From the Guidelines
Therapeutic anticoagulation for more than 3 months is recommended for all patients with pulmonary embolism after thrombectomy. The 2020 European Society of Cardiology guidelines suggest that the duration and regimen of anticoagulation should be individualized based on the patient's risk of recurrence versus bleeding risk 1.
Key Considerations
- For patients with a first pulmonary embolism (PE) secondary to a major transient or reversible risk factor, discontinuation of therapeutic oral anticoagulation is recommended after 3 months 1.
- Oral anticoagulant treatment of indefinite duration is recommended for patients presenting with recurrent venous thromboembolism (VTE) not related to a major transient or reversible risk factor 1.
- Extended oral anticoagulation of indefinite duration should be considered for patients with a first episode of PE and no identifiable risk factor, or those with a persistent risk factor other than antiphospholipid antibody syndrome 1.
Anticoagulation Regimens
- Initial treatment may involve low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) such as rivaroxaban or apixaban 1.
- If extended oral anticoagulation is decided after PE in a patient without cancer, a reduced dose of the NOACs apixaban (2.5 mg twice daily) or rivaroxaban (10 mg once daily) should be considered after 6 months of therapeutic anticoagulation 1.
Monitoring and Follow-up
- The patient's bleeding risk should be assessed to identify and treat modifiable bleeding risk factors, and it may influence decision-making on the duration and regimen/dose of anticoagulant treatment 1.
- Regular follow-up is essential to assess treatment efficacy and monitor for complications 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Anticoagulation Treatment After Thrombectomy for Pulmonary Embolus
The recommendations for anticoagulation treatment after thrombectomy for a pulmonary embolus are based on several studies, including 2, which addresses the clinical challenges associated with the choice of anticoagulant agent, duration of treatment, and risk-to-benefit ratio of prolonged anticoagulation.
Duration of Anticoagulation
- All patients with pulmonary embolism (PE) require therapeutic anticoagulation for at least three months, as stated in the 2019 guidelines of the European Society of Cardiology (ESC) 2.
- The decision on the duration of anticoagulation should consider both 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, while patients with strong persistent risk factors (such as active cancer) have a high risk of recurrence and should receive anticoagulant treatment of indefinite duration 2.
Choice of Anticoagulant Agent
- The current guidelines 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.
- Apixaban, Edoxaban, and Rivaroxaban are effective alternatives to treatment with low molecular weight heparin (LMWH) in patients with active cancer 2.
- A systematic review and network meta-analysis found that apixaban treatment was associated with the most favorable safety profile of the NOACs, showing a statistically significantly reduced risk of major or clinically relevant non-major bleed compared with rivaroxaban, dabigatran, and edoxaban 3.
Considerations for Thrombectomy
- Percutaneous thrombectomy is a promising alternative to reduce pulmonary artery pressure in patients with high-risk pulmonary embolism who cannot receive thrombolytic therapy 4.
- A systematic review and meta-analysis found that percutaneous thrombectomy in patients with intermediate- and high-risk pulmonary embolism and contraindications to thrombolytics had a low in-hospital and 30-day mortality rate, and a significant reduction in systolic and mean pulmonary arterial pressures 5.
- Anesthetic management is crucial in patients having catheter-based thrombectomy for acute pulmonary embolism, and anesthesiologists should be prepared to assess and manage patients prior to the procedure, as well as mitigate hemodynamic perturbations and right ventricular dysfunction during the procedure 6.