Can catheter-based thrombectomy be used as the first line of treatment in a patient with a massive symptomatic pulmonary embolism (PE)?

From the Guidelines

Catheter-based thrombectomy can be considered as a first-line treatment for patients with massive symptomatic pulmonary embolism (PE), particularly in those with hemodynamic instability, right ventricular dysfunction, or contraindications to systemic thrombolysis, as recommended by the 2019 ESC guidelines 1.

Key Considerations

• The procedure involves inserting a catheter through a vein, typically in the groin, and advancing it to the pulmonary arteries to mechanically remove or dissolve the clot.
• Before proceeding with thrombectomy, patients should be stabilized with supportive measures including oxygen, fluid management, and vasopressors if needed.
• Anticoagulation with unfractionated heparin (initial bolus of 80 units/kg followed by infusion at 18 units/kg/hr, adjusted to target aPTT of 1.5-2.5 times normal) should be initiated unless contraindicated, as recommended by the American Heart Association 1.

Catheter-Based Approaches

• Mechanical thrombectomy
• Catheter-directed thrombolysis (using tPA at lower doses than systemic therapy, typically 0.5-1 mg/hr per catheter for 12-24 hours)
• A combination of both

Decision Making

• The decision to use catheter-based thrombectomy should be made by a multidisciplinary team considering the patient's clinical status, bleeding risk, local expertise, and available resources.
• The team should take into account the patient's hemodynamic stability, right ventricular function, and the presence of any contraindications to systemic thrombolysis.

Post-Procedure Care

• Patients require continued anticoagulation, typically transitioning to oral anticoagulants for at least 3-6 months.
• Close monitoring of the patient's clinical status and laboratory results is necessary to adjust the anticoagulation regimen as needed.

Recommendations

• The 2019 ESC guidelines recommend percutaneous catheter-directed treatment for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed 1.
• The American Heart Association recommends catheter embolectomy and fragmentation or surgical embolectomy for patients with massive PE and contraindications to fibrinolysis 1.

From the Research

Catheter-Based Thrombectomy as First-Line Treatment for Massive Symptomatic Pulmonary Embolism (PE)

• The use of catheter-based thrombectomy as the first line of treatment for massive symptomatic pulmonary embolism (PE) is a topic of ongoing research and debate 2, 3, 4, 5, 6.
• According to a 2022 study, catheter-directed treatments, including catheter-directed thrombolysis and catheter embolectomy, are minimally invasive reperfusion treatments for high- and intermediate-risk APE, and can be used either as the primary treatment or as salvage treatment after failure of systemic thrombolysis 2.
• A 2013 study recommends systemic thrombolysis as the first-line treatment for massive PE, but suggests that surgical pulmonary embolectomy or catheter-directed thrombectomy should be considered in patients with contraindications to fibrinolysis or those with persistent hemodynamic compromise or RV dysfunction despite fibrinolytic therapy 3.
• A 2024 study evaluates the role of extracorporeal membrane oxygenation (ECMO) as a supportive treatment for high-risk patients undergoing surgical pulmonary embolectomy or catheter-based thrombectomy, and finds that ECMO provides effective life support and stabilizes hemodynamics in these patients 4.
• A 2019 study compares outcomes of catheter-directed therapy plus anticoagulation versus anticoagulation alone for submassive and massive pulmonary embolism, and finds that catheter-directed therapy significantly improves RV/LV ratio at 24-48 hours and may lower hospital readmission rates 5.
• A 2018 study reviews the current medical management as well as catheter-directed therapies and surgical embolectomy in the treatment of patients with massive PE, and suggests that prompt intervention with catheter thrombectomy/thromboaspiration, systemic lysis, or surgical thrombectomy can be lifesaving in these patients 6.

Key Findings

• Catheter-based thrombectomy may be a viable option for patients with massive symptomatic PE, particularly those with contraindications to systemic thrombolysis or those who have failed thrombolysis 2, 3, 6.
• The use of ECMO as a supportive treatment for high-risk patients undergoing surgical pulmonary embolectomy or catheter-based thrombectomy may improve outcomes in these patients 4.
• Catheter-directed therapy may be more advantageous in patients with mild to moderate RV dilation, and may lower hospital readmission rates 5.