Endovascular therapy for acute severe pulmonary embolism

  • Qasim A. JavedEmail author
  • Akhilesh K. Sista
Original Paper


Acute pulmonary embolism (PE) is a major public health problem and accounts for 100,000–180,000 deaths per year in the United States. Current prognostic stratification separates acute PE into massive, submassive, and low-risk by the presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive and low-risk PE have mortality rates of 25–65%, 3%, and < 1%, respectively. In this review we will focus on therapies currently available to manage acute massive and submassive PE.


Pulmonary embolism Venous thromboembolic disease Massive pulmonary embolism Submassive pulmonary embolism Catheter-directed therapy Catheterdirected thrombolysis Thrombolysis Embolectomy 


Compliance with Ethical Standards

Conflict of interest

Authors declare no conflicts of interest.


  1. 1.
    Pulido T, Aranda A, Zevallos MA et al (2006) Pulmonary embolism as a cause of death in patients with heart disease: an autopsy study. Chest 129(5):1282–1287CrossRefGoogle Scholar
  2. 2.
    Tapson VF (2008) Acute pulmonary embolism. N Engl J Med 358(10):1037–1052CrossRefGoogle Scholar
  3. 3.
    Sista AK, Miller LE, Kahn SR, Kline JA (2017) Persistent right ventricular dysfunction, functional capacity limitation, exercise intolerance, and quality of life impairment following pulmonary embolism: systematic review with meta-analysis. Vasc Med 22(1):37–43CrossRefGoogle Scholar
  4. 4.
    Piazza G, Goldhaber SZ (2010) Management of submassive pulmonary embolism. Circulation 122(11):1124–1129CrossRefGoogle Scholar
  5. 5.
    Tarbox AK, Swaroop M (2013) Pulmonary embolism. Int J Crit Illn Inj Sci 3(1):69–72Google Scholar
  6. 6.
    McIntyre KM, Sasahara AA (1971) The hemodynamic response to pulmonary embolism in patients without prior cardiopulmonary disease. Am J Cardiol 28(3):288–294CrossRefGoogle Scholar
  7. 7.
    Jaff MR, McMurtry MS, Archer SL et al. (2011) Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123(16):1788–1830CrossRefGoogle Scholar
  8. 8.
    Becattini C, Agnelli G, Vedovati MC et al (2011) Multidetector computed tomography for acute pulmonary embolism: diagnosis and risk stratification in a single test. Eur Heart J 32(13):1657–1663CrossRefGoogle Scholar
  9. 9.
    Trujillo-Santos J, den Exter PL, Gómez V et al. (2013) Computed tomography-assessed right ventricular dysfunction and risk stratification of patients with acute non-massive pulmonary embolism: systematic review and meta-analysis. J Thromb Haemost 11(10):1823–1832Google Scholar
  10. 10.
    Becattini C, Vedovati MC, Agnelli G (2007) Prognostic value of troponins in acute pulmonary embolism: a meta-analysis. Circulation 116(4):427–433CrossRefGoogle Scholar
  11. 11.
    Klok FA, Mos IC, Huisman MV (2008) Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Am J Respir Crit Care Med 178(4):425–430CrossRefGoogle Scholar
  12. 12.
    Konstantinides SV, Torbicki A, Agnelli Get et al. (2014) ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 35(43):3033–3069 3069a–3069k. [Published corrections appear in Eur Heart J 2015;36(39):2666 and Eur Heart J 2015;36(39):2642.]CrossRefGoogle Scholar
  13. 13.
    Wicki J, Perrier A, Perneger TV, Bounameaux H, Junod AF (2000) Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost 84(4):548–552Google Scholar
  14. 14.
    Jiménez D, Aujesky D, Moores L et al (2010) Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 170(15):1383–1389CrossRefGoogle Scholar
  15. 15.
    Kearon C, Akl EA, Ornelas J et al (2016) Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 149(2):315–352 [Published correction appears in Chest 2016;149(2):315–352.]CrossRefGoogle Scholar
  16. 16.
    Casazza F, Becattini C, Bongarzoni A et al (2012) Clinical features and short term outcomes of patients with acute pulmonary embolism. The Italian Pulmonary Embolism Registry (IPER). Thromb Res 130(6):847–852CrossRefGoogle Scholar
  17. 17.
    Kasper W, Konstantinides S, Geibel A et al (1997) Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 30(5):1165–1171CrossRefGoogle Scholar
  18. 18.
    Goldhaber SZ, Visani L, De Rosa M (1999) Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 353(9162):1386–1389CrossRefGoogle Scholar
  19. 19.
    Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H (1997) Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism. Heart 77(4):346–3499CrossRefGoogle Scholar
  20. 20.
    Ribeiro A, Lindmarker P, Juhlin-Dannfelt A, Johnsson H, Jorfeldt L (1997) Echocardiography doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate. Am Heart J 134(3):479–487CrossRefGoogle Scholar
  21. 21.
    Konstantinides SV, Vicaut E, Danays T et al (2017) Impact of thrombolytic therapy on the long-term outcome of intermediate-risk pulmonary embolism. J Am Coll Cardiol 69(12):1536–1544CrossRefGoogle Scholar
  22. 22.
    Chatterjee S, Chakraborty A, Weinberg I et al (2014) Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 311(23):2414–2421CrossRefGoogle Scholar
  23. 23.
