Chapter 48
Treatment of Pulmonary Embolism
Medical, Surgical, and Percutaneous
Ian del Conde,
Barry T. Katzen,
Ian del Conde
Search for more papers by this authorBarry T. Katzen
Search for more papers by this authorIan del Conde,
Barry T. Katzen,
Ian del Conde
Search for more papers by this authorBarry T. Katzen
Search for more papers by this authorBook Editor(s):George D. Dangas MD, MACC, MSCAI, FAHA, FESC,
Carlo Di Mario MD, PhD, FRCP, FACC, FSCAI, FESC,
Holger Thiele MD,
Peter Barlis MBBS, MPH, PHD, FACC, FESC, FRACP,
Tayo Addo MD, Bimmer Claessen MD, Christian Hengstenberg MD, Nicholas Kipshidze MD,
George D. Dangas MD, MACC, MSCAI, FAHA, FESC
Professor of Medicine (Cardiology) & Surgery (Vascular) Professor of Cardiology Adjunct Professor of Internal Medicine
Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
National Kapodistrian University of Athens, Greece
Medical University of Vienna, Austria
Search for more papers by this authorCarlo Di Mario MD, PhD, FRCP, FACC, FSCAI, FESC
Professor of Cardiology Director of the Structural Interventional Cardiology Division Honorary Consultant
University of Florence
University Hospital Careggi, Florence, Italy
Cardiologist Royal Brompton Hospital, London, UK
Search for more papers by this authorHolger Thiele MD
Professor of Cardiology at University of Leipzig
Heart Center Leipzig at University of Leipzig, Leipzig, Germany
Search for more papers by this authorPeter Barlis MBBS, MPH, PHD, FACC, FESC, FRACP
Professor of Cardiology Interventional Cardiologist
University of Melbourne, Melbourne, Victoria, Australia
St Vincent's & Northern Hospitals Victoria, Australia
Search for more papers by this authorFirst published: 06 May 2022
Summary
Pulmonary embolism (PE) presents in a continuum of severity that spans from incidentally discovered subsegmental PE to massive PE resulting in cardiogenic shock and death. The main cause of death in patients with large PE is right ventricular failure, cardiogenic shock, and refractory hypoxemia. Therefore, rapid recanalization of the pulmonary arteries is the ultimate goal of all therapies for acute PE, regardless whether pharmacologic (anticoagulation or systemic fibrinolysis), surgical, or catheter-based. All patients presenting with PE should be risk-stratified with the goal of identifying patients who are at high risk of dying if they do not receive treatment with thrombolysis or surgical embolectomy and identifying patients who are likely to develop chronic thromboembolic pulmonary hypertension. Anticoagulation therapy remains a cornerstone in the management of patients with acute PE. Selected patients with submassive or massive PE can also benefit from placement of a retrievable inferior vena cava filter, even if they are candidates for anticoagulation.
References
- Becattini C , Agnelli G , Pesavento R , et al . Incidence of chronic thromboembolic pulmonary hypertension after a first episode of pulmonary embolism . Chest 2006 ; 130 : 172 – 175 .
- Pengo V , Lensing AW , Prins MH , et al . Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism . N Engl J Med 2004 ; 350 : 2257 – 2264 .
- Piazza G , Goldhaber SZ . Chronic thromboembolic pulmonary hypertension . N Engl J Med 2011 ; 364 : 351 – 360 .
- Nakazawa K , Tajima H , Murata S , et al . Catheter fragmentation of acute massive pulmonary thromboembolism: distal embolisation and pulmonary arterial pressure elevation . Br J Radiol 2008 ; 81 : 848 – 854 .
- Casazza F , Becattini C , Bongarzoni A , et al . Clinical features and short term outcomes of patients with acute pulmonary embolism. The Italian Pulmonary Embolism Registry (IPER) . Thromb Res 2012 ; 130 : 847 – 852 .
- Jaff MR , McMurtry MS , Archer SL , et al . 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 : 1788 – 1830 .
- Piazza G . Submassive pulmonary embolism . JAMA 2013 ; 309 : 171 – 180 .
- Piazza G , Goldhaber SZ . Management of submassive pulmonary embolism . Circulation 2010 ; 122 : 1124 – 1129 .
- Konstantinides S , Geibel A , Olschewski M , et al . Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism . Circulation 2002 ; 106 : 1263 – 1268 .
- Becattini C , Casazza F , Forgione C , et al . Acute pulmonary embolism: external validation of an integrated risk stratification model . Chest 2013 ; 144 : 1539 – 1545 .
- Trujillo-Santos J , den Exter PL , Gomez V , et al . Computed tomography-assessed right ventricular dysfunction and risk stratification of patients with acute nonmassive pulmonary embolism: systematic review and meta-analysis . J Thromb Haemost 2013 ; 11 : 1823 – 1832 .
- Konstantinides S , Geibel A , Heusel G , et al . Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism . N Engl J Med 2002 ; 347 : 1143 – 1150 .
- Konstantinides SV , Meyer G , Becattini C , et al . ESC Scientific Document Group . 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) . Eur Heart J. 2020 Jan 21; 41 ( 4 ): 543 – 603 .
- Reid JH , Murchison JT . Acute right ventricular dilatation: a new helical CT sign of massive pulmonary embolism . Clin Radiol 1998 ; 53 : 694 – 698 .
- Schoepf UJ , Kucher N , Kipfmueller F , et al . Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism . Circulation 2004 ; 110 : 3276 – 3280 .
- van der Meer RW , Pattynama PM , van Strijen MJ , et al . Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism . Radiology 2005 ; 235 : 798 – 803 .
