7.3 Novel Devices and New Strategies for the Management of High-Risk Pulmonary Embolism

These proceedings summarize the educational activity of the 17th Biennial Meeting of the International Andreas Gruentzig Society held January 30 to February 2, 2024 in Chiang Rai, Thailand.

Faculty Disclosures     Vendor Acknowledgments

2024 IAGS Summary Document

Statement of the problem or issue

Pulmonary embolism (PE) is a serious disease, and overall mortality is high. So, we have to treat it seriously. The first step is diagnosis and clinical evaluation. The CT pulmonary angiogram is the greatest diagnostic aid that has come along to help us. But, in addition, there are clinical items we need to evaluate in order to decide how serious a pulmonary embolism may be, and the associated risks, and whether we should treat it aggressively and invasively or with medications only. There are tools which can help us with these assessments.^1-4

Gaps in current knowledge

Although there are several algorithms covering the approach to diagnosis, risk stratification, and treatment of PE, they are all rather complicated. We do not have an “ideal” algorithm. Fundamentally, the two basic choices are (1) a medical therapy approach which can involve fibrinolytic agents and anticoagulation; (2) an invasive approach which can involve catheter-based therapies such as fibrinolysis, mechanical aspiration, or combinations of both. There are many catheter-based devices, and, as of yet there are no studies demonstrating superiority for one or more of them.

Possible solutions and future directions

Many institutions have created pulmonary embolism response teams (PERT). These teams typically are multidisciplinary and include combined interventional cardiology, interventional radiology, cardiac surgery, critical care, and cardiac imaging. PERT teams can help determine risk and help guide therapy. Ongoing developments to produce lower profile catheters with improved efficacy are slowly shifting the emphasis to more catheter-based interventions.

References

1. van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179. doi: 10.1001/jama.295.2.172. PMID: 16403929.
2. Aujesky D, Obrosky DS, Stone RA, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172(8):1041-1046. doi: 10.1164/rccm.200506-862OC. PMID: 16020800.
3. Jiménez D, Aujesky D, Moores L, et al. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med. 2010;170(15):1383-1389. doi: 10.1001/archinternmed.2010.199. PMID: 20696966.
4. Hull RD, Raskob GE, Rosenbloom D, Panju AA, Brill-Edwards P, Ginsberg JS, et al. Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis. N Engl J Med. 1990;322(18):1260-1264. doi: 10.1056/NEJM199005033221802. PMID: 2183055.