From the Guidelines
Thrombolysis followed by thrombectomy can be a viable treatment option for patients with massive pulmonary embolism (PE) who are hemodynamically unstable and do not improve with initial thrombolytic therapy. According to the guidelines on the diagnosis and management of acute pulmonary embolism by the European Society of Cardiology (ESC) 1, thrombolytic therapy should be used in patients with high-risk PE presenting with cardiogenic shock and/or persistent arterial hypotension. Additionally, surgical pulmonary embolectomy is a recommended therapeutic alternative in patients with high-risk PE in whom thrombolysis is absolutely contraindicated or has failed.
The American Heart Association (AHA) also supports the use of catheter-based interventions, including thrombectomy, in selected patients with massive or submassive PE 1. The AHA recommends that catheter-based therapy be performed by experienced operators in centers with interventional capabilities and critical care support.
Some key points to consider when administering thrombolysis followed by thrombectomy include:
- Patient selection: careful consideration of the risks and benefits of the procedure, including the risk of bleeding and the potential for improved outcomes
- Contraindications: active internal bleeding, recent stroke, intracranial tumors, or recent major surgery
- Center capabilities: the procedure should be performed in centers with interventional capabilities and critical care support
- Hemodynamic monitoring: continuous monitoring throughout both procedures to quickly identify and address any complications
In terms of specific treatment protocols, alteplase (tPA) is typically given at 100 mg IV over 2 hours, or as a 10 mg bolus followed by 90 mg over 2 hours for thrombolysis. Catheter-directed thrombectomy can be performed using various devices, including aspiration thrombectomy, thrombus fragmentation, and rheolytic thrombectomy devices. The choice of device and technique will depend on the specific patient and institutional factors.
Overall, the decision to administer thrombolysis followed by thrombectomy in patients with massive PE should be made on a case-by-case basis, taking into account the individual patient's risk factors, clinical presentation, and institutional capabilities.
From the Research
Treatment Options for Massive Pulmonary Embolism
- Thrombolysis is a mainstay of therapy for massive pulmonary embolism, although data to support its effectiveness are limited 2.
- Surgical embolectomy is an alternate, accepted treatment strategy, but is rarely performed due to high surgical risk 2.
- Percutaneous, catheter-based thrombectomy or thrombus fragmentation is a reasonable alternative when contraindications to fibrinolytics exist or surgical embolectomy is not feasible 2.
- Thrombolytic therapy by tissue plasminogen activator can be effective in saving the lives of high-risk PE patients, but clinicians must carefully consider the risks of major complications from bleeding 3.
Considerations for Thrombolysis Followed by Thrombectomy
- There is no direct evidence to support the use of thrombolysis followed by thrombectomy as a standard treatment approach for massive pulmonary embolism.
- However, studies suggest that a combination of medical and surgical therapies may be used in the treatment of massive PE, and the choice of treatment should be individualized based on patient characteristics and circumstances 4.
- Invasive strategies, including thrombectomy, should be considered when absolute contraindications for thrombolytic therapy exist, serious complications arise, or thrombolytic therapy fails 3.
Mortality and Treatment Outcomes
- Massive pulmonary embolism has a high mortality rate, and no significant mortality benefit has been associated with any particular therapy, including thrombolysis, embolectomy, or anticoagulation 4.
- Patients who receive no definitive treatment due to poor prognosis of underlying disease have a high mortality rate, highlighting the importance of individualized treatment approaches 4.