From the Guidelines
Thrombectomy is recommended for patients with high-risk pulmonary embolism (PE), particularly those with contraindications to thrombolysis or who have failed standard anticoagulation therapy, as stated in the 2019 ESC guidelines 1.
Key Considerations
- The procedure involves using specialized catheters to physically remove the clot from the pulmonary arteries, and may be used in conjunction with catheter-directed thrombolysis.
- Patient selection is crucial, with ideal candidates including those with significant clot burden, hypotension, severe hypoxemia, or evidence of right heart strain on imaging.
- The procedure carries risks including bleeding, vascular injury, and arrhythmias, so a multidisciplinary approach is essential for determining appropriate candidates.
Recommendations
- Systemic thrombolytic therapy is recommended for high-risk PE, as per the 2019 ESC guidelines 1.
- Surgical pulmonary embolectomy is recommended for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed, as stated in the 2019 ESC guidelines 1.
- Percutaneous catheter-directed treatment should be considered for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed, as recommended in the 2019 ESC guidelines 1.
Important Considerations
- Following thrombectomy, patients still require anticoagulation therapy, typically with heparin initially, followed by oral anticoagulants for at least 3-6 months.
- The American Heart Association also recommends catheter embolectomy and fragmentation or surgical embolectomy for patients with massive PE and contraindications to fibrinolysis, or who remain unstable after receiving fibrinolysis 1.
From the Research
Thrombectomy for Pulmonary Embolism
- Thrombectomy is a treatment option for pulmonary embolism, particularly in patients with hemodynamic instability or those who are at high risk of poor outcomes 2, 3.
- The treatment modalities for reducing embolic burden in patients with submassive, high-risk pulmonary embolism include use of intravenous or catheter-directed thrombolytic agents, catheter-directed mechanical thrombectomy, and surgical embolectomy 2.
- Surgical embolectomy and catheter-based therapies are options for patients with massive pulmonary embolism who have a contraindication to anticoagulation and thrombolytic therapy 3.
- The role of thrombectomy in the management of pulmonary embolism is supported by studies that show improved outcomes in patients who undergo this procedure, particularly those with high-risk or submassive pulmonary embolism 4, 5.
Indications for Thrombectomy
- Thrombectomy is recommended for patients with massive pulmonary embolism, characterized by hypotension, and those with submassive pulmonary embolism who have evidence of right ventricular dysfunction 3, 5.
- The decision to perform thrombectomy should be based on individual patient risk factors, including the presence of hemodynamic instability, right ventricular dysfunction, and the risk of poor outcomes 2, 3.
Treatment Options
- Treatment options for pulmonary embolism include anticoagulation, thrombolysis, and thrombectomy, with the choice of treatment depending on the estimated risk of poor outcome 3, 4, 5.
- Direct oral anticoagulants, such as apixaban, edoxaban, rivaroxaban, or dabigatran, are noninferior to heparin combined with a vitamin K antagonist for treating pulmonary embolism and have a lower rate of bleeding 5.
- Systemic thrombolysis is recommended for patients with pulmonary embolism and systolic blood pressure lower than 90 mm Hg, and is associated with a reduction in mortality 5.