Download PDF
Semin Thromb Hemost 2023; 49(08): 785-796
DOI: 10.1055/s-0043-1772840
Review Article

Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up

Brian Fulton
1   Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
,
Riyaz Bashir
2   Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
,
Mitchell D. Weinberg
3   Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
,
Vladimir Lakhter
2   Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
,
Parth Rali
4   Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
,
Steve Pugliese
5   Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
,
Jay Giri
1   Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
6   Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
,
Taisei Kobayashi
1   Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
6   Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.

Keywords

high-risk pulmonary embolism - catheter-based embolectomy - catheter-based thrombolysis - surgical embolectomy - mechanical circulatory support


Publication History

Article published online:
11 September 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Tapson VF. Acute pulmonary embolism. N Engl J Med 2008; 358 (10) 1037-1052
    CrossrefPubMedGoogle Scholar
  • 2 Blood Clots. A Serious but Preventable Medical Condition. Centers for Disease Control and Prevention (CDC); 2016
    Google Scholar
  • 3 Becattini C, Agnelli G. Predictors of mortality from pulmonary embolism and their influence on clinical management. Thromb Haemost 2008; 100 (05) 747-751
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Giri J, Sista AK, Weinberg I. et al. Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: a scientific statement from the American Heart Association. Circulation 2019; 140 (20) e774-e801
    CrossrefPubMedGoogle Scholar
  • 5 Jaff MR, McMurtry MS, Archer SL. et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123 (16) 1788-1830
    CrossrefPubMedGoogle Scholar
  • 6 Konstantinides SV, Meyer G, Becattini C. et al; The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019; 54 (03) 1901647
    CrossrefPubMedGoogle Scholar
  • 7 Green EM, Givertz MM. Management of acute right ventricular failure in the intensive care unit. Curr Heart Fail Rep 2012; 9 (03) 228-235
    CrossrefPubMedGoogle Scholar
  • 8 Ventetuolo CE, Klinger JR. Management of acute right ventricular failure in the intensive care unit. Ann Am Thorac Soc 2014; 11 (05) 811-822
    CrossrefPubMedGoogle Scholar
  • 9 Manier G, Castaing Y. Influence of cardiac output on oxygen exchange in acute pulmonary embolism. Am Rev Respir Dis 1992; 145 (01) 130-136
    CrossrefPubMedGoogle Scholar
  • 10 Kline JA, Hall CL, Jones AE, Puskarich MA, Mastouri RA, Lahm T. Randomized trial of inhaled nitric oxide to treat acute pulmonary embolism: the iNOPE trial. Am Heart J 2017; 186: 100-110
    CrossrefPubMedGoogle Scholar
  • 11 Kooter AJ, Ijzerman RG, Kamp O, Boonstra AB, Smulders YM. No effect of epoprostenol on right ventricular diameter in patients with acute pulmonary embolism: a randomized controlled trial. BMC Pulm Med 2010; 10: 18
    CrossrefPubMedGoogle Scholar
  • 12 Lyhne MD, Kline JA, Nielsen-Kudsk JE, Andersen A. Pulmonary vasodilation in acute pulmonary embolism - a systematic review. Pulm Circ 2020; 10 (01) 2045894019899775
    CrossrefPubMedGoogle Scholar
  • 13 Rali P, Sacher D, Rivera-Lebron B. et al. Interhospital transfer of patients with acute pulmonary embolism: challenges and opportunities. Chest 2021; 160 (05) 1844-1852
    CrossrefPubMedGoogle Scholar