- Lu MT , Demehri S , Cai T , et al . Axial and reformatted four-chamber right ventricleto-left ventricle diameter ratios on pulmonary CT angiography as predictors of death after acute pulmonary embolism . AJR Am J Roentgenol 2012 ; 198 : 1353 – 1360 .
- Kearon C , Akl EA , Comerota AJ , et al . Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th edn . American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012 ; 141 : e419S – 94S .
- Guyatt GH , Akl EA , Crowther M , et al . Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines . Chest 2012 ; 141 : 7S – 47S .
- Agnelli G , Buller HR , Cohen A , et al . Oral apixaban for the treatment of acute venous thromboembolism . N Engl J Med 2013 ; 369 : 799 – 808 .
- Hokusai VTEI , Buller HR , Decousus H , et al . Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism . N Engl J Med 2013 ; 369 : 1406 – 1415 .
- EINSTEIN–PE Investigators , Bauersachs R , Berkowitz SD , et al . Oral rivaroxaban for symptomatic venous thromboembolism . N Engl J Med 2010 ; 363 : 2499 – 2510 .
- EINSTEIN–PE Investigators , Buller HR , Prins MH , et al . Oral rivaroxaban for the treatment of symptomatic pulmonary embolism . N Engl J Med 2012 ; 366 : 1287 – 1297 .
- Schulman S , Kakkar AK , Goldhaber SZ , et al . Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis . Circulation 2014 ; 129 : 764 – 772 .
- Schulman S , Kearon C , Kakkar AK , et al . Dabigatran versus warfarin in the treatment of acute venous thromboembolism . N Engl J Med 2009 ; 361 : 2342 – 2352 .
- Chai-Adisaksopha C , Crowther M , Isayama T , Lim W . The impact of bleeding complications in patients receiving target-specific oral anticoagulants: a systematic review and meta-analysis . Blood 2014 ; 124 : 2450 – 2458 .
- Yeh CH , Gross PL , Weitz JI . Evolving use of new oral anticoagulants for treatment of venous thromboembolism . Blood 2014 ; 124 : 1020 – 1028 .
- Jerjes-Sanchez C , Ramirez-Rivera A , de Lourdes Garcia M , et al . Streptokinase and heparin versus heparin alone in massive pulmonary embolism: a randomized controlled trial . J Thromb Thrombolysis 1995 ; 2 : 227 – 229 .
- 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 : 744 – 749 .
- Kucher N , Goldhaber SZ . Management of massive pulmonary embolism . Circulation 2005 ; 112 : e28 – 32 .
- Kucher N , Rossi E , De Rosa M , Goldhaber SZ . Massive pulmonary embolism . Circulation 2006 ; 113 : 577 – 582 .
- Meyer G , Vicaut E , Danays T , et al . Fibrinolysis for patients with intermediate-risk pulmonary embolism . N Engl J Med 2014 ; 370 : 1402 – 1411 .
- Dauphine C , Omari B . Pulmonary embolectomy for acute massive pulmonary embolism . Ann Thoracic Surg 2005 ; 79 : 1240 – 1244 .
- Leacche M , Unic D , Goldhaber SZ , et al . Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach . J Thoracic Cardiovasc Surg 2005 ; 129 : 1018 – 1023 .
- Piazza G. Multicenter trial of ultrasound-facilitated, low-dose fibrinolysis for acute massive and submassive pulmonary embolism (SEATTLE II) . 2014 American College of Cardiology meeting, 2014.
- Dudiy Y , Kronzon I , Cohen HA , Ruiz CE . Vacuum thrombectomy of large right atrial thrombus . Catheter Cardiovasc Interv 2012 ; 79 : 344 – 347 .
- Geller BJ , Morrow DA , Sobieszczyk P . Percutaneous right ventricular assist device for massive pulmonary embolism . Circ Cardiovasc Interv 2012 ; 5 : e74 – 75 .
- Kaltenbock F , Gombotz H , Tscheliessnigg KH , et al . [ Right ventricular assist device (RVAD) in septic, fulminating pulmonary artery embolism ]. Der Anaesthesist 1993 ; 42 : 807 – 810 .
- Eid-Lidt G , Gaspar J , Sandoval J , et al . Combined clot fragmentation and aspiration in patients with acute pulmonary embolism . Chest 2008 ; 134 : 54 – 60 .
- https://venousnews.com/viva19-penumbra-indigo-aspiration-system-acute-pe-primary-safety-and-efficacy-endpoints . Accessed 10/3/2020
- Tu T , Toma C , Tapson VF , et al . A Prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism: The FLARE Study . JACC Cardiovasc Interv. 2019 May 13; 12 ( 9 ): 859 – 869
- Schmitz-Rode T , Janssens U , Duda SH , et al . Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter . J Am Coll Cardiol 2000 ; 36 : 375 – 380 .
- Bonvini RF , Righini M , Roffi M . Angiojet rheolytic thrombectomy in massive pulmonary embolism: locally efficacious but systemically deleterious? J Vasc Interv Radiol 2010 ; 21 : 1774 – 1776 ; author reply 1776–1777.
- Kuo WT , Gould MK , Louie JD , et al . Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques . J Vasc Interv Radiol. 2009 Nov; 20 ( 11 ): 1431 – 40 .
- Karnabatidis D , Katsanos K , Kagadis GC , Siablis D . Re: Bradyarrhythmias during use of the angiojet system . J Vasc Interv Radiol 2007 ; 18 : 937 ; author reply 938.
- Stein PD , Matta F , Keyes DC , Willyerd GL . Impact of vena cava filters on in-hospital case fatality rate from pulmonary embolism . Am J Med 2012 ; 125 : 478 – 484 .
