What is the best management approach for an elderly lady with a massive pulmonary embolism (PE) and shock, who is on triple inotropes (inotropic agents) and is contraindicated for thrombolysis?

Management of Massive PE with Shock and Contraindication to Thrombolysis

For an elderly patient with massive PE, shock on triple inotropes, and contraindications to thrombolysis, surgical embolectomy is the preferred definitive treatment, with catheter-based embolectomy as a reasonable alternative depending on local expertise and availability. 1

Immediate Stabilization

• Continue unfractionated heparin as the anticoagulant of choice in this hemodynamically unstable patient, as LMWH and fondaparinux have not been tested in shock states 1
• Maintain invasive arterial access for continuous blood pressure monitoring to guide vasopressor titration 1
• Continue aggressive hemodynamic support with inotropes/vasopressors to prevent right ventricular failure progression and maintain systemic perfusion 2
• Provide supplemental oxygen to correct hypoxemia 2

Definitive Treatment Options

First-Line: Surgical Embolectomy

Surgical pulmonary embolectomy is the recommended treatment when thrombolysis is contraindicated in massive PE. 1 The procedure involves:

• Median sternotomy with normothermic cardiopulmonary bypass 1
• Direct thrombus extraction under visualization without aortic cross-clamping 1
• Can be performed even in patients requiring cardiopulmonary resuscitation 1
• Dramatic hemodynamic improvement typically follows successful embolectomy 1

Critical consideration: Previous thrombolysis is not a contraindication to surgical embolectomy, though bleeding may be more problematic 1

Alternative: Catheter-Based Intervention

Catheter embolectomy and fragmentation is a reasonable alternative to surgical embolectomy for massive PE with contraindications to fibrinolysis (Class IIa recommendation). 1

Available catheter techniques include:

• Rheolytic thrombectomy (AngioJet) with 75-92% technical success rates 1
• Aspiration thrombectomy with 81% clinical success 1
• Fragmentation devices with 82% clinical success 1

Important caveats for catheter intervention: 1

• Should only be performed by operators experienced in managing cardiogenic shock, bradyarrhythmias, and cardiac tamponade
• Requires anticoagulation with UFH (70 IU/kg bolus, maintain ACT >250 seconds) or bivalirudin
• May require temporary transvenous pacemaker during rheolytic thrombectomy
• In-hospital mortality remains 16% even with successful intervention

Transfer Considerations

If neither surgical nor catheter embolectomy is available locally, urgent transfer to a center with these capabilities should be considered, provided safe transfer can be achieved. 1

• Transfer should only occur with appropriately trained and equipped ambulance crews capable of managing critically ill unstable patients 1
• Institutions with PE intervention expertise should be identified in advance with explicit transfer criteria and procedures 1

The Thrombolysis Dilemma

While thrombolysis would typically be first-line for massive PE with shock 1, the presence of absolute contraindications creates a critical decision point:

Important nuance: Contraindications traditionally considered "absolute" (such as recent surgery within 3 weeks or recent gastrointestinal bleeding) may become relative in immediately life-threatening massive PE with imminent cardiac arrest. 1, 3 However, this decision requires careful risk-benefit assessment on a case-by-case basis.

The meta-analysis data shows that in massive PE, thrombolysis reduces death or recurrent PE (9.4% vs 19.0%, OR 0.45) but increases major bleeding (21.9% vs 11.9%, OR 1.98). 1 In a patient already on triple inotropes with shock, the mortality risk without intervention is extremely high, potentially justifying thrombolysis despite relative contraindications if mechanical interventions are unavailable.

Common Pitfalls to Avoid

• Do not delay definitive intervention while waiting for diagnostic confirmation beyond what is already available—time is critical as most deaths occur within the first few hours 4
• Do not use LMWH or fondaparinux in this hemodynamically unstable patient; UFH is mandatory 1
• Do not attempt catheter intervention without experienced operators and appropriate backup surgical capability 1
• Do not dismiss thrombolysis entirely if mechanical options are unavailable—reassess whether contraindications are truly absolute versus relative in this life-threatening scenario 1, 3

Multidisciplinary Coordination

This patient requires immediate involvement of:

• Cardiac surgery for surgical embolectomy evaluation 1
• Interventional cardiology/radiology if catheter-based approach considered 1
• Critical care for ongoing hemodynamic management 4
• A Pulmonary Embolism Response Team approach, if available, can expedite decision-making and coordinate the optimal intervention 5