Anticoagulant Therapy in Patients Undergoing Acute Pulmonary Embolism Interventions

Abstract

Catheter-based interventions and surgical embolectomy represent alternatives to systemic fibrinolysis in well-selected patients with high-risk pulmonary embolism (PE), or those with intermediate-high-risk PE who suffer from subsequent hemodynamical deterioration. They are indicated when systemic fibrinolysis is contraindicated or has failed, and in those patients who experience (or are at high risk of experiencing) obstructive shock that is likely to cause death before systemic fibrinolysis can take effect. Catheter-directed therapies are being investigated in randomized trials for less sick patients with intermediate-risk PE. Extracorporeal membrane oxygenation can be used as add-on to reperfusion therapies or alone in patients who suffer from severe RV dysfunction and cardiogenic shock. These advanced therapies do not replace anticoagulation, which remains the cornerstone of PE management. However, anticoagulation regimens throughout the different phases of each PE intervention are not well standardized, the evidence base is limited, and there is no comprehensive review of available regimens for these procedures. In this review, we summarize this evidence and share practical recommendations for use anticoagulant therapy before, during and after interventional reperfusion therapies and mechanical circulatory support for acute PE. Intravenous unfractionated heparin infusion is the anticoagulant of choice during each PE intervention and the proximate periprocedural period. Transition to subcutaneous low molecular weight heparins or to oral anticoagulants should be done cautiously after subsequent hemostasis and clinical stability are verified. Some future perspectives are also discussed.