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  • Review Article
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Interventional therapies for pulmonary embolism

Nature Reviews Cardiology volume 20, pages 670–684 (2023)Cite this article

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Abstract

Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate–high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discuss future perspectives and unmet needs.

Key points

  • Pulmonary embolism (PE) remains the leading cause of preventable death in hospitalized patients; risk stratification of PE is advised on the basis of clinical presentation, haemodynamics and comorbidities.

  • Patients with low-risk or intermediate–low-risk PE benefit from anticoagulation alone, whereas treatment of patients with intermediate–high-risk or high-risk PE poses difficulties; systemic thrombolysis is the first-line recommendation for patients with high-risk PE but is associated with severe adverse events, especially bleeding.

  • In patients with intermediate–high-risk PE and those with high-risk PE and contraindications to thrombolysis, interventional therapies, such as catheter-directed thrombolysis (CDT), ultrasound-assisted CDT (USCDT), pharmacomechanical CDT and aspiration thrombectomy, are possible options.

  • Despite showing promising results in reducing right ventricular dysfunction and relief of haemodynamic compromise in small studies and registries, these interventional therapies have not been rigorously investigated in adequately powered randomized controlled trials.

  • CDT, USCDT and pharmacomechanical CDT reduce the dose of thrombolytics used, whereas aspiration thrombectomy eliminates the use of thrombolytics.

  • Large, adequately powered, randomized controlled trials investigating low-dose thrombolysis, CDT, USCDT and large-bore thrombectomy are ongoing and more are planned.

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Fig. 1: Timeline of studies of interventional therapies in PE.
Fig. 2: Pathophysiology of PE and concomitant pulmonary hypertension after pulmonary artery obstruction and vasoconstriction.
Fig. 3: Treatment algorithm for PE.
Fig. 4: Large-bore thrombectomy.

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Acknowledgements

F.G. is supported by Deutsche Herzstiftung. M.B. is supported by Deutsche Forschungsgemeinschaft (SFB TRR219, S-01, M-03 and M-05). F.M. is supported by Deutsche Gesellschaft für Kardiologie (DGK), Deutsche Forschungsgemeinschaft (SFB TRR219) and Deutsche Herzstiftung.

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Authors and Affiliations

  1. Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany

    Felix Götzinger, Lucas Lauder, Michael Böhm & Felix Mahfoud

  2. Department of Cardiology, University Hospital of Wales, Cardiff, UK

    Andrew S. P. Sharp

  3. Cardiff University, Cardiff, UK

    Andrew S. P. Sharp

  4. Department of Cardiology, Internal Medicine II, Medical University of Vienna, Vienna, Austria

    Irene M. Lang

  5. Department of Cardiology - Internal Medicine III, Cologne University Heart Center, Cologne, Germany

    Stephan Rosenkranz

  6. Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany

    Stephan Rosenkranz

  7. Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany

    Stavros Konstantinides

  8. Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece

    Stavros Konstantinides

  9. Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA

    Elazer R. Edelman & Felix Mahfoud

  10. Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA

    Wissam Jaber

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Contributions

F.G. and F.M. researched data for the article, discussed its content and wrote the manuscript. All the authors reviewed/edited the article before submission.

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Correspondence to Felix Mahfoud.

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Competing interests

F.G. has received speaker honoraria from AstraZeneca. L.L. has received speaker honoraria from Medtronic and ReCor Medical. I.M.L. has relationships with the following drug companies: Actelion-Janssen, AOP-Health, Ferrer, Medtronic, MSD, Neutrolis and United Therapeutics; in addition to being an investigator in trials involving these companies, relationships include consultancy services, research grants and membership of scientific advisory boards. S.R. has received fees for lectures and/or consultations from Abbott, Acceleron, Actelion, Aerovate, Altavant, AOP Orphan, AstraZeneca, Bayer, Boehringer Ingelheim, Edwards, Ferrer, Gossamer, Janssen, MSD, United Therapeutics and Vifor; his institution has received research grants from Actelion, AstraZeneca, Bayer and Janssen. S.K. reports grants or contracts from Bayer, Boston Scientific and Daiichi Sankyo, and consulting and lecture fees from Bayer, Boston Scientific, Daiichi Sankyo, MSD and Pfizer–Bristol-Myers Squibb. M.B. is supported by Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Medtronic, Novartis, ReCor Medical, Servier and Vifor. W.J. is a consultant for Inari Medical and Medtronic. F.M. has received scientific support from Ablative Solutions, Medtronic and ReCor Medical and speaker honoraria/consulting fees from Ablative Solutions, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Inari, Medtronic, Merck, ReCor Medical, Servier and Terumo. The other authors declare no competing interests.

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Nature Reviews Cardiology thanks Efthymios Avgerinos, Menno Huisman, David Jiménez and Akhilesh Sista for their contribution to the peer review of this work.

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Götzinger, F., Lauder, L., Sharp, A.S.P. et al. Interventional therapies for pulmonary embolism. Nat Rev Cardiol 20, 670–684 (2023). https://doi.org/10.1038/s41569-023-00876-0

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