Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Pulmonary Embolism

Phase 4

Completed

Conditions: Pulmonary Embolism and Thrombosis

Interventions: Device: Ekosonic® Endovascular Device ultrasonic infusion catheter
Biological: Recombinant tissue plasminogen activator

Registration Number: NCT02396758

Lead Sponsor: Boston Scientific Corporation

Brief Summary: The objective is to determine the optimum dose of thrombolytic and duration of the ultrasound procedure (together defined as the APT Procedure) as a treatment for acute submassive pulmonary embolism (PE). Symptomatic submassive PE are participants with acute (less than or equal to \[≤\]14 days) PE with normal systemic arterial blood pressure (greater than \[\>\] 90 mmHg) and evidence of RV dysfunction (right ventricular to left ventricular diameter ratio, that is; RV/LV ratio greater than or equal to \[≥\] 0.9). Participants with submassive PE will be randomized to one of four APT treatment groups: ultrasound of 2 and 6 hours (hrs) with r-tPA 2 milligrams (mg)/hr/catheter and ultrasound 4 and 6 hours with r-tPA, 1 mg/hr/catheter. On 08 June 2016, randomization into treatment group 4 (APT/6 hours-r-tPA/2 mg/hr/catheter) was closed following a reported intracranial hemorrhage (ICH) and death in a study participant in this arm.

Detailed Description: This study is designed to investigate the lowest recombinant tissue plasminogen activator (r-tPA) dose-ultrasound treatment time required to achieve the same reductions in thrombus burden and associated improvement in physiologic parameters demonstrated in ULTIMA (EKOS 08 \[NCT01166997\]) and SEATTLE II (EKOS 09 \[NCT01513759\]). Results of this study are intended to inform the study design for further studies of the Acoustic Pulse Thrombolysis (APT) Procedure. Analysis of the first 100 evaluable participants in the United States study suggested a degree of equipoise between treatment groups 1, 2 and 3 of the protocol and therefore the sample size has been extended and additional sites in the United Kingdom (UK) National Health Service included, with a view to adding to the findings of the OPTALYSE study from sites in the UK and increasing the number of participants treated by treatment protocol.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 131

Inclusion Criteria

Male or female greater than or equal to (≥) 18 years of age and less than or equal to (≤) 75 years of age.
CTA evidence of proximal PE (filling defect in at least one main or lobar pulmonary artery).
PE symptom duration ≤14 days.
Submassive PE: RV/LV diameter ≥ 0.9 from CTA and hemodynamically stable. For Participants in UK Sites: Submassive PE: RV/LV diameter ≥ 0.9 from CTA, hemodynamically stable and an elevated biomarker.
Must be treated within 48 hours of diagnosis of PE by CTA.
Signed Informed consent obtained from subject or Legally Authorized Representative.

Exclusion Criteria

Stroke or transient ischemic attack (TIA), head trauma, or other active intracranial or intraspinal disease within one year.
Recent (within one month) or active bleeding from a major organ.
Major surgery within seven days of screening for study enrollment.
Clinician deems the subject high-risk for catastrophic bleeding.
History of heparin-induced thrombocytopenia (HIT).
Catheter-based pharmacomechanical treatment for PE within 3 days of study enrollment.
Systolic blood pressure (SBP) less than 90 mm Hg and/or use of vasopressors.
Cardiac arrest (including pulseless electrical activity and asystole) requiring active cardiopulmonary resuscitation (CPR).
Evidence of irreversible neurological compromise.
Life expectancy < one year. For Participants in UK Sites: Life expectancy < one year or enrollment in hospice care.
Use of thrombolytics or glycoprotein IIb/IIIa antagonists within 3 days prior to inclusion in the study.
Out-of-Range Laboratory Values: Hematocrit < 30%, Platelets < 100 thousand/microliter (μL), International normalized ratio (INR) > 3.
Creatinine outside the normal range for the treating institution.
Participant is pregnant (positive pregnancy test; women of childbearing capacity must be tested) or breast feeding.
Active cancer (metastatic, progressive, or treated within the last 6 months). Exception: participants with non-melanoma primary skin cancers are eligible to participate in the study.
Known allergy, hypersensitivity, or thrombocytopenia from heparin, r-tPA, or iodinated contrast except for mild-moderate contrast allergies for which steroid pre-medication can be used.
History of any hematologic disease potentially involving abnormal platelet number or function.

