Percutaneous Management of High-Risk Pulmonary Embolism

Abstract

Acute pulmonary embolism (PE) leads to an abrupt increase in pulmonary vascular resistance and right ventricular afterload, and when significant enough, can result in hemodynamic instability. High-risk PE is a dire cardiovascular emergency and portends a poor prognosis. Traditional therapeutic options to rapidly reduce thrombus burden like systemic thrombolysis and surgical pulmonary endarterectomy have limitations, both with regards to appropriate candidates and efficacy, and have limited data demonstrating their benefit in high-risk PE. There are growing percutaneous treatment options for acute PE that include both localized thrombolysis and mechanical embolectomy. Data for such therapies with high-risk PE are currently limited. However, given the limitations, there is an opportunity to improve outcomes, with percutaneous treatments options offering new mechanisms for clot reduction with a possible improved safety profile compared with systemic thrombolysis. Additionally, mechanical circulatory support options allow for complementary treatment for patients with persistent instability, allowing for a bridge to more definitive treatment options. As more data develop, a shift toward a percutaneous approach with mechanical circulatory support may become a preferred option for the management of high-risk PE at tertiary care centers.

Keywords: extracorporeal membrane oxygenation; mechanical thrombolysis; pulmonary embolism; shock; thrombectomy.

Figure 1.

Chest x-ray of Ekosonic catheter in pulmonary arteries.

Figure 2.. A patient with significant bilateral proximal pulmonary embolism (PE), hypotension, and hypoxemia requiring intubation was taken emergently to the cardiac catheterization lab.

FlowTriever catheter on fluoroscopy (A) and thrombus removed following procedure (B). Patient subsequently underwent placement of ProtekDuo right ventricular support with oxygenator given persistent shock and respiratory failure (C).

Figure 3.. Approaches to management of high-risk pulmonary embolism.

CBT indicates catheter-based thrombectomy; ECMO, extracorporeal membrane oxygenation; MCS, mechanical circulatory support; PE, pulmonary embolism; RV, right ventricular; and V-A, veno-arterial.

Figure 3.. Approaches to management of high-risk pulmonary embolism.

CBT indicates catheter-based thrombectomy; ECMO, extracorporeal membrane oxygenation; MCS, mechanical circulatory support; PE, pulmonary embolism; RV, right ventricular; and V-A, veno-arterial.