The latest in the management of pulmonary embolism

Abstract

Therapeutic anticoagulation is the mainstay therapy in acute pulmonary embolism (PE), however, select patients benefit from emergent reperfusion to prevent or rescue acute right ventricular failure and haemodynamic collapse. Compared to other leading causes of cardiovascular mortality such as myocardial infarction and stroke, there is a substantial paucity of literature informing on advanced therapies in PE. Recent years have seen significant evolution in the armamentarium available for PE care with the uptake of several endovascular treatment modalities and increased use of mechanical circulatory support. While several ongoing randomised controlled trials may alter the therapeutic landscape and approach to PE management, at present, we are left with multiple selections with limited guidance. In this review, we discuss the latest therapeutic options available for acute PE and offer an approach to their implementation.

FIGURE 1

Proposed management of haemodynamically significant pulmonary embolism (PE). PERT: pulmonary embolism response team; VA-ECMO: venoarterial extracorporeal membrane oxygenation. Created with BioRender.com.

FIGURE 2

Catheter-directed thrombolysis. Uni-Fuse infusion catheters positioned in the right pulmonary artery (R PA) and left pulmonary artery (L PA).

FIGURE 3

Aspiration thrombectomy. a) Computed tomography pulmonary angiogram demonstrating a thrombus (arrow) in the right pulmonary artery. b) Contrast injection of the right pulmonary artery demonstrating a large filling defect (arrow) and the FlowTriever device. c) Post procedure angiogram. d) Example of an aspirated thrombus.

FIGURE 4

Clot-in-transit. a) Transthoracic echocardiogram demonstrating a large clot-in-transit (CIT) straddling the right atrium (RA) and right ventricle (RV). b) The AngioVac system with inflow cannula demonstrated with fluoroscopic imaging.