Non-Pharmacological Management of
HS Natraj Setty*, Rahul Patil, Raghavendra Murthy P, Shivanand S Patil, Vijayakumar, and CN Manjunath
Sri Jayadeva Institute of Cardiovascular Sciences and Research, India
Submission: February 18, 2017; Published: September 20, 2017
*Corresponding author: HS Natraj Setty MD, DM, FICC, Assistant Professor of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India, Tel: 9845612322; 080-26580051; Fax: 080-22977261; Email: [email protected]
How to cite this article: HS Natraj Setty MD. Non-Pharmacological Management of Pulmonary Thromboembolism. Int J Pul & Res Sci. 2017; 2(2):
Acute massive pulmonary embolism is a most common life-threatening complication, Current treatment paradigm in patients with massive pulmonary thromboembolism mandates prompt risk stratification with aggressive therapeutic strategies. With the advent of endovascular technologies, various catheter-based thrombectomy and thrombolytic devices are available to treat patients with massive or submassive pulmonary thromboembolism.
The objective of interventional treatment in pulmonary embolism is the removal of obstructing thrombi from the main pulmonary arteries to facilitate RV recovery and improve symptoms and survival .
The different modes of intervention used in the treatment of pulmonary embolism include:
Percutaneous Transcatheter Interventions
Inferior Vena Cava Filter Insertion
Pulmonary endarterectomy (PEA)
a. Percutaneous transcatheter interventions
Percutaneous Transcatheter Interventions are potentially lifesaving in selected patients with massive or submissive PE . They are usually performed when thrombolysis is contraindicated/failed or when emergency surgical thrombectomy is unavailable or contraindicated. Hybrid therapy that includes both is an emerging strategy. For patients without absolute contraindications to thrombolysis, catheter-directed thrombolysis or pharmaco- mechanical thrombolysis are preferred approaches.
There are 3 general categories of percutaneous intervention for removing pulmonary emboli and decreasing thrombus burden:
Thrombus fragmentation, and
Aspiration thrombectomy uses sustained suction applied to the catheter tip to secure and remove the thrombus. Thrombus fragmentation has been performed with balloon angioplasty , or a more advanced Amplatze catheter, which uses an impeller to homogenize the thrombus . Rheolytic thrombectomy catheters (AngioJet catheters), use a high-velocity saline jet to fragment adjacent thrombus by creating a Venturi effect and removing the debris from an evacuation lumen . Ideal thrombectomy catheters for use in the pulmonary circulation must be readily maneuverable, effective in removal of thromboembolic, and safe by virtue of minimizing distal embolization, mechanical hemolysis, or damage to cardiac structures and pulmonary arteries.
In a systematic review of available cohort data comprising a total of 348 patients, clinical success with percutaneous therapy alone for patients with acute massive PE was 8% (aspiration thrombectomy 81%; fragmentation 82%; rheolytic thrombectomy 75%) and 95% when combined with local infusion of thrombolytic agents (aspiration thrombectomy 100%; fragmentation 90%; rheolytic thrombectomy 91%) . Only operators experienced with these techniques should
perform a catheter-based intervention. Invasive arterial access
is recommended for patients with shock or hypotension to help
guide vasopressor management. Patients with massive PE who
have contraindications to fibrinolytic therapy who present to
centers unable to offer catheter or surgical embolectomy should
be considered for urgent transfer to a center with these services
available so that they can be evaluated for this therapy. Jaff, et
al.  describes the procedure in brief. Through a 6F femoral
venous sheath, a 6F angled pigtail catheter is advanced into each
main pulmonary artery, followed by injection of low-osmolar or
isosmolar contrast (30mL over 2 seconds). Either UFH 70IU/
kg intravenous bolus, with additional heparin as needed to
maintain an activated clotting time 250 seconds or the direct
thrombin inhibitor bivalirudin (0.75mg/kg intravenous bolus,
then 1.75mg kg 1 h 1) should be used for anticoagulation. For
rheolytic thrombectomy, a 6F multipurpose guiding catheter may
be used to reach the thrombus, which is crossed with a 0.014-
inch hydrophilic guidewire (Choice PT Extra-Support, Boston
Scientific, Natick, MA). Temporary transvenous pacemaker
insertion may be required during rheolytic thrombectomy. In
general, mechanical thrombectomy should be limited to the
main and lobar pulmonary arterial branches. For patients
with massive PE, the procedure should continue until systemic
hemodynamics stabilize, regardless of the angiographic
result. Substantial improvement in pulmonary blood flow may
result from what appears to be an only modest angiographic
Major complications (approx 2%), may include death
from worsening RV failure, distal embolization, pulmonary
artery perforation with lung hemorrhage, systemic bleeding
complications, pericardial tamponade, heart block or
bradycardia, hemolysis, contrast-induced nephropathy, and
puncture-related complications .
