SVS Reports Study Showing Propofol Is Associated With Increased Adverse Events in Catheter-Directed Interventions for Intermediate-Risk PE

June 2, 2021—The Society for Vascular Surgery (SVS) announced that a single-center retrospective study suggests avoiding Propofol or intraprocedural sedation during catheter-directed interventions (CDIs) for intermediate-risk pulmonary embolism (PE) because it can have detrimental effects.

According to SVS, Propofol is the most commonly used parenteral anesthetic agent in the United States, extensively used for minor and outpatient surgical procedures because of its rapid onset and reversal of action, and in intensive care units for maintenance of coma. The study was published by Patrick Cherfan, MD, et al in the May 2021 issue of the Journal of Vascular Surgery: Venous and Lymphatic Disorders (2021;9:621-626).

As noted in the SVS announcement, the use of CDIs to treat intermediate-risk PE has increased during the past decade because of the presumed similar therapeutic benefits compared with systemic thrombolysis, in addition to a better safety profile. These procedures are performed using intravenous anesthetics with sedative and hypnotic properties, usually in conjunction with opioids for adequate pain control.

The investigators sought to assess “whether using Propofol during CDIs for submassive PE is associated with in-hospital intra- or postprocedural major adverse events,” corresponding investigator Efthymios Avgerinos, MD, told SVS. Dr. Avgerinos is from the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania.

As summarized in the SVS press release, the study was composed of 340 consecutive patients who had undergone CDIs for acute intermediate-risk submassive PE from 2009 to 2019. Submassive PE was defined as right ventricular strain without systemic hypotension. The primary endpoint was any major adverse event defined by postoperative intubation, progression to massive PE, the need for surgical conversion or in-hospital death.

Patient characteristics included age 59 ± 15 years, and 174 men (51%). The procedures were standard thrombolysis (n = 85), ultrasound assisted thrombolysis (n = 229), and suction catheter embolectomy (n = 26). Thirty-six patients (11%) received Propofol during their procedure; the remaining received midazolam plus a narcotic.

The investigators reported that 18 of the 340 patients experienced at least one major adverse event including 10 intubations, 11 decompensations, two surgical conversions, and three deaths. The patients receiving Propofol had a higher major adverse event rate (14%) versus the non-Propofol group (4%; P = .015). Propofol was a predictive factor for adverse events with an odds ratio of 3.8 (P = .03).

Dr. Avgerinos commented in the SVS press release, “Propofol has increased in popularity after demonstrating satisfactory amnestic effects in addition to a fast recovery profile. The results of our study demonstrate a high safety profile for CDIs for acute submassive PE, yet a detrimental effect from the use of this drug.”

Further, he stated, “Although we hypothesize that the mechanism for this adverse effect is blood pressure fluctuations (mainly hypotension) combined with a failing right ventricle, the exact pathophysiology is unknown.”

SVS noted that a limitation of this study is the lack of standardization of anesthetic care, as the anesthesia team provided the sedation in the operating room while the operating physician provided that care when the procedure was done in an interventional suite. Nonetheless, the study concluded that Propofol should be used with caution in caring for critically ill patients, especially with PE.