Prevention of early complications and late consequences after acute pulmonary embolism: Focus on reperfusion techniques

Abstract

Pulmonary embolism (PE) is a major cause of acute cardiovascular mortality and long-term morbidity. Right ventricular (RV) dysfunction is the key determinant of prognosis in the acute phase of PE, and residual RV dysfunction is associated with the development of post-PE functional impairment, chronic thromboembolic disease, and higher costs of treatment over the long term. Patients with clinically overt RV failure, i.e. hemodynamic collapse at presentation (high-risk PE), necessitate immediate thrombolytic treatment to relieve the obstruction in the pulmonary circulation; surgical or catheter-directed removal of the thrombus can be an alternative option. For patients with a high risk of bleeding or active hemorrhage, or for normotensive patients with intermediate-risk PE, systemic (intravenous) standard-dose thrombolysis is not recommended since the risks of treatment outweigh its benefits. In such cases, rescue thrombolysis should be considered only if hemodynamic decompensation develops while on heparin anticoagulation. For survivors of acute PE, little is known on the possible effects of thrombolytic treatment on the risk of chronic functional and hemodynamic impairment. Catheter-directed, ultrasound-assisted, low-dose thrombolysis leads to recovery of RV dysfunction, and its safety profile appears promising. However, adequately powered prospective trials focusing on both short- and long-term clinical outcomes are needed to establish novel interventional techniques in the treatment of PE.