b. Surgical embolectomy
The first successful surgical pulmonary embolectomy was
performed in 1924. Emergency surgical embolectomy with
cardiopulmonary bypass has re-emerged as an effective strategy
for managing patients with massive PE or submissive PE with RV
dysfunction when contraindications preclude thrombolysis .
This operation is also suited for acute PE patients who require
surgical excision of a right atrial thrombus or paradoxical
embolism. Surgical embolectomy can also rescue patients whose
condition is refractory to thrombolysis . The results of
embolectomy will be optimized if patients are referred before
the onset of cardiogenic shock.
Older case series suggest a mortality rate between 20%
and 30% despite surgical embolectomy , Following median
sternotomy, normothermic cardiopulmonary bypass should be
instituted. Aortic cross-clamping and cardioplegic cardiac arrest
should be avoided . With bilateral PA incisions, clots can be removed from both pulmonary arteries down to the segmental
level under direct vision. Prolonged periods of post-operative
cardiopulmonary bypass and weaning may be necessary for the
recovery of RV function. Preoperative thrombolysis increases
the risk of bleeding, but it is not an absolute contraindication to
surgical embolectomy .
Recommendations for Catheter/ Surgical Embolectomy and
Depending on local expertise, either catheter
embolectomy and fragmentation or surgical embolectomy
is reasonable for patients with massive PE and
contraindications to fibrinolysis (Class IIa; Level of Evidence
Catheter embolectomy and fragmentation or surgical
embolectomy are reasonable for patients with massive PE
who remain unstable after receiving fibrinolysis (Class IIa;
Level of Evidence C).
For patients with massive PE who cannot receive
fibrinolysis or who remain unstable after fibrinolysis,
it is reasonable to consider a transfer to an institution
experienced in either catheter embolectomy or surgical
embolectomy if these procedures are not available locally
and safe transfer can be achieved (Class IIa; Level of Evidence
Either catheter embolectomy or surgical embolectomy
may be considered for patients with submassive acute PE
judged to have clinical evidence of adverse prognosis (new
hemodynamic instability, worsening respiratory failure,
severe RV dysfunction, or major myocardial necrosis) (Class
IIb; Level of Evidence C).
Catheter embolectomy and surgical thrombectomy
are not recommended for patients with low-risk PE or
submassive acute PE with minor RV dysfunction, minor
myocardial necrosis, and no clinical worsening (Class III;
Level of Evidence C).
c. Inferior vena cava filter insertion
The ICOPER (International Cooperative Pulmonary
Embolism Registry) registry examined clinical outcomes in
patients treated with IVC filters for PE  The PREPIC Trial
(Prevention du Risque d’Embolie Pulmonaire par Interruption
Cave)  randomized 400 patients with proximal deep venous
thrombosis (DVT) at high risk for PE.
