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World J Clin Cases. Mar 16, 2023; 11(8): 1702-1711
Published online Mar 16, 2023. doi: 10.12998/wjcc.v11.i8.1702
Evolving paradigm of thrombolysis in pulmonary embolism: Comprehensive review of clinical manifestations, indications, recent advances and guideline
Rohan Kumar Ochani, Rafi Aibani, Hafsa Nazir Jatoi, Masroor Anwar, Syed Anjum Khan, Iqbal Ratnani, Salim Surani
Rohan Kumar Ochani, Rafi Aibani, Hafsa Nazir Jatoi, Department of Internal Medicine, Dow University of Health Science, Karachi 74200, Sindh, Pakistan
Masroor Anwar, Department of Internal Medicine, Khyber Teaching Hospital, Peshawar 00000, Pakistan
Syed Anjum Khan, Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
Iqbal Ratnani, Department of Anesthesiology & Critical Care, Houston Methodist Hospital, Houston, TX 77030, United States
Salim Surani, Department of Medicine, Texas A&M University, College Station, TX 77843, United States
Salim Surani, Department of Medicine, Aga Khan University, Nairobi, Kenya
Author contributions: Ochani RK, Aibani R, Jatoi HN and Anwar M were involved in the literature search and writing of the manuscript; Ochani RK was lead in writing and revising; Ratnani I and Khan SA were involved in proofreading the manuscript and revision; Surani S was involved in idea creation, writing and revision of the manuscript.
Conflict-of-interest statement: None of the authors have any conflict of interest to disclose.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Salim Surani, FCCP, MD, MS, Professor, Department of Medicine, Texas A&M University, Administration Building, 400 Bizzell St, College Station, TX 77843, United States. srsurani@hotmail.com
Received: November 26, 2022
Peer-review started: November 26, 2022
First decision: January 17, 2023
Revised: January 27, 2023
Accepted: February 21, 2023
Article in press: February 21, 2023
Published online: March 16, 2023
Processing time: 100 Days and 10.2 Hours
Abstract

Thrombolytic therapy has been the mainstay for patients with pulmonary embolism (PE). Despite being linked to a higher risk of significant bleeding, clinical trials demonstrate that thrombolytic therapy should be used in patients with moderate to high-risk PE, in addition to hemodynamic instability symptoms. This prevents the progression of right heart failure and impending hemodynamic collapse. Diagnosing PE can be challenging due to the variety of presentations; therefore, guidelines and scoring systems have been established to guide physicians to correctly identify and manage the condition. Traditionally, systemic thrombolysis has been utilized to lyse the emboli in PE. However, newer techniques for thrombolysis have been developed, such as endovascular ultrasound-assisted catheter-directed thrombolysis for massive and intermediate-high submassive risk groups. Additional newer techniques explored are the use of extracorporeal membrane oxygenation, direct aspiration, or fragmentation with aspiration. Because of the constantly changing therapeutic options and the scarcity of randomized controlled trials, choosing the best course of treatment for a given patient may be difficult. To help, the Pulmonary Embolism Reaction Team is a multidisciplinary, rapid response team that has been developed and is used at many institutions. Hence to bridge the knowledge gap, our review highlights various indications of thrombolysis in addition to the recent advances and management guidelines

Keywords: Pulmonary embolism; Thrombolytics; Systemic; Catheter-directed; Pulmonary embolism reaction team; Guidelines

Core Tip: There are now many treatments to treat acute pulmonary embolism (PE). Patients are divided into low, moderate, and high-risk PE groups to identify those needing more advanced treatment. Unless contraindicated, systemic thrombolysis is advised for high-risk pulmonary embolism. Other than systemic thrombolysis, a number of treatment options for PE are being investigated, such as catheter-directed thrombolysis, extracorporeal membrane oxygenation, direct aspiration, or fragmentation with aspiration. Choosing the appropriate course of treatment for a certain patient may be challenging due to the plethora of therapeutic choices that are continually evolving and the paucity of randomized controlled trials. Therefore, the Pulmonary Embolism Reaction Team, is a multidisciplinary, rapid response team has been developed and is employed by various institutions to customize therapeutic options according to the need of the patient to address the ever-evolving therapeutic care.