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Assessment of Safety and Procedural Learning Curve for Pulmonary Embolism Patients Undergoing Percutaneous Mechanical Thrombectomy under Local Anesthesia: A Retrospective Chart Review
Perry J. Diaz1, Grace Knoer
1, Allison Willett
1, Callie Fernandez
1, Rachel Eom
1, Qingwen Kawaji
2, Ricardo Quarrie
2, Jason Crowner
2, Steven Abramowitz
3, Raghuveer Vallabhaneni
3, Jason Chin
2
1Georgetown University School of Medicine, Washington, DC, 2MedStar Union Memorial Hospital, Baltimore, MD, 3MedStar Heart and Vascular Institute, Washington, DC
INTRODUCTION: Pulmonary embolism (PE) is a significant cause of morbidity and mortality. Advances in the use of percutaneous mechanical thrombectomy have shown a low 30-day mortality rate and a positive safety profile for patients with intermediate- and high-risk PE; however, this procedure has not been readily adopted as the first line of treatment for PE. The study aims to evaluate the adoption and learning curve associated with percutaneous mechanical thrombectomy over time, using fluoroscopy time, procedure time, and contrast volume as metrics of procedural efficiency.
METHODS: This multisite retrospective study included 420 patients undergoing percutaneous mechanical thrombectomy for PE from January 2020 to July 2024 across three medical centers involving 16 surgeons. We analyzed procedural efficiency by examining trends in fluoroscopy time, procedure time, and contrast volume over time elapsed since the first surgery. Regression and learning curve analyses were used to assess changes in these efficiency metrics. T-tests compared the changes in the outcome metrics: ICU and hospital length of stay, and complication rate in the first 50 cases versus the most recent 50 cases. Additionally, we analyzed associations between these metrics and patient factors, including body mass index, sex, age, and comorbidities (e.g. cancer, diabetes, hypertension, renal disease, etc.).
RESULTS: Regression analysis revealed statistically significant reductions in fluoroscopy time (Rē = 0.103, p < 0.001), procedure time (Rē = 0.071, p < 0.001), and contrast volume (Rē = 0.068, p < 0.001) over time, indicating a learning curve effect. The learning curve analysis identified plateaus for improving procedure and fluoroscopy times after 55 and 138 cases, respectively. T-tests indicated no statistically significant differences between the first and last 50 cases in hospital length of stay (6.23 days vs 5.00 days, p = 0.406), ICU length of stay (2.31 days vs 1.23 days, p = 0.256), or complications (0.14 vs 0.00, p = 0.134). The overall mortality rate for this study was 4.49%.
CONCLUSIONS: This study demonstrates that performance of percutaneous mechanical thrombectomy for PE improves significantly over time, as evidenced by reductions in fluoroscopy time, procedure time, and contrast volume. Although thrombectomy could be performed with low mortality and complication rates in both early and late experience, proficiency plateaus were identified after approximately 55 procedures for fluoroscopy time and 138 procedures for procedure time. These results suggest a favorable learning curve effect, with minimal impact from patient demographics or comorbidities. The findings support the safety and feasibility of performing this procedure in a wide range of clinical settings, potentially improving patient outcomes. Further studies should explore the long-term impact of this intervention on patient morbidity and mortality.
Figure 1: Fluoroscopy Time (minutes) vs Days Elapsed Since First Surgery
Figure 2: Procedure Time (minutes) vs Days Elapsed Since First Surgery
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