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
APT/6 Hours-r-tPA/2 mg/hr/Catheter	Recombinant tissue plasminogen activator	A total of 12 or 24 mg r-tPA (as 2 mg/hr/catheter) will be delivered through EKOS ultrasonic infusion catheter for 6 hrs.
APT/6 Hours-r-tPA/1 mg/hr/Catheter	Ekosonic® Endovascular Device ultrasonic infusion catheter	A total of 6 or 12 mg r-tPA (as 1 mg/hr/catheter) will be delivered through EKOS ultrasonic infusion catheter for 6 hrs.
APT/4 Hours-r-tPA/1 mg/hr/Catheter	Ekosonic® Endovascular Device ultrasonic infusion catheter	A total of 4 or 8 mg r-tPA (as 1 mg/hr/catheter) will be delivered through EKOS ultrasonic infusion catheter for 4 hrs.
APT/4 Hours-r-tPA/1 mg/hr/Catheter	Recombinant tissue plasminogen activator	A total of 4 or 8 mg r-tPA (as 1 mg/hr/catheter) will be delivered through EKOS ultrasonic infusion catheter for 4 hrs.
APT/2 Hours-r-tPA/2 mg/hr/Catheter	Ekosonic® Endovascular Device ultrasonic infusion catheter	A total of 4 or 8 mg r-tPA (as 2 mg/hour \[hr\]/catheter) will be delivered through Ekosonic® Endovascular Device (EKOS) ultrasonic infusion catheter for 2 hrs.
APT/2 Hours-r-tPA/2 mg/hr/Catheter	Recombinant tissue plasminogen activator	A total of 4 or 8 mg r-tPA (as 2 mg/hour \[hr\]/catheter) will be delivered through Ekosonic® Endovascular Device (EKOS) ultrasonic infusion catheter for 2 hrs.
APT/6 Hours-r-tPA/1 mg/hr/Catheter	Recombinant tissue plasminogen activator	A total of 6 or 12 mg r-tPA (as 1 mg/hr/catheter) will be delivered through EKOS ultrasonic infusion catheter for 6 hrs.
APT/6 Hours-r-tPA/2 mg/hr/Catheter	Ekosonic® Endovascular Device ultrasonic infusion catheter	A total of 12 or 24 mg r-tPA (as 2 mg/hr/catheter) will be delivered through EKOS ultrasonic infusion catheter for 6 hrs.

Primary Outcome Measures

Name	Time	Method
Change From Baseline in the Right Ventricle (RV) Diameter-to-Left Ventricle (LV) Diameter Ratio to 48 ± 6 Hours After the Start of the APT Procedure	Change from Baseline to 48 hrs ± 6 hours	Change from baseline in RV/LV will be determined by computed tomographic angiography (CTA).
Number of Participants With Major Bleeding Within 72 Hours After Initiating the APT Procedure	Day 3 (within 72 hours after initiating the APT procedure)	Criteria for major bleeding events, as defined by the International Society on Thrombosis and Haemostasis (ISTH): 1. Fatal bleeding and/or; 2. Symptomatic bleeding in a critical area or organ (intracranial, intraspinal, intraocular, retroperitoneal, intra-articular or pericardial, or intramuscular with compartment syndrome) and/or; 3. Bleeding causing a fall in hemoglobin level of 20 grams/liter (g/L) or more, or leading to transfusion of two or more units of whole blood or red blood cells.