  • 14 Sekhri V, Mehta N, Rawat N, Lehrman SG, Aronow WS. Management of massive and nonmassive pulmonary embolism. Arch Med Sci 2012; 8 (06) 957-969
    CrossrefPubMedGoogle Scholar
  • 15 Layish DT, Tapson VF. Pharmacologic hemodynamic support in massive pulmonary embolism. Chest 1997; 111 (01) 218-224
    CrossrefPubMedGoogle Scholar
  • 16 Goldhaber SZ, Elliott CG. Acute pulmonary embolism: part I: epidemiology, pathophysiology, and diagnosis. Circulation 2003; 108 (22) 2726-2729
    CrossrefPubMedGoogle Scholar
  • 17 Tsang JY, Hogg JC. Gas exchange and pulmonary hypertension following acute pulmonary thromboembolism: has the emperor got some new clothes yet?. Pulm Circ 2014; 4 (02) 220-236
    CrossrefPubMedGoogle Scholar
  • 18 Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998; 97 (19) 1946-1951
    CrossrefPubMedGoogle Scholar
  • 19 Messika J, Goutorbe P, Hajage D, Ricard JD. Severe pulmonary embolism managed with high-flow nasal cannula oxygen therapy. Eur J Emerg Med 2017; 24 (03) 230-232
    CrossrefPubMedGoogle Scholar
  • 20 Stevens SM, Woller SC, Baumann Kreuziger L. et al. Executive summary: antithrombotic therapy for VTE disease: second update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160 (06) 2247-2259
    CrossrefPubMedGoogle Scholar
  • 21 Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet 1960; 1 (7138) 1309-1312
    CrossrefPubMedGoogle Scholar
  • 22 Smith SB, Geske JB, Maguire JM, Zane NA, Carter RE, Morgenthaler TI. Early anticoagulation is associated with reduced mortality for acute pulmonary embolism. Chest 2010; 137 (06) 1382-1390
    CrossrefPubMedGoogle Scholar
  • 23 Becattini C, Agnelli G, Lankeit M. et al. Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model. Eur Respir J 2016; 48 (03) 780-786
    CrossrefPubMedGoogle Scholar
  • 24 Fasullo S, Scalzo S, Maringhini G. et al. Six-month echocardiographic study in patients with submassive pulmonary embolism and right ventricle dysfunction: comparison of thrombolysis with heparin. Am J Med Sci 2011; 341 (01) 33-39
    CrossrefPubMedGoogle Scholar
  • 25 Mi YH, Liang Y, Lu YH, Li YM, Liu WX, Qian W. Recombinant tissue plasminogen activator plus heparin compared with heparin alone for patients with acute submassive pulmonary embolism: one-year outcome. J Geriatr Cardiol 2013; 10 (04) 323-329
    PubMedGoogle Scholar
  • 26 Kucher N, Boekstegers P, Müller OJ. et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 2014; 129 (04) 479-486
    CrossrefPubMedGoogle Scholar
  • 27 Tu T, Toma C, Tapson VF. et al; FLARE Investigators. A prospective, single-arm, multicenter trial of catheter-directed mechanical thrombectomy for intermediate-risk acute pulmonary embolism: the FLARE Study. JACC Cardiovasc Interv 2019; 12 (09) 859-869
    CrossrefPubMedGoogle Scholar
  • 28 Rivera-Lebron B, McDaniel M, Ahrar K. et al; PERT Consortium. Diagnosis, treatment and follow up of acute pulmonary embolism: consensus practice from the PERT Consortium. Clin Appl Thromb Hemost 2019; 25: 1076029619853037
    CrossrefPubMedGoogle Scholar
  • 29 Prucnal CK, Jansson PS, Deadmon E, Rosovsky RP, Zheng H, Kabrhel C. Analysis of partial thromboplastin times in patients with pulmonary embolism during the first 48 hours of anticoagulation with unfractionated heparin. Acad Emerg Med 2020; 27 (02) 117-127
    CrossrefPubMedGoogle Scholar
  • 30 Konstantinides S, Tiede N, Geibel A, Olschewski M, Just H, Kasper W. Comparison of alteplase versus heparin for resolution of major pulmonary embolism. Am J Cardiol 1998; 82 (08) 966-970
    CrossrefPubMedGoogle Scholar
