Advanced Therapies for Acute Pulmonary Embolism: A Focus on Catheter-Based Therapies and Future Directions

ABSTRACT

Patients with acute pulmonary embolism (PE) present on a spectrum of clinical severity with a subset at risk for significant morbidity and mortality. Individuals without contraindications should be treated with systemic anticoagulation therapy; however, advanced therapies including systemic fibrinolysis, catheter-based approaches, surgical embolectomy, and mechanical circulatory support may be considered in the setting of hemodynamic instability or deterioration. Catheter-based therapies, categorized into lytic and non-lytic based approaches, have recently broadened treatment options, and may be of benefit to patients who are in intermediate- or high-risk categories. These approaches may allow for rapid improvement of right ventricular function and have the potential to lower the risk of bleeding complications compared to systemic fibrinolytic therapy. Emerging strategies utilizing adjunctive mechanical circulatory support may improve outcomes in the highest risk patients, providing stabilization prior to definitive therapy and potentially obviating the need for invasive measures. To help navigate these rapidly evolving treatment paradigms, pulmonary embolism response teams (PERT) have been established. Further studies focusing on the safety and efficacy of novel therapies and impact of PERT will be crucial for advancement of the field. This review focuses on currently available therapies, recent advances, and future directions in the treatment of acute pulmonary embolism.

Abbreviations: PE: pulmonary embolism; VTE; venous thromboembolism; CBT: catheter-based therapy; RV: right ventricle; AHA: American Heart Association; ACCP: American College of Chest Physicians; ESC: European Society of Cardiology; PESI: pulmonary embolism severity index; LV: left ventricle; DOAC: direct oral anticoagulant; FDA: Food and Drug Administration; tPA: tissue plasminogen activator; CTEPH: chronic thromboembolic pulmonary hypertension; USAT: ultrasound-assisted catheter-directed thrombolysis; VA-ECMO: veno-arterial extracorporeal membrane oxygenation; PERT: pulmonary embolism response team

KEYWORDS:

• Pulmonary embolism
• venous thromboembolic disease
• catheter-based therapy
• PERT
• ECMO
• systemic thrombolysis
• thrombectomy
• EKOS
• FlowTriever
• AngioVac
• Inari thrombectomy device

Acknowledgments

The authors wish to acknowledge Amy Mousley for her help with graphic design.

Disclosure statement

Dr. Bikdeli reports that he is a consulting expert, on behalf of the plaintiff, for litigation related to a specific type of IVC filter. Dr Kirtane reports Institutional funding to Columbia University and/or Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, ReCor Medical. In addition to research grants, institutional funding includes fees paid to Columbia University and/or Cardiovascular Research Foundation for speaking engagements and/or consulting; no speaking/consulting fees were personally received. Personal: Travel Expenses/Meals from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, ReCor Medical, Chiesi, OpSens, Zoll, and Regeneron. Dr Parikh reports institutional grants/research support from Abbott Vascular, Shockwave Medical, TriReme Medical and Surmodics; consulting fees from Terumo and Abiomed; and Advisory Board participation for Abbott, Medtronic, Boston Scientific, CSI, Janssen and Philips. Dr. Sethi reports honoraria from Chiesi and Janssen. The remaining authors report no conflicts of interest.

Supplementary material

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Additional information

Funding

Dr. Madhavan has received support from an institutional grant by the National Institutes of Health/National Heart, Lung, and Blood Institute to Columbia University Irving Medical Center (T32 HL007854).