Dr. Simon Gibbs,
Interventional techniques may have an important role to play in massive pulmonary embolism. The ESC Guidelines on Acute Pulmonary Embolism do not make any specific recommendations about this intervention due to lack of trial evidence and the anecdotal use of this approach. Interventions which employ a dual pharmacological and mechanical approach to blood clot dispersion such as ultrasound assisted thrombolysis offer the best opportunity for clot lysis. A meta-analysis of 594 patients in 35 studies suggests that haemodynamic stability, resolution of hypoxaemia and survival can be achieved in 86% of cases. The low reported rate of complications and excellent results may of course reflect reporting bias. Reported complications include pulmonary haemorrhage, haemoptysis, right ventricular failure as a result of distal pulmonary arterial embolization, bleeding, haemolysis and haemoglobinuria and arrhythmias.
The management of patients with acute pulmonary embolism at intermediate risk, namely those who are haemodynamically stable but have impaired right ventricular function on echocardiography, remains uncertain. These patients are prone to rapid decompensation. An answer to this clinical dilemma is in sight in 2012 when the results of the PEITHO trial, an international trial which is investigating the clinical benefits of thrombolysis (tenecteplase) over placebo in normotensive patients with acute intermediate-risk pulmonary embolism, will report. This will constitute the largest trial yet in acute pulmonary embolism: watch out for the results at the Munich congress one year from now. In the meantime these patients continue to be treated with low molecular weight heparin.
Managing difficult pulmonary embolism
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