From the Guidelines
Thrombolytics or embolectomy for pulmonary embolism (PE) should be considered for patients with high-risk PE, characterized by hemodynamic instability, as recommended by the 2019 ESC guidelines 1. The criteria for thrombolytics or embolectomy include patients with high-risk PE, in whom anticoagulation with UFH should be initiated without delay, and systemic thrombolytic therapy is recommended 1.
- The decision to use these aggressive treatments requires careful risk-benefit assessment, as thrombolytics carry a risk of bleeding complications.
- Embolectomy (surgical or catheter-directed) is reserved for patients with contraindications to thrombolytics, failed thrombolytic therapy, or when immediate clinical deterioration is expected.
- Contraindications to thrombolytics include active internal bleeding, recent stroke, recent major surgery, or trauma within 3 weeks. The goals of catheter-based therapy include rapidly reducing pulmonary artery pressure, RV strain, and pulmonary vascular resistance (PVR); increasing systemic perfusion; and facilitating RV recovery, as described in the management of massive and submassive pulmonary embolism 1.
- Percutaneous techniques to recanalize complete and partial occlusions in the pulmonary trunk or major pulmonary arteries are potentially life-saving in selected patients with massive or submassive PE.
- Catheter interventions can also be performed when thrombolysis has failed to improve hemodynamics in the acute setting. Systemic thrombolytic therapy is recommended for high-risk PE, and surgical pulmonary embolectomy is recommended for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed 1.
From the Research
Criteria for Thrombolytics or Embolectomy
The decision to use thrombolytics or embolectomy for the treatment of pulmonary embolism (PE) depends on the estimated risk of poor outcome. The criteria for thrombolytics or embolectomy are as follows:
- Hemodynamic instability: Patients with hypotension or shock are considered high-risk and may benefit from thrombolytic therapy 2, 3, 4, 5.
- Right ventricular dysfunction: Normotensive patients with evidence of right ventricular (RV) dysfunction, as assessed by echocardiography, are considered sub-massive and may benefit from thrombolytic therapy 2.
- Contraindications to anticoagulation: Patients with a contraindication to anticoagulation and thrombolytic therapy may be considered for surgical embolectomy or catheter-based therapies 2.
- Age and comorbid conditions: Elderly patients and those with comorbid conditions may be less likely to receive thrombolytic therapy, but those who receive it may have a lower in-hospital case fatality rate 6.
Thrombolytic Therapy
Thrombolytic therapy is recommended for patients with massive PE, defined as those with hypotension or shock 2, 3, 4, 5. The benefits of thrombolytic therapy include:
- Reduced risk of recurrent PE
- Rapid improvement in hemodynamics
- Possible reduction in mortality compared with anticoagulation alone 2
Embolectomy
Embolectomy, either surgical or catheter-based, may be considered for patients with contraindications to anticoagulation and thrombolytic therapy, or for those who have failed thrombolytic therapy 2, 4. The role of embolectomy in the treatment of PE is still unclear and requires further study.