Version July 2025
BNP: brain natriuretic peptide; CDT: catheter-directed therapy; CTPA: computed tomographic pulmonary angiography; PE: pulmonary embolism; PERT: PE response team; RV: right ventricle.
* Evidence of RV dysfunction includes biochemical markers of RV dysfunction, such as BNP, N-terminal BNP, and troponin levels, as well as echocardiographic or computed tomographic evidence of RV enlargement or reduced function.
¶ PERTs comprised of emergency department, pulmonary, thoracic surgery, and interventional radiology experts are increasingly but not universally available. Consultation with PERT or other specialist is advised to facilitate the controversial decision regarding thrombolytic therapy in those with intermediate-risk PE. Patients should be anticoagulated while the decision is pending. Consideration should also be given to transferring such patients to a specialized center if catheter-directed techniques are not locally available.
Δ While all patients with intermediate-risk PE are at risk of deterioration, generally patients on the higher end of the spectrum (ie, intermediate-high-risk PE) may be considered for thrombolysis. Expert consultants weigh the potential benefits (faster resolution of RV dysfunction, lower risk of developing shock, possible mortality benefit) against the risk of bleeding.
◊ Unfractionated heparin is generally the initial anticoagulant of choice that is temporarily reduced while CDT is administered. CDT may involve the administration of thrombolytic agent in combination with extraction, and this choice is dependent upon the operator and other factors. Refer to UpToDate text on thrombolytic administration. While systemic thrombolysis is an alternative, our preference for CDT is based upon our clinical experience and the lower likelihood of bleeding with CDT compared with systemic agents due to the lower total dose of agent administered. In addition, during CDT, other mechanical interventions can be simultaneously performed to aid clot dissolution (eg, ultrasound) or mechanical removal (eg, embolectomy). Such mechanical interventions can be used independently in the event that thrombolysis is contraindicated. Expertise is required.
