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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolic disease &#40;VTE&#41; is a pathology that encompasses deep vein thrombosis &#40;DVT&#41; and pulmonary embolism &#40;PE&#41;&#44; with an incidence of approximately 116 cases per 100&#44;000 inhabitants in Europe<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> and up to 1 per 1000 inhabitants in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> Acute PE is the leading cause of hypertensive lung disease and right ventricular failure&#44; with a mortality of up to 68&#37; in massive PE in the first three months&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">PE can be divided into massive &#40;high-risk&#41; and submassive &#40;intermediate-risk&#41;&#46; The American College of Chest Physicians &#40;ACCP&#41; clinical guidelines differentiate treatment of these two classifications&#44; recommending endovascular therapy in massive PE only when systemic fibrinolysis fails or is contraindicated&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> The European Society of Cardiology &#40;ESC&#41; in collaboration with the European Respiratory Society &#40;ERS&#41; in their 2019 consensus<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> developed a clinical guideline for the diagnosis and management of acute PE in which they indicate that&#44; in the management of high-risk PE&#44; systemic thrombolysis is the treatment of choice&#46; Catheter directed thrombolysis &#40;CDT&#41; or surgical pulmonary embolectomy are alternative reperfusion options in patients with contraindications to thrombolysis&#44; if experience with these methods and adequate resources are available&#46; In intermediate-risk PE&#44; where the management of choice is oral or parenteral anticoagulation&#44; rescue thrombolytic therapy or&#44; alternatively&#44; surgical embolectomy or CDT should be reserved for patients with haemodynamic instability&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Systemic use of thrombolytics carries an increased bleeding risk of up to 20&#37; and tPA doses of up to 100<span class="elsevierStyleHsp" style=""></span>mg over 2<span class="elsevierStyleHsp" style=""></span>h&#44; which is associated with an increased likelihood of intracranial haemorrhage of up to 3&#8211;5&#37;&#46; Current treatment strategies in PD should aim at resolving pulmonary tree obstruction&#44; right heart dysfunction and haemodynamic instability&#44; avoiding chronic pulmonary hypertension and decreasing the risk of haemorrhage&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Relegating the indication for a technique&#44; in this case CDT or thrombectomy&#44; to patients who are exclusively unstable on admission&#44; who become unstable early or who have a poor baseline prognosis&#44; selects a cohort of patients who have a worse prognosis&#46; This is why decision making should rely on a coordinated multidisciplinary group&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies such as PERFECT&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> associate a high clinical success rate with a low rate of major complications and improvements in cardiac and respiratory parameters in this type of patient&#46; The decision to treat should be individualised according to clinical evolution&#44; and this should be the parameter that decides whether to scale up the application of different therapeutic techniques&#44; taking into account the resources and professionals available at each centre&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In 2011&#44; the concept of Pulmonary Embolism Response Teams &#40;PERT&#41; was developed at Massachusetts General Hospital &#40;United States&#41;&#46; Basically&#44; they are multidisciplinary teams coordinated in decision making for the individualised treatment of intermediate and high-risk PE patients&#46; Especially intermediate-risk patients are a very heterogeneous population where a multidisciplinary scientific committee is particularly useful&#46; There is now a National PERT Consortium with more than 180 groups in the United States and the concept has spread beyond its borders&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The establishment of multidisciplinary teams &#40;call them PERT or TEP Code&#41; depends on many factors&#58; from the political-administrative strategy&#44; to the competency element between specialties&#44; to the simple willingness of specialists to participate&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Each hospital has its own organisation&#44; even within its area of influence&#59; precisely because of this&#44; the implementation of a new technique depends on the resources available and the skill of its professionals&#44; as has been shown in recent years with the stroke code units&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Galmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> define three levels of possible response in PERTs&#58; basic&#44; advanced and centres of excellence&#46; They are based on the fulfilment of items differentiated into 6 fields&#58; process&#44; evaluation&#44; medical&#44; procedure&#44; surgical and research&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is