  • 31 Jerjes-Sanchez C, Ramírez-Rivera A, Arriaga-Nava R. et al; de Lourdes García M. Streptokinase and heparin versus heparin alone in massive pulmonary embolism: a randomized controlled trial. J Thromb Thrombolysis 1995; 2 (03) 227-229
    CrossrefPubMedGoogle Scholar
  • 32 Meyer G, Vicaut E, Danays T. et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
    CrossrefPubMedGoogle Scholar
  • 33 Bĕlohlávek J, Dytrych V, Linhart A. Pulmonary embolism, Part II: Management. Exp Clin Cardiol 2013; 18 (02) 139-147
    PubMedGoogle Scholar
  • 34 Kearon C, Akl EA, Ornelas J. et al. Antithrombotic therapy for VTE disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149 (02) 315-352
    CrossrefPubMedGoogle Scholar
  • 35 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353 (9162) 1386-1389
    CrossrefPubMedGoogle Scholar
  • 36 Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation 2006; 113 (04) 577-582
    CrossrefPubMedGoogle Scholar
  • 37 Wang C, Zhai Z, Yang Y. et al; China Venous Thromboembolism (VTE) Study Group. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest 2010; 137 (02) 254-262
    CrossrefPubMedGoogle Scholar
  • 38 Marti C, John G, Konstantinides S. et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2015; 36 (10) 605-614
    CrossrefPubMedGoogle Scholar
  • 39 Wan S, Quinlan DJ, Agnelli G, Eikelboom JW. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation 2004; 110 (06) 744-749
    CrossrefPubMedGoogle Scholar
  • 40 Brandt K, McGinn K, Quedado J. Low-dose systemic alteplase (tPA) for the treatment of pulmonary embolism. Ann Pharmacother 2015; 49 (07) 818-824
    CrossrefPubMedGoogle Scholar
  • 41 Sista AK, Bhatheja R, Rali P. et al. First-in-human study to assess the safety and feasibility of the Bashir endovascular catheter for the treatment of acute intermediate-risk pulmonary embolism. Circ Cardiovasc Interv 2021; 14 (01) e009611
    CrossrefPubMedGoogle Scholar
  • 42 Bashir R, Foster M, Iskander A. et al. Pharmacomechanical catheter-directed thrombolysis with the Bashir endovascular catheter for acute pulmonary embolism: the RESCUE Study. JACC Cardiovasc Interv 2022; 15 (23) 2427-2436
    CrossrefPubMedGoogle Scholar
  • 43 Braaten JV, Goss RA, Francis CW. Ultrasound reversibly disaggregates fibrin fibers. Thromb Haemost 1997; 78 (03) 1063-1068
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Kuo WT, Banerjee A, Kim PS. et al. Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis (PERFECT): initial results from a prospective multicenter registry. Chest 2015; 148 (03) 667-673
    CrossrefPubMedGoogle Scholar
  • 45 Kuo WT, Gould MK, Louie JD, Rosenberg JK, Sze DY, Hofmann LV. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol 2009; 20 (11) 1431-1440
    CrossrefPubMedGoogle Scholar
  • 46 Piazza G, Hohlfelder B, Jaff MR. et al; SEATTLE II Investigators. A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II Study. JACC Cardiovasc Interv 2015; 8 (10) 1382-1392
    CrossrefPubMedGoogle Scholar
  • 47 Avgerinos ED, Jaber W, Lacomis J. et al; SUNSET sPE Collaborators. Randomized trial comparing standard versus ultrasound-assisted thrombolysis for submassive pulmonary embolism: the SUNSET sPE Trial. JACC Cardiovasc Interv 2021; 14 (12) 1364-1373
    CrossrefPubMedGoogle Scholar
  • 48 Toma C, Jaber WA, Weinberg MD. et al. Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism. EuroIntervention 2023; 18 (14) 1201-1212
    CrossrefPubMedGoogle Scholar
  • 49 Silver MH, Outcomes J. In high-risk pulmonary embolism patients undergoing FlowTriever mechanical thrombectomy: results from the FLAME study. Paper/Poster Presented at: American College of Cardiology; 2023 ; New Orleans, LA
