From the Guidelines
Inari thrombectomy is recommended for patients with high-risk pulmonary embolism (PE) who have contraindications to thrombolytic therapy or have failed thrombolysis, as it provides a mechanical clot removal option without the need for thrombolytics. The criteria for using Inari thrombectomy include patients with intermediate-high or high-risk status who have significant clot burden causing hemodynamic compromise or right ventricular strain, such as systolic blood pressure <90 mmHg for >15 minutes, shock requiring vasopressors, cardiac arrest, or evidence of right ventricular dysfunction on imaging with elevated cardiac biomarkers (troponin, BNP) 1. Patients should have proximal clot in the main, lobar, or segmental pulmonary arteries accessible by the device. Contraindications include recent major surgery within 7 days, active internal bleeding, recent stroke within 3 months, or known bleeding disorders.
The European Society of Cardiology guidelines recommend systemic thrombolytic therapy for high-risk PE, but also suggest considering percutaneous catheter-directed treatment, such as Inari thrombectomy, for patients with high-risk PE who have contraindications to thrombolysis or have failed thrombolysis 1. The guidelines also recommend surgical pulmonary embolectomy for patients with high-risk PE who have contraindications to thrombolysis or have failed thrombolysis, but Inari thrombectomy provides a less invasive alternative.
Key considerations for Inari thrombectomy include:
- Patient selection: intermediate-high or high-risk PE patients with significant clot burden and contraindications to thrombolytic therapy
- Clot location: proximal clot in the main, lobar, or segmental pulmonary arteries accessible by the device
- Timing: procedure should be performed within 14 days of symptom onset for optimal outcomes
- Multidisciplinary team assessment: recommended before proceeding with Inari thrombectomy
- Anticoagulation therapy: patients should receive appropriate anticoagulation therapy unless contraindicated 1.
From the Research
Criteria for Using Inari Thrombectomy for Pulmonary Embolism
The criteria for using Inari thrombectomy for pulmonary embolism include:
- Elevated risk patients with a Pulmonary Embolism Severity Index (PESI) score of 4 or 5, and European Society of Cardiology (ESC) classification of intermediate-high or high risk 2
- Patients with acute central pulmonary embolism (PE) who are at high risk of poor outcomes, such as those with hypotension or evidence of right ventricular (RV) dysfunction 3
- Intermediate-risk (submassive) or high-risk (massive) PE patients who have higher mortality than low-risk patients 4
- Patients with unstable hemodynamics due to pulmonary thromboembolism, who have a contraindication to thrombolysis, failed catheter therapy, or failed thrombolysis 5
- High-risk PE patients who are critically ill, with complex underlying physiology, and require care and management from an intensivist 6
Key Considerations
When considering the use of Inari thrombectomy for pulmonary embolism, the following key considerations should be taken into account:
- The patient's risk stratification, including PESI score and ESC classification 2
- The presence of hypotension or evidence of RV dysfunction 3
- The patient's underlying physiology and comorbidities 4
- The potential benefits and risks of thrombectomy, including the risk of hemorrhagic complications 5
- The need for prompt and effective treatment to improve outcomes in high-risk PE patients 6
Treatment Options
The treatment options for pulmonary embolism include:
- Anticoagulation, which is the cornerstone of acute PE therapy 4
- Thrombolysis, which is recommended for patients with massive PE 3
- Surgical embolectomy, which is indicated for patients with a contraindication to thrombolysis, failed catheter therapy, or failed thrombolysis 5
- Catheter-based therapies, such as Inari thrombectomy, which may be effective for patients with intermediate-risk or high-risk PE 2