in the area of procedure that interventional radiology has its contribution and participation&#44; as these are common procedures in clinical practice&#46; It should be remembered that only 12&#37; of PEs receive CDT or thrombectomy &#40;mechanical aspiration or surgical&#41; and 15&#37; will have an inferior vena cava filter placed&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The organisation of this multidisciplinary team should not be based so much on who should do what&#44; but on who is most used to doing it and what is available in the health care setting&#46; The answer to this question will determine the efficiency and safety of the entire therapeutic process of managing the clinical situation of intermediate-high risk PD&#46; For example&#44; implanting a filter is not essentially difficult&#44; but knowing when and how to remove it may be more complex&#46; The PREPIC 2 study did not recommend its placement in a generalised manner in patients with anticoagulation and submassive PE&#44; a fact that is also pointed out in the multidisciplinary consensus for the management of pulmonary thromboembolism&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> but there will always be cases in which it should be placed&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The only speciality without competence will be cardiovascular surgery in the limited cases of surgical thrombectomy&#46; For the rest&#44; balance should be sought with as much participation as possible from specialties that add value in rapid decision making depending on the hospital ecosystem&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Kabhrel<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> comments that if patients with massive or submassive PE were homogeneous and there were robust data on the type of treatment to follow in the decision tree&#44; multidisciplinary teams would not be necessary&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It will always be essential that someone mentors and coordinates the decision-making process based on the opinion of each of the participants in the multidisciplinary team&#46; From our point of view&#44; it should be Pneumology&#44; in the same way that in the stroke code it is Neurology&#46;</p></span>"
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Editorial
The implication of including Interventional Radiologists in multidisciplinary pulmonary embolism treatment teams
Sara Lojo-Lendoiroa,1,
Corresponding author
sara.lojo.lendoiro@gmail.com

Corresponding author.
, Fernando López-Zárragab,1
a Departamento de Radiología, Sección Radiología Vascular Intervencionista, Hospital Povisa, C/ Salamanca 5, 326211 Vigo, Pontevedra, Spain
b Jefe de Sección de Radiología Vascular Intervencionista, Hospital Universitario de Álava, OSI Araba, Vitoria-Gasteiz, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolic disease &#40;VTE&#41; is a pathology that encompasses deep vein thrombosis &#40;DVT&#41; and pulmonary embolism &#40;PE&#41;&#44; with an incidence of approximately 116 cases per 100&#44;000 inhabitants in Europe<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> and up to 1 per 1000 inhabitants in the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> Acute PE is the leading cause of hypertensive lung disease and right ventricular failure&#44; with a mortality of up to 68&#37; in massive PE in the first three months&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">PE can be divided into massive &#40;high-risk&#41; and submassive &#40;intermediate-risk&#41;&#46; The American College of Chest Physicians &#40;ACCP&#41; clinical guidelines differentiate treatment of these two classifications&#44; recommending endovascular therapy in massive PE only when systemic fibrinolysis fails or is contraindicated&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> The European Society of Cardiology &#40;ESC&#41; in collaboration with the European Respiratory Society &#40;ERS&#41; in their 2019 consensus<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a> developed a clinical guideline for the diagnosis and management of acute PE in which they indicate that&#44; in the management of high-risk PE&#44; systemic thrombolysis is the treatment of choice&#46; Catheter directed thrombolysis &#40;CDT&#41; or surgical pulmonary embolectomy are alternative reperfusion options in patients with contraindications to thrombolysis&#44; if experience with these methods and adequate resources are available&#46; In intermediate-risk PE&#44; where the management of choice is oral or parenteral anticoagulation&#44; rescue thrombolytic therapy or&#44; alternatively&#44; surgical embolectomy or CDT should be reserved for patients with haemodynamic instability&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Systemic use of thrombolytics carries an increased bleeding risk of up to 20&#37; and tPA doses of up to 100<span class="elsevierStyleHsp" style=""></span>mg over 2<span class="elsevierStyleHsp" style=""></span>h&#44; which is associated with an increased likelihood of intracranial haemorrhage of up to 3&#8211;5&#37;&#46; Current treatment strategies in PD should aim at resolving pulmonary tree obstruction&#44; right heart dysfunction