    PubMedGoogle Scholar
  • 50 Sista AK, Horowitz JM, Tapson VF. et al; EXTRACT-PE Investigators. Indigo aspiration system for treatment of pulmonary embolism: results of the EXTRACT-PE Trial. JACC Cardiovasc Interv 2021; 14 (03) 319-329
    CrossrefPubMedGoogle Scholar
  • 51 Cross FS, Mowlem A. A survey of the current status of pulmonary embolectomy for massive pulmonary embolism. Circulation 1967; 35 (4, Suppl): I86-I91
    CrossrefPubMedGoogle Scholar
  • 52 Clarke DB. Pulmonary embolectomy re-evaluated. Ann R Coll Surg Engl 1981; 63 (01) 18-24
    PubMedGoogle Scholar
  • 53 Goldberg JB, Spevack DM, Ahsan S. et al. Survival and right ventricular function after surgical management of acute pulmonary embolism. J Am Coll Cardiol 2020; 76 (08) 903-911
    CrossrefPubMedGoogle Scholar
  • 54 Miller GA. The diagnosis and management of massive pulmonary embolism. Br J Surg 1972; 59 (10) 837-839
    CrossrefPubMedGoogle Scholar
  • 55 Paneth M. Pulmonary embolectomy. An analysis of 12 cases. J Thorac Cardiovasc Surg 1967; 53 (01) 77-83
    PubMedGoogle Scholar
  • 56 Goldberg JB, Giri J, Kobayashi T. et al. Surgical management and mechanical circulatory support in high-risk pulmonary embolisms: historical context, current status, and future directions: a scientific statement from the American Heart Association. Circulation 2023; 147 (09) e628-e647
    CrossrefPubMedGoogle Scholar
  • 57 Baldetti L, Beneduce A, Cianfanelli L. et al. Use of extracorporeal membrane oxygenation in high-risk acute pulmonary embolism: a systematic review and meta-analysis. Artif Organs 2021; 45 (06) 569-576
    CrossrefPubMedGoogle Scholar
  • 58 Tice C, Seigerman M, Fiorilli P. et al. Management of acute pulmonary embolism. Curr Cardiovasc Risk Rep 2020; 14 (12) 24
    CrossrefPubMedGoogle Scholar
  • 59 Ain DL, Albaghdadi M, Giri J. et al. Extra-corporeal membrane oxygenation and outcomes in massive pulmonary embolism: two eras at an urban tertiary care hospital. Vasc Med 2018; 23 (01) 60-64
    CrossrefPubMedGoogle Scholar
  • 60 Yusuff HO, Zochios V, Vuylsteke A. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review. Perfusion 2015; 30 (08) 611-616
    CrossrefPubMedGoogle Scholar
  • 61 Scott JH, Gordon M, Vender R. et al. Venoarterial extracorporeal membrane oxygenation in massive pulmonary embolism-related cardiac arrest: a systematic review. Crit Care Med 2021; 49 (05) 760-769
    CrossrefPubMedGoogle Scholar
  • 62 Klok FA, Ageno W, Ay C. et al. Optimal follow-up after acute pulmonary embolism: a position paper of the European Society of Cardiology Working Group on Pulmonary Circulation and Right Ventricular Function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the European Respiratory Society. Eur Heart J 2022; 43 (03) 183-189
    CrossrefPubMedGoogle Scholar
  • 63 Klok FA, van der Hulle T, den Exter PL, Lankeit M, Huisman MV, Konstantinides S. The post-PE syndrome: a new concept for chronic complications of pulmonary embolism. Blood Rev 2014; 28 (06) 221-226
    CrossrefPubMedGoogle Scholar
  • 64 Rivera-Lebron BN, Rali PM, Tapson VF. The PERT concept: a step-by-step approach to managing pulmonary embolism. Chest 2021; 159 (01) 347-355
    CrossrefPubMedGoogle Scholar
  • 65 Stadlbauer A, Philipp A, Blecha S. et al. Long-term follow-up and quality of life in patients receiving extracorporeal membrane oxygenation for pulmonary embolism and cardiogenic shock. Ann Intensive Care 2021; 11 (01) 181
    CrossrefPubMedGoogle Scholar