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Interventional Treatment of Pulmonary Embolism

Pulmonary embolism (PE) is a serious and prevalent cause of vascular disease. Nevertheless, optimal treatment for many phenotypes of PE remains uncertain. Treating PE requires appropriate risk stratification as a first step. For the highest-risk PE, presenting as shock or arrest, emergent systemic thrombolysis or embolectomy is reasonable, while for low-risk PE, anticoagulation alone is often chosen. Normotensive patients with PE but with indicia of right heart dysfunction (by biomarkers or imaging) constitute an intermediate-risk group for whom there is controversy on therapeutic strategy. Some intermediate-risk patients with PE may require urgent stabilization, and ≈10% will decompensate…

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 Current Status of Interventional Therapies in Acute Pulmonary Embolism

More aggressive options may be considered for patients presenting with intermediate- and high-risk PE. In general, these options can be grouped into three different categories: systemic thrombolysis, catheter-directed interventions and surgical embolectomy.

Articles of Interest

Interventional therapies for pulmonary embolism

Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate–high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles.

Pulmonary Embolism Interventions

Pulmonary embolism interventions include catheter-directed thrombolysis, mechanical thrombectomy, & surgical embolectomy. Catheter directed thrombolysis and mechanical thrombectomy are alternative treatments for patients who do not respond well to systemic anticoagulation.

Acute pulmonary embolism: endovascular therapy

PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach

This document summarizes current invasive treatment options beyond anticoagulation available to intermediate- and high-risk PE patients, with the understanding that data supporting any of them is either inconclusive or lacking, and therefore not covered by American and European guidelines. Most PE patients only require simple anticoagulation; patients with high-risk features deserve consideration for an invasive treatment approach.

Advanced Management Options for Massive and Submassive Pulmonary Embolism

Therapeutic anticoagulation is indicated in all patients in the absence of contraindications. Thrombolysis should be strongly considered in selected high- and intermediate-risk patients, either by systemic infusion or percutaneous catheter-directed therapy. Other therapeutic modalities, such as vena cava filters and surgical embolectomy, are options for patients who fail or cannot tolerate anticoagulation and/or thrombolysis.

How should you decide between available therapies in acute pulmonary embolism

When should we offer more advanced therapies?

Interventional and Surgical Therapies for Massive PE: What`s PERTinent?

Massive (also known as “high-risk”) PE, where there is associated hypotension, comprises only about 5% of all PE presentations but is associated with approximately a 30% mortality rate. Various therapeutic interventions are available, including systemic full-dose fibrinolysis, surgical embolectomy and catheter-directed therapy (CDT), but robust comparative safety and effectiveness data for these approaches are lacking.

Surgical Embolectomy of Acute Pulmonary Embolism

Treatment options for pulmonary embolism include oral anticoagulation, systemic thrombolysis, catheter-directed the-rapy (CDT), and surgical pulmonary embolectomy with or without extra-corporeal life support.

Resources

PERT Consortium

The Pulmonary Embolism Response Team (PERT) Consortium was developed after the initial efforts of a team of physicians at Massachusetts General Hospital. The PERT Consortium™ intends to guide and influence pulmonary embolism (PE) care and research in institutions across the U.S. and will be the driving force behind increased survival rates and the future of PE treatment.

the NNT

PE can be categorized as low-risk, submassive (associated with evidence of right heart strain), or massive (associated with hemodynamic instability). The latter two subtypes are associated with increased morbidity and mortality. Traditionally, anticoagulation has been the mainstay of treatment. In massive PE, however, it is important to restore pulmonary blood flow rapidly, which is often accomplished by the use of thrombolytic agents or surgical embolectomy.