and haemodynamic instability&#44; avoiding chronic pulmonary hypertension and decreasing the risk of haemorrhage&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Relegating the indication for a technique&#44; in this case CDT or thrombectomy&#44; to patients who are exclusively unstable on admission&#44; who become unstable early or who have a poor baseline prognosis&#44; selects a cohort of patients who have a worse prognosis&#46; This is why decision making should rely on a coordinated multidisciplinary group&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies such as PERFECT&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> associate a high clinical success rate with a low rate of major complications and improvements in cardiac and respiratory parameters in this type of patient&#46; The decision to treat should be individualised according to clinical evolution&#44; and this should be the parameter that decides whether to scale up the application of different therapeutic techniques&#44; taking into account the resources and professionals available at each centre&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In 2011&#44; the concept of Pulmonary Embolism Response Teams &#40;PERT&#41; was developed at Massachusetts General Hospital &#40;United States&#41;&#46; Basically&#44; they are multidisciplinary teams coordinated in decision making for the individualised treatment of intermediate and high-risk PE patients&#46; Especially intermediate-risk patients are a very heterogeneous population where a multidisciplinary scientific committee is particularly useful&#46; There is now a National PERT Consortium with more than 180 groups in the United States and the concept has spread beyond its borders&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The establishment of multidisciplinary teams &#40;call them PERT or TEP Code&#41; depends on many factors&#58; from the political-administrative strategy&#44; to the competency element between specialties&#44; to the simple willingness of specialists to participate&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Each hospital has its own organisation&#44; even within its area of influence&#59; precisely because of this&#44; the implementation of a new technique depends on the resources available and the skill of its professionals&#44; as has been shown in recent years with the stroke code units&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Galmer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> define three levels of possible response in PERTs&#58; basic&#44; advanced and centres of excellence&#46; They are based on the fulfilment of items differentiated into 6 fields&#58; process&#44; evaluation&#44; medical&#44; procedure&#44; surgical and research&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is in the area of procedure that interventional radiology has its contribution and participation&#44; as these are common procedures in clinical practice&#46; It should be remembered that only 12&#37; of PEs receive CDT or thrombectomy &#40;mechanical aspiration or surgical&#41; and 15&#37; will have an inferior vena cava filter placed&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The organisation of this multidisciplinary team should not be based so much on who should do what&#44; but on who is most used to doing it and what is available in the health care setting&#46; The answer to this question will determine the efficiency and safety of the entire therapeutic process of managing the clinical situation of intermediate-high risk PD&#46; For example&#44; implanting a filter is not essentially difficult&#44; but knowing when and how to remove it may be more complex&#46; The PREPIC 2 study did not recommend its placement in a generalised manner in patients with anticoagulation and submassive PE&#44; a fact that is also pointed out in the multidisciplinary consensus for the management of pulmonary thromboembolism&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> but there will always be cases in which it should be placed&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The only speciality without competence will be cardiovascular surgery in the limited cases of surgical thrombectomy&#46; For the rest&#44; balance should be sought with as much participation as possible from specialties that add value in rapid decision making depending on the hospital ecosystem&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Kabhrel<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> comments that if patients with massive or submassive PE were homogeneous and there were robust data on the type of treatment to follow in the decision tree&#44; multidisciplinary teams would not be necessary&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It will always be essential that someone mentors and coordinates the decision-making process based on the opinion of each of the participants in the multidisciplinary team&#46; From our point of view&#44; it should be Pneumology&#44; in the same way that in the stroke code it is Neurology&#46;</p></span>"
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Article information
ISSN: 03002896
Original language: English
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