Catheter-Based Approaches for the Treatment of Acute Pulmonary Embolism

Abstract

Except when contraindicated, anticoagulation should be initiated when pulmonary embolism (PE) is strongly suspected and the bleeding risk is perceived to be low, even if the evaluation has not been completed. Low-risk patients with acute PE are simply continued on anticoagulation. Severely ill patients with high-risk (massive) PE require aggressive therapy, and if the bleeding risk is acceptable, systemic thrombolysis should be considered. However, despite clear evidence that parenteral thrombolytic therapy leads to more rapid clot resolution than anticoagulation alone, the risk of major bleeding including intracranial bleeding is significantly higher with thrombolytic therapy. It has been demonstrated that right ventricular dysfunction as well as abnormal biomarkers (troponin and brain natriuretic peptide) are associated with increased mortality in acute PE. In spite of this, intermediate-risk (submassive) PE comprises a fairly broad clinical spectrum so that there is not a solid evidence base permitting a consistent algorithm for clinicians to follow. Thus, for several decades, thromboembolism basic scientists, clinical trialists, and clinicians have worked toward a lower risk solution for treatment of patients with more than simply low-risk PE. Catheter-based therapy, consisting of various devices and techniques, with or without low-dose thrombolytic therapy, offers one potential solution and continues to evolve.

Effects of a Consensus-Based Pulmonary Embolism Treatment Algorithm and Response Team on Treatment Modality Choices, Outcomes, and Complications

“…The CDI complication rates were consistent with previous publications. 33,34 Treatment selections in our patient cohort differed from other centers where the increase in RT was driven by either both SL and CDI 23 or by CDI only. 30 In this observational study, direct comparisons of the treatments were not possible.…”

Percutaneous Mechanical Thrombectomy of Submassive Pulmonary Embolism and Extensive Deep Venous Thrombosis for Early Thrombus Removal

“…Therefore, PMT is an attractive treatment option since www.vsijournal.org it limits the impact of thrombolytics and can extract central and peripheral emboli quickly and easily [10,[12][13][14]. Although thrombus removal as a primary treatment for DVT was dropped from the American College of Chest Physicians guideline due to a lack of evidence of reducing post-thrombotic syndrome, the long-term results of PMT including those of the Catheter-directed Venous Thrombolysis (CaVenT) study now support PMT for patients with a high proximal DVT and low risk of bleeding, such as in this case [15].…”

“…Furthermore, there is not yet sufficient data to prove the benefits of catheter-based approaches for the treatment of acute PE; thus, they are recommended for use in only high-risk or “massive” PE cases [ 10 , 20 ]. The present case, based on the American Heart Association classification, was a “submassive” PE due to the mildly elevated brain natriuretic peptide and troponin I levels and would not normally be recommended for such treatment.…”

“…Percutaneous Mechanical Thrombectomy of Submassive Pulmonary Embolism and Extensive Deep Venous Thrombosis for Early Thrombus Removal www.vsijournal.org large emboli [10,11]. The case report was approved by the Institutional Review Board of the Seoul National University Hospital (IRB no.…”

“…The availability of various new catheter-based approaches for the treatment of acute PE has opened a vast field of research to improve both short- and long-term outcomes in such patients [ 9 ]. The percutaneous rheolytic thrombectomy device (AngioJet system; Boston Scientific, Marlborough, MA, USA) combines the advantages and benefits of the clot fragmentation technique and catheter-directed thrombolysis (CDT), allowing for the rapid dissolution and removal of large emboli [ 10 , 11 ]. The case report was approved by the Institutional Review Board of the Seoul National University Hospital (IRB no.…”