Observational studies suggest that insertion of a venous
filter might reduce PE-related mortality rates in the acute phase,
[16,17] benefit possibly coming at the cost of an increased
risk of recurrence of VTE . Complications associated with
permanent IVC filters are common, although they are rarely fatal
. Overall, early complications which include insertion site
thrombosis occur in approximately 10% of patients. Placement of a filter in the superior vena cava carries the risk of pericardial
tamponade . Late complications are more frequent and
include recurrent DVT in approximately 20% of patients and
post-thrombotic syndrome in up to 40%.Occlusion of the IVC
affects approximately 22% of patients at 5 years and 33% at
9 years, regardless of the use and duration of anticoagulation
[20,21]. Eight-year follow-up of a randomized study on 400
patients with DVT (with or without PE), all of whom had initially
received anticoagulant treatment for at least 3 months, showed
that patients undergoing permanent IVC filter insertion had a
reduced risk of recurrent PE at the cost of an increased risk of
recurrent DVT and no overall effect on survival .
Non-permanent IVC filters are classified as temporary
or retrievable devices. Temporary filters must be removed
within few days, while retrievable filters can be left in place
for longer periods . When non-permanent filters are used,
it is recommended that they are removed as soon as it is safe
to use anticoagulants. Despite this, they are often left in situ for
longer periods, with a late complication rate of at least 10%;
this includes filter migration, tilting or deformation, penetration
of the cava wall by filter limbs, fracturing of the filter and
embolization of fragments, and thrombosis of the device [23,24].
Recommendations on IVC Filters in the Setting of Acute PE
Adult patients with any confirmed acute PE (or
proximal DVT) with contraindications to anticoagulation
or with active bleeding complication should receive an IVC
filter (Class I; Level of Evidence B).
Anticoagulation should be resumed in patients with
an IVC filter once contraindications to anticoagulation or
active bleeding complications have resolved (Class I; Level of
Patients who receive retrievable IVC filters should be
evaluated periodically for filter retrieval within the specific
filter’s retrieval window (Class I; Level of Evidence C).
For patients with recurrent acute PE despite therapeutic
anticoagulation, it is reasonable to place an IVC filter (Class
IIa; Level of Evidence C).
For DVT or PE patients who will require permanent
IVC filtration (eg, those with a long-term contraindication to
anticoagulation), it is reasonable to select a permanent IVC
filter device (Class IIa; Level of Evidence C).
For DVT or PE patients with a time-limited indication
for an IVC filter (eg, those with a short-term contraindication
to anticoagulation therapy), it is reasonable to select a
retrievable IVC filter device (Class IIa; Level of Evidence C).
Placement of an IVC filter may be considered for
patients with acute PE and very poor cardiopulmonary
reserve, including those with massive PE (Class IIb; Level of
h. An IVC filter should not be used routinely as an adjuvant
to anticoagulation and systemic fibrinolysis in the treatment
of acute PE (Class III; Level of Evidence C).
d. Pulmonary endarterectomy (PEA)
PEA is the treatment of choice for CTEPH. In Europe, inhospital
mortality is currently as low as 4.7% in expert centers
. The majority of patients experience substantial relief from
symptoms and near-normalization of hemodynamics [26-28].
In contrast to surgical embolectomy for acute PE, treatment of
CTEPH necessitates a true endarterectomy through the medial
layer of the pulmonary arteries, which is performed under deep
hypothermia and circulatory arrest . General operability
criteria include preoperative New York Heart Association
functional class II–IV and the surgical accessibility of thrombi in
the main, lobar, or segmental pulmonary arteries. Advanced age
per se is no contraindication for surgery. There is no pulmonary
vascular resistance threshold or measure of RV dysfunction that
absolutely precludes PEA . Patients who do not undergo
surgery, or suffer from persistent or residual pulmonary
hypertension after PEA, face a poor prognosis. Advances in
balloon pulmonary angioplasty are continuing in an attempt
to make this technique a therapeutic alternative for selected
patients with non-operable CTEPH [31,32].
Rapid risk stratification by identifying patients with acute
massive and acute submassive PE is essential in determining
appropriate management. Acute PE can be associated
with high rates of mortality. Devices for catheter-directed
thromboembolectomy continue to emerge and main stay in
the management of pulmonary thrombo embolism. The use of
modern Catheter-directed therapy (CDT) has proven to be a lifesaving
treatment in patients dying from acute massive PE.