    Meyer G, Vicaut E, Danays T et al (2014) Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 370(15):1402–1411CrossRefGoogle Scholar
  24. 24.
    Nakamura S, Takano H, Kubota Y, Asai K, Shimizu W (2014) Impact of the efficacy of thrombolytic therapy on the mortality of patients with acute submassive pulmonary embolism: a meta-analysis. J Thromb Haemost 12(7):1086–1095CrossRefGoogle Scholar
  25. 25.
    Stein PD, Alnas M, Beemath A, Patel NR (2007) Outcome of pulmonary embolectomy. Am J Cardiol 99(3):421–423CrossRefGoogle Scholar
  26. 26.
    Stein PD, Matta F (2012) Case fatality rate with pulmonary embolectomy for acute pulmonary embolism. Am J Med 125(5):471–477Google Scholar
  27. 27.
    Neely RC, Byrne JG, Gosev I et al (2015) Surgical embolectomy for acute massive and submassive pulmonary embolism in a series of 115 patients. Ann Thorac Surg 100(4):1245–1251; discussion 1251–1252CrossRefGoogle Scholar
  28. 28.
    Kuo WT (2012) Endovascular therapy for acute pulmonary embolism. J Vasc Interv Radiol 23(2):167–179.e4; quiz 179CrossRefGoogle Scholar
  29. 29.
    Kuo WT, Gould MK, Louie JD, Rosenberg JK, Sze DY, Hofmann LV (2009) Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol 20(11):1431–1440CrossRefGoogle Scholar
  30. 30.
    Liu B, Liu M, Yan L et al (2018) Percutaneous mechanical thrombectomy combined with catheter-directed thrombolysis in the treatment of acute pulmonary embolism and lower extremity deep venous thrombosis: A novel one-stop endovascular strategy. J Int Med Res 46(2):836–851CrossRefGoogle Scholar
  31. 31.
    Kuo WT, Banerjee A, Kim PS et al (2015) Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT): initial results from a prospective multicenter registry. Chest 148(3):667–673CrossRefGoogle Scholar
  32. 32.
    Piazza G, Hohlfelder B, Jaff MR et al (2015) A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II study. JACC Cardiovasc Interv 8(10):1382–1392CrossRefGoogle Scholar
  33. 33.
    Kucher N, Boekstegers P, Müller OJ et al (2014) Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 129(4):479–486CrossRefGoogle Scholar
  34. 34.
    Tapson VF, Sterling K, Jones N et al (2018) A randomized trial of the optimum duration of acoustic pulse thrombolysis procedure in acute intermediate-risk pulmonary embolism: the OPTALYSE PE trial. JACC Cardiovasc Interv 11(14):1401–1410CrossRefGoogle Scholar
  35. 35.
    Weinberg AS, Dohad S, Ramzy D, Madyoon H, Tapson VF (2016) Clot extraction With the flowtriever device in acute massive pulmonary embolism. J Intensive Care Med 31(10):676–679CrossRefGoogle Scholar
  36. 36.
    Inari Medical (2016) FlowTriever Pulmonary Embolectomy Clinical Study (FLARE). Identifier NCT02692586. (Retrieved from
  37. 37.
    Ciampi-dopazo JJ, Romeu-prieto JM, Sánchez-casado M et al (2018) Aspiration thrombectomy for treatment of acute massive and submassive pulmonary embolism: initial single-center prospective experience. J Vasc Interv Radiol 29(1):101–106CrossRefGoogle Scholar
  38. 38.
    Penumbra Inc (2017) Evaluating the Safety and Efficacy of the Indigo Aspiration System in Acute Pulmonary Embolism (EXTRACT-PE). Identifier NCT03218566. (Retrieved from
  39. 39.
    Pasha AK, Elder MD, Khurram D, Snyder BA, Movahed MR (2014) Successful management of acute massive pulmonary embolism using Angiovac suction catheter technique in a hemodynamically unstable patient. Cardiovasc Revasc Med 15(4):240–243CrossRefGoogle Scholar
  40. 40.
    D’ayala M, Worku B, Gulkarov I, Sista A, Horowitz J, Salemi A (2017) Factors associated with successful thrombus extraction with the angiovac device: an institutional experience. Ann Vasc Surg 38:242–247Google Scholar
  41. 41.
    Barjaktarevic I, Friedman O, Ishak C, Sista AK (2014) Catheter-directed clot fragmentation using the Cleaner™ device in a patient presenting with massive pulmonary embolism. J Radiol Case Rep 8(2):30–36Google Scholar
  42. 42.
    Nakazawa K, Tajima H, Murata S, Kumita SI, Yamamoto T, Tanaka K (2008) Catheter fragmentation of acute massive pulmonary thromboembolism: distal embolisation and pulmonary arterial pressure elevation. Br J Radiol 81(971):848–854CrossRefGoogle Scholar
  43. 43.
    Sista AK, Horowitz JM, Goldhaber SZ (2016) Four key questions surrounding thrombolytic therapy for submassive pulmonary embolism. Vasc Med 21(1):47–52CrossRefGoogle Scholar
  44. 44.
    Bhatt A, Al-hakim R, Benenati JF (2017) Techniques and devices for catheter-directed therapy in pulmonary embolism. Tech Vasc Interv Radiol 20(3):185–192CrossRefGoogle Scholar
  45. 45.
    Stein PD, Matta F, Keyes DC, Willyerd GL (2012) Impact of vena cava filters on in-hospital case fatality rate from pulmonary embolism. Am J Med 125(5):478–484Google Scholar
  46. 46.
    Mismetti P, Laporte S, Pellerin O et al (2015) Effect of a retrievable inferior vena cava filter plus anticoagulation versus anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA 313(16):1627–1635CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.NYU Langone HealthNew YorkUSA

Personalised recommendations