Thrombectomy in High-Risk Pulmonary Embolism

Primary Indication: High-Risk PE with Contraindications or Failed Thrombolysis

The American College of Chest Physicians recommends thrombectomy in patients with high-risk pulmonary embolism presenting with shock or persistent hypotension who have absolute contraindications to thrombolysis, have failed systemic thrombolysis, or are in such profound shock that death is imminent before thrombolysis can take effect 1
High-risk pulmonary embolism is defined as shock or persistent hypotension, and the clearest indication for thrombectomy is in these patients when systemic thrombolysis cannot be used or has failed, according to the European Society of Cardiology 1, 2

The European Society of Cardiology recommends risk stratification to precede any decision about thrombectomy, with high-risk pulmonary embolism patients having the highest mortality and warranting aggressive reperfusion therapy 1, 2, 5
High-risk pulmonary embolism patients are those with shock (systolic BP <90 mmHg) or persistent hypotension requiring vasopressors, and these patients should receive aggressive reperfusion therapy, including thrombectomy if necessary 2, 5

The European Heart Journal recommends surgical pulmonary embolectomy as the preferred method when absolute contraindications to thrombolysis exist in high-risk pulmonary embolism 4
Catheter-based thrombectomy is an alternative when surgical embolectomy is not immediately available or when surgery carries prohibitive risk, according to the American College of Chest Physicians 1, 4

The European Society of Cardiology recommends against performing thrombectomy in intermediate-risk pulmonary embolism that remains hemodynamically stable, as these patients should receive anticoagulation alone 1, 4
Systemic thrombolysis remains the first-line treatment for high-risk pulmonary embolism if no contraindications exist, and thrombectomy is reserved for when thrombolysis cannot be used or has failed, according to the American College of Chest Physicians 1, 4
Anticoagulation must continue after thrombectomy, with unfractionated heparin initiated immediately in high-risk pulmonary embolism, and transition to therapeutic anticoagulation for a minimum of 3 months, as recommended by the European Society of Cardiology 4, 5, 6