Secondary Outcome Measures

Name	Time	Method
Percentage of Participants With Collapse of the Inferior Vena Cava (IVC) With Respiration at Days 0, 2, 30, 90, and 365, as Assessed by Echocardiograph	Baseline (Day -2 [within -48 hrs of APT start]), Day 0 (within 4 hours after APT end), Day 2 (48 [± 6] hrs of APT start), Day 30 (± 5 days), Day 90 (± 10 days) and Day 365 (± 14 days)	The collapse of IVC was measured at specified timepoints using echocardiogram.
Change in 6 Minute Walk (6MW) Distance From Day 30 to Day 90 and 365	Days 30, 90, 365	The 6 minute Walk Test is a measure of functional exercise capacity. Participants will be asked to walk as far as possible within a 6-minute period, and the distance covered at the end will be noted and recorded.
Change From Baseline in Tricuspid Annular Plane Systolic Excursion (TAPSE) at Days 0, 2, 30, 90, and 365, as Assessed by Echocardiograph	Baseline (Day -2 [within -48 hrs of APT start]), Day 0 (within 4 hours after APT end), Day 2 (48 [± 6] hrs of APT start), Day 30 (± 5 days), Day 90 (± 10 days) and Day 365 (± 14 days)	The extent of displacement of the tricuspid valves, termed as TAPSE was measured at specified timepoints using echocardiogram.
Change in Borg Scale Score Before and After 6MW Distance Test at Days 30, 90, and 365	Days 30, 90, and 365	Borg is a 10-point scale rating the maximum level of dyspnea (difficulty in breathing) and fatigue experienced before and after the 6MW distance test. Scores ranges from 0 (for no shortness of breath, or no fatigue) to 10 (for the greatest shortness of breath ever experienced, or maximum amount of fatigue felt). Higher scores indicates worse outcome.
Number of Participants Who Received Oxygen Therapy	Days 30, 90, and 365	Oxygen source is categorized as room air, nasal prongs, mask, and intubated.
Percentage of Participants With Treatment Success of an APT Procedure	From Baseline up to Day 30	Treatment success of an APT procedure will be assessed by an Adjudication Committee that is blinded to the participant's treatment. The criteria for treatment success are defined as follows: A decrease in RV/LV from baseline to 48 hours after the start of the procedure of at least 0.2; and no life-threatening adverse events related to PE or its treatment through 30 days after the start of the APT procedure.
For Participants of UK Sites:Change in EuroQual - 5 Dimensions - 5 Levels (EQ-5D-5L) Score From Day 30 to Day 365	Day 30, Day 365	The EQ-5D-5L consists of 2 parts - the descriptive system (Index Score) and the EQ Visual Analogue scale (VAS Score). The EQ-5D-5L descriptive system comprises 5 dimensions (mobility, self care, usual activities, pain/discomfort, anxiety/depression) and each dimension has 5 levels: no problems (1), slight problems (2), moderate problems (3), severe problems (4), and extreme problems (5). Each one digit number expressing the level selected for each dimension is combined into a 5-digit number describing the respondent's heath state. These 5-digit numbers are converted into an index value, where 1 represents full health and 0 is equivalent to death. The EQ VAS records the respondent's self-rated health on a vertical, visual analogue scale with 100 being the best health imaginable and 0 being the worst health imaginable. Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
Change From Baseline in RV/LV at Days 0, 2, 30, 90, and 365, as Assessed by Echocardiograph.	Baseline (Day -2 [within -48 hrs of APT start]), Day 0 (within 4 hours after APT end), Day 2 (48 [± 6] hrs of APT start), Day 30 (± 5 days), Day 90 (± 10 days) and Day 365 (± 14 days)	An echocardiogram was obtained at specified timepoints to evaluate RV/LV.
Change From Baseline in Thrombus Burden by Miller Score as Assessed by Pulmonary Arteriogram (PAgram) at Day 0	Baseline, Day 0 (within 4 hours after APT end)	Miller score is composed of a score for arterial obstruction (objective score) and a score for reduction of peripheral perfusion of lungs (subjective evaluation). Right pulmonary artery (PA) is assigned 9 segmental arteries (3 to the upper, 2 to the middle, and 4 to the lower lobe), and left PA is assigned only 7 segmental arteries (2 to the upper, 2 to the lingula, and 3 to the lower lobe). Presence of segmental emboli, regardless of the degree of obstruction, is scored 1 point. Proximal emboli to the segmental level are scored a value equal to the number of segmental arteries arising distally. Maximal score of obstruction=16. Reduction of peripheral perfusion is scored by dividing each lung into upper, middle, and lower zones and by using a 4-point scale: 0=normal perfusion; 1=moderately reduced perfusion; 2=severely reduced perfusion; 3=no perfusion. Maximal score of reduced perfusion=18. Thus, the maximal Miller score =34. Higher Miller score=more thrombus burden.
Change in Pulmonary Embolism Quality of Life (PEmb-QOL) Score From Day 30 to Day 365	Day 30, Day 365	The PEmb-QoL questionnaire contains 6 dimensions that has been created based on the contents of the items, frequency of complaints (Question \[Q\]1; score range: 1 \[every day\] to 5 \[never\]), activities of daily living (ADL) limitations (Q4; score range: 1 \[limited a lot\] to 3 \[not at all\]), work-related problems (Q5; response: yes/no), social limitations (Q6; score range: 1 \[not at all\] to 5 \[extremely\]), intensity of complaints (Q7 \[pain in chest/shoulders\]/8 \[breathlessness\]; score range: 1 \[none\] to 6 \[very serious\]) and emotional complaints (Q9; score range: 1 \[at all times\] to 6 \[none of the times\]). Total Score for all dimensions are calculated by the sum of the scores for each item of the dimension divided by the number of items. Total score ranges from 1 (better quality of life) to 100 (worst quality of life). Higher scores indicate poorer outcome (decreased quality of life). Questions 1, 4, 5, and 9 are reverse scored. Questions 2 and 3 provide descriptive information.
Number of Participants Who Die Due to Any Cause	From Baseline up to Day 365	Number of participants who died due to any cause for up to 365 days following the APT procedure, were reported.
Healthcare Resource Utilization: Number of Healthcare Professionals (HCP) Visits for Venous Thromboembolism (VTE) After Hospitalization and During 12month Follow-up. (UK Participants Only)	From Day 30 up to Day 365	Number of Healthcare Professional (HCP) Specialists involved with care of participant for Venous Thromboembolism (VTE) after hospitalization through 365 days for UK participants. Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
