Interventional therapies for pulmonary embolism

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. Pulmonary embolism is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. In this Review, Mahfoud and colleagues discuss the growing range of interventional, catheter-based approaches for the treatment of pulmonary embolism as well as risk stratification and patient selection for these procedures. 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, a