What are the recommendations for anticoagulation treatment after thrombectomy for a pulmonary embolus?

From the Guidelines

After thrombectomy for pulmonary embolism, patients should receive therapeutic anticoagulation for at least 3 months, as recommended by the 2019 ESC guidelines 1. The guidelines suggest that therapeutic anticoagulation for more than 3 months is recommended for all patients with pulmonary embolism (PE) 1.

• The recommended duration of anticoagulation depends on the presence of risk factors, with 3 months being sufficient for patients with a first PE secondary to a major transient or reversible risk factor 1.
• For patients with recurrent venous thromboembolism (VTE) or those with antiphospholipid antibody syndrome, oral anticoagulant treatment of indefinite duration is recommended 1.
• The choice of anticoagulant depends on various factors, including the patient's bleeding risk, renal function, and ability to tolerate oral anticoagulants. Some key points to consider when selecting an anticoagulant include:
• Direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban are preferred for most patients due to their efficacy and safety profile 1.
• Vitamin K antagonists like warfarin can be used as an alternative, with a target INR of 2.0-3.0 1.
• For patients who refuse or are unable to tolerate oral anticoagulants, aspirin or sulodexide may be considered for extended VTE prophylaxis 1. It is essential to reassess the patient's bleeding risk and recurrence risk regularly, with consideration of reduced-dose DOACs for extended therapy beyond the initial treatment period 1. Regular monitoring of the patient's condition and adjustment of the anticoagulation regimen as needed is crucial to minimize the risk of recurrent thrombosis and bleeding complications.

From the Research

Anticoagulation Treatment After Thrombectomy for Pulmonary Embolus

The recommendations for anticoagulation treatment after thrombectomy for a pulmonary embolus are as follows:

• All patients with pulmonary embolism (PE) require therapeutic anticoagulation for at least three months 2.
• The decision on the duration of anticoagulation should consider both the individual risk of PE recurrence and the individual risk of bleeding 2.
• The current guidelines of the European Society of Cardiology (ESC) recommend that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant (NOAC) in preference to a vitamin K antagonist (VKA) 2.
• In patients with active cancer, Apixaban, Edoxaban, and Rivaroxaban are effective alternatives to treatment with low molecular weight heparin (LMWH) 2.

Choice of Anticoagulant Agent

The choice of anticoagulant agent depends on various factors, including:

• The clinical probability of pulmonary embolism 2.
• The presence of hemodynamic instability 2.
• The risk of bleeding 2, 3.
• The presence of active cancer 2, 4.

Duration of Anticoagulation

The duration of anticoagulation depends on the individual risk of PE recurrence and the individual risk of bleeding 2.

• Patients with a strong transient risk factor have a low risk of recurrence and anticoagulation can be discontinued after three months 2.
• Patients with strong persistent risk factors (such as active cancer) have a high risk of recurrence and thus should receive anticoagulant treatment of indefinite duration 2.

Efficacy and Safety of Non-VKA Oral Anticoagulants

Non-VKA oral anticoagulants (such as rivaroxaban, apixaban, and edoxaban) have been shown to be effective and safe in the treatment of pulmonary embolism 3, 4, 5.

• They have been shown to be non-inferior to standard therapy, with significant reductions in major bleeding 3, 4.
• They are associated with a consistently lower risk of clinically relevant bleeding than standard treatment of acute VTE 3.