Healthcare Resource Utilization: Number of Healthcare Professionals (HCP) Visits for Venous Thromboembolism (VTE) After Hospitalization and During 12 Month Follow-up. (UK Participants Only)	From Day 30 up to Day 365	Number of Healthcare Professional (HCP) Specialists involved with care of participant for Venous Thromboembolism (VTE) after hospitalization through 365 days for UK participants. Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
Change From Baseline in Estimated Right Ventricular Systolic Pressure (RVSP) at Days 0, 2, 30, 90, and 365, as Assessed by Echocardiograph	Baseline (Day -2 [within -48 hrs of APT start]), Day 0 (within 4 hours after APT end), Day 2 (48 [± 6] hrs of APT start), Day 30 (± 5 days), Day 90 (± 10 days) and Day 365 (± 14 days)	RVSP was measured at specified timepoints using echocardiogram.
Change From Baseline in Thrombus Burden by Modified Miller Score as Assessed by CTA Scan at 48 ± 6 Hours After the Start of the APT Procedure	From Baseline to 48 hrs ± 6 hours	Modified miller score quantifies thrombus burden on CTA scans. Each segmental pulmonary artery (9 on the right, 7 on the left) that is fully or partly occluded by thrombus is given a score of 1. Any further proximal involves vessels score the number of segmental branches distal to that vessel, thereby giving a modified miller score of 0 (no thrombus) to 16 (thrombus in all segmental arteries or saddle embolism).
For Participants of UK Sites: Time From Hospital Admission to Diagnosis of PE	From Baseline through Day 3	Duration of time between hospital admission and the diagnosis of pulmonary embolism (PE) measured in hours for UK participants.Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
Change in Participant Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) 6b Score From Day 30 to Day 365	Day 30, Day 365	PROMIS-PF 6b questionnaire is developed by including 2-items from item-improved Health Assessment Questionnaire (HAQ) and 4-items from item-improved Physical Function-10 (PF-10) instruments. Both of these instruments assess participant's present abilities. Both "Item-Improved instruments" have 5-response options: HAQ - 1="without any difficulty," 2="with a little difficulty," 3="with some difficulty," 4="with much difficulty," 5="unable to do"; PF-10 - 1="not at all," 2="very little," 3="somewhat," 4="quite a lot," 5="cannot do." Total score is the average of all scores of component items, which ranges from 0 (no disability) to 100 (worst disability).
Number of Participants Who Encountered Technical Procedural Complications	From device placement through Day 2	Technical complications associated with the use of the EKOS device will be recorded during catheter placement in the pulmonary artery and during the infusion procedure.
Number of Participants With Symptomatic Recurrent Pulmonary Embolism (Per Adjudication)	From Baseline up to Day 365	Number of participants with symptomatic recurrent pulmonary embolism up to 365 days following the APT procedure, were reported. A summary of serious and all other non-serious adverse events regardless of causality is located in the Reported Adverse Events module.
For Participants of UK Sites: Freedom From Major Harm Occurring Between Enrolment and 30 Days	From Baseline up to Day 30	Number of UK participants with freedom from major harms assessed by Safety Monitor using the following criteria: 1) Mortality - all cause and PE related; 2) Cardiovascular (CV) collapse defined as one or more of the following: a) Greater than (\>) 40 millimeters of mercury (mmHg) drop in systolic blood pressure (SBP) (for \>15 minutes from documented blood pressure as an in-patient) despite intravenous (IV) fluid challenge and absence of new atrial arrhythmia; b) Requirement for emergency systemic thrombolysis; c) Requirement for emergency surgical embolectomy ; d) Requirement for vasopressors; e)and/or Intubation/Ventilation; 3) Major bleeding per ISTH; 4) Recurrent PE (confirmed by imaging); and/or 5) Surgical correction of device related complication. Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
For Participants of UK Sites: Time From Diagnostic Computed Tomography (CT) Scan to Initiation of Treatment for PE	From Baseline through Day 3	Duration of time between Diagnostic Computed Tomography (CT) Scan to Initiation of Treatment for pulmonary embolism (PE) measured in hours for UK Participants. Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
For Participants of UK Sites: Time in Each Level of Care (Level 0 and 1; Level 2; and/or Level 3) Through Discharge	From Baseline up to Hospital Discharge	Levels are defined according to National Framework Document: Level 0 - normal acute ward care (patients whose needs can be met through normal ward care in an acute hospital), Level 1 - acute ward care, with additional advice and support from the critical care team (Patients at risk of their condition deteriorating, or those recently relocated from higher levels of care, whose needs can be met on an acute ward with additional advice from a critical care team), Level 2 - more detailed observation or intervention (requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those 'stepping down' from higher levels of care) and Level 3 - advanced respiratory support alone, or basic respiratory support together with support of at least two organ systems (includes all complex patients requiring support for multi-organ failure). Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
Healthcare Resource Utilization: Team Managing the Participant During Hospitalization - Number of Healthcare Professional (HCP) Specialties Involved. (UK Participants Only)	From Baseline up to Day 365	Number of Healthcare Professional (HCP) Specialists involved with care of participant during hospitalization of UK participants.Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
Healthcare Resource Utilization: Number of Hospital Re-Admissions After Hospitalization and During 12 Month Follow-up. (UK Participants Only)	From Day 30 up to Day 365	Number of Hospital Re-Admissions after hospitalization and during 12 month follow-up for UK Participants. Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.
Healthcare Resource Utilization: Duration of Hospital Re-Admissions After Hospitalization and During 12 Month Follow-up. (UK Participants Only)	From Day 30 through Day 365	Duration of Hospital Re-Admissions after hospitalization and during 12 month follow-up for UK Participants. Due to changes in the protocol, there were no subjects enrolled in the UK in Treatment Arm 4.

