Pulmonary embolism (PE) is a serious disease with life-threatening implications and an array of treatment possibilities. Creating a treatment plan, as well as determining which patients would benefit from treatment, can be a complex task that is best accomplished by tapping into the expertise of multiple specialists. In this Q&A, James Benenati, MD, explains how a pulmonary embolism response team (PERT) can improve outcomes for patients with PE. Dr Benenati is the Medical Director of the Peripheral Vascular Laboratory at Miami Cardiac & Vascular Institute. He is also a course director for the International Symposium on Endovascular Therapy (ISET), which takes place from February 3-7, 2018 in Hollywood, Florida.
What is a pulmonary embolism response team (PERT), and how does it help to optimize patient treatment?
PERT teams are multidisciplinary teams that come together to with the goal of establishing optimal treatment for patients with either massive or sub-massive pulmonary embolism. The team discusses treatment options and individualizes treatment for patients based on the clinical findings, laboratory data, local expertise with therapies, and evidenced-based medicine.
The PERT team relies on multispecialty collaboration to help decide how to best treat patients. Since there are several options available for patients with massive and sub-massive PE, it helps to have the expertise of the team to weigh in on decisions that may be difficult to make individually. The specialties involved may include interventional radiologists, cardiologists, surgeons, pulmonary medicine specialties, emergency medicine, and intensive care specialists. Teams composition varies from institution to institution but the critical point is that a team exists that is available to consult on these patients at all times
When an appropriate case presents at institutions with a PERT team, physicians from those multiple specialties meet and discuss whether the patient is a good candidate for a specific treatment and what the appropriate treatment should be. We’ve learned that we’re able to make better decisions when working with a team than working alone. The primary decisions that need to be made include the use conventional anticoagulation, systemic thrombolysis, catheter-directed thrombolysis, mechanical clot extraction, or surgical embolectomy. At times, combinations of these therapies may be applied. Patients benefit from having physicians arrive at decisions based on collaborative involvement instead of a single person making the decision.
What are some current trends in the treatment of PE?
In our practice, we’re treating many PE patients who have appropriate indications with thrombolytic drugs rather than anticoagulation. Thrombolytic drugs have been used to dissolve clot in arteries or veins for a long time, and these drugs have historically been sparingly used in pulmonary circulation. However, thrombolytic drugs are now becoming more commonly used, and there are data suggesting that catheter-directed thrombolytic therapy may have benefits for patients with massive or sub-massive PE with low complication rates. Of course, much research is needed to confirm results of trials that are now showing benefits to more aggressive therapy. These more aggressive therapies can be life saving in certain situations.
In addition to using thrombolytic drugs, we’re also investigating mechanical devices to remove clot in the pulmonary arteries in patients who are not good candidates for thrombolytic drugs. There are a number of devices that are being tested and evaluated for pulmonary embolism therapy. I think that ultimately these devices will expand our indications for treatment and include patients who aren’t good candidates for the thrombolytic drugs. These devices include clot extraction devices, fragmentation devices, and suction and aspiration devices. PE therapy is becoming an area of growth in endovascular medicine because we now have options to enhance therapy for this disease.
Can you give an example of a hypothetical case in which the collective expertise of the PERT team could improve outcomes?
Let’s say an elderly woman presents with a high-risk sub-massive PE, but she is felt to be high risk for thrombolytic therapy because of a recent laminectomy. Some of the decision-making that would go into treating that patient might involve a question of whether the patient should only receive anticoagulation, or whether she should receive a thrombolytic drug. If there is too much risk involved with those options, would a mechanical option be better? Would surgical embolectomy be a consideration? We would also consider whether the patient should have an inferior vena cava filter.
In places without PERT teams in place, these types of decisions are often made without access to all the scientific knowledge in each discipline. By bringing together a multidisciplinary team, we can work through these questions very rapidly and thoroughly, and come up with a treatment plan that is tailored for that patient and provides the best potential outcome.
As with any team, there may be disagreement among colleagues, but we are able to debate them as a team and collectively decide on the most appropriate treatment for that woman who might have a life-threatening disease. When the decision is made alone, some factors might not be considered as strongly as others. When the decision is made as a team, the patient benefits from everyone’s expertise.
What are some examples of factors that might be overlooked without a team?
Some physicians may be uncomfortable with thrombolytic techniques or might not know they’re available. Other physicians might have strong opinions about which mechanical devices should be used, or even whether the patient should be treated with anything other than anticoagulation.
The problem of deciding on anticoagulation, thrombolytic or mechanical intervention or surgery is really where the PERT team comes into play the most. Alone, some people may not be aware of all of the options and may not be aware of the safety profile of some of the drugs we use. By working as a team, we’re able to educate each other.
What have you learned from colleagues on your team?
In the past year, I’ve learned about the possibility of using shorter thrombolytic times and lower doses to increase safety profiles. We’ve learned about mechanical thrombectomy, which is a new concept. My interactions with vascular medicine and cardiology colleagues have taught me more about the physiology of PE and issues related to chronic pulmonary hypertension as a result of PE. I certainly learn a lot more when working with other people.
If someone isn’t part of a team, how can he/she get involved?
PERT programs are growing quickly and are being well received throughout the US.
You can Google “PERT consortium” and formally join, and there are CME activities you can attend, newsletters you can receive, and educational information you can receive from the PERT consortium.
If you’re not quite ready to make that big of a step, you can collaborate with doctors in your own institution and informally create your own PERT program. Once your team starts working, you can then join the larger PERT consortium.
The takeaway is that it is not hard to get started and many resources are available. Of course, it’s important to have the buy-in from your hospital administration because you do need some institutional support. You may need to educate others on the prevalence and importance of this disease entity.
What are some strategies for getting buy-in from your hospital?
It’s important to educate stakeholders about the morbidity and mortality of untreated PE, and how we can reduce costs by treating earlier. Treatment is also beneficial for increasing patients’ quality of life.
Do you receive any pushback on the PERT approach from others in the field?
People sometimes are resistant to joining the national consortium and prefer the local approach. In general, though, there’s no pushback about the benefits of working in a collaborative, multidisciplinary way. I think most people now understand that PE is an underdiagnosed, life-threatening disease. Additionally, many physicians support a more aggressive approach to treating PE.
Some pushback comes from physicians who would like to see more data. And there’s truth to that point. Many studies are being conducted, some that are prospective and randomized, but more are needed. We’re in the infancy of figuring out best therapies and algorithms, and we’ll need more robust data to justify various treatment options to payers and CMS. We’re early on in the process, but the work is being done. This is an exciting, expanding area for interventionalists to pursue.