, as supported by the American Heart Association 1. This is significantly lower than the 100 mg used in systemic thrombolysis. Heparin is administered concurrently at a reduced dose (typically 300-500 units/hour) to maintain an aPTT of 40-60 seconds.

Patient selection requires multidisciplinary evaluation, with contraindications including active bleeding, recent major surgery, or hemorrhagic stroke. The ultrasound component of Ekos enhances thrombolytic penetration into the clot through acoustic streaming and cavitation, allowing for more effective clot dissolution with lower tPA doses, thereby reducing bleeding complications while maintaining efficacy, as demonstrated in studies such as ULTIMA and SEATTLE II 1. Following the procedure, patients transition to standard anticoagulation therapy for at least 3-6 months, in line with guidelines from the European Society of Cardiology 1.

Key considerations in the management of pulmonary embolism include the need for prompt anticoagulation, the role of thrombolytic therapy in high-risk patients, and the importance of multidisciplinary evaluation in patient selection for catheter-directed therapies like Ekos CDT. The European Heart Journal guidelines emphasize the importance of individualized treatment approaches, considering factors such as the severity of the pulmonary embolism, the presence of contraindications to thrombolysis, and the patient's overall clinical condition 1.

In terms of specific patient populations, Ekos CDT may be particularly beneficial for those with intermediate to high-risk pulmonary embolism who are at increased risk of bleeding complications from systemic thrombolysis. The procedure's ability to deliver targeted thrombolytic therapy directly to the clot, while minimizing systemic exposure, makes it an attractive option for these patients. However, careful patient selection and monitoring are crucial to minimize the risk of complications and ensure optimal outcomes.

Overall, the use of Ekos catheter-directed thrombolysis in the management of pulmonary embolism represents a valuable treatment option for selected patients, offering the potential for improved clinical outcomes and reduced morbidity and mortality.

From the Research

Guidelines for Ekos Catheter Ablation for PE

The guidelines for Ekos (ultrasound-accelerated) catheter ablation for Pulmonary Embolism (PE) are as follows:

• The Ekos system is used for catheter-directed thrombolysis in patients with submassive PE who have relative contraindications to systemic thrombolysis 2.
• The system has been shown to be effective and safe in the long-term management of submassive PE, with a significant reduction in right heart strain and few complications 2.
• The use of Ekos is considered in patients with relative contraindications to systemic thrombolytic therapy 2.
• Catheter-directed therapy (CDT) has emerged as a treatment option for acute PE, offering the benefits of systemic thrombolysis with a potentially reduced risk of bleeding 3.
• The Ekos ultrasound-accelerated thrombolysis procedure has been used successfully in the treatment of bilateral submassive pulmonary emboli and saddle pulmonary embolus, resulting in rapid clinical improvement and resolution of pulmonary emboli 4.
• Bilateral Ekos EndoWave catheter thrombolysis has been used in the treatment of acute bilateral pulmonary embolism in hemodynamically unstable patients 5.

Indications for Ekos Catheter Ablation

The indications for Ekos catheter ablation for PE include:

• Submassive PE with relative contraindications to systemic thrombolysis 2.
• High-risk PE with contraindications to thrombolysis or surgical embolectomy 6.
• Acute bilateral pulmonary embolism in hemodynamically unstable patients 5.
• Bilateral submassive pulmonary emboli and saddle pulmonary embolus 4.

Contraindications and Considerations

The contraindications and considerations for Ekos catheter ablation for PE include:

• Absolute contraindications to thrombolysis, such as active bleeding or recent stroke 6.
• Relative contraindications to systemic thrombolysis, such as bleeding risk or recent surgery 2.
• The need for careful patient selection and risk stratification to determine the best treatment approach 6, 3.