Trial Locations

Locations (21): Royal Devon & Exeter Hospital
🇬🇧
Exeter, England, United Kingdom
Medway Maritime Hospital
🇬🇧
Gillingham, England, United Kingdom
Tallahassee Memorial Hospital
🇺🇸
Tallahassee, Florida, United States
Piedmont Hospital
🇺🇸
Atlanta, Georgia, United States
Royal Free Hospital
🇬🇧
London, England, United Kingdom
St. Thomas Hospital
🇬🇧
London, England, United Kingdom
Cedars Sinai
🇺🇸
Beverly Hills, California, United States
Lankenau Medical Center
🇺🇸
Wynnewood, Pennsylvania, United States
Houston Methodist Sugarland Hospital
🇺🇸
Richmond, Texas, United States
Inova Alexandria Hospital
🇺🇸
Alexandria, Virginia, United States
Providence Sacred Heart Medical Center
🇺🇸
Spokane, Washington, United States
University Hospital
🇺🇸
Augusta, Georgia, United States
St. Vincent Medical Group
🇺🇸
Indianapolis, Indiana, United States
Jewish Hospital
🇺🇸
Louisville, Kentucky, United States
East Jefferson General Hospital
🇺🇸
Metairie, Louisiana, United States
Detroit Medical Center
🇺🇸
Detroit, Michigan, United States
Mount Carmel Health System
🇺🇸
Columbus, Ohio, United States
UPMC Hamot
🇺🇸
Erie, Pennsylvania, United States
Vanderbilt University Medical Center
🇺🇸
Nashville, Tennessee, United States
Ninewells Hospital
🇬🇧
Dundee, Scotland, United Kingdom
Florida Hospital Tampa
🇺🇸
Tampa, Florida, United States