Evolving paradigm of thrombolysis in pulmonary embolism: Comprehensive review of clinical manifestations, indications, recent advances and guideline

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.