Int J Angiol 2022; 31(03): 203-212
DOI: 10.1055/s-0042-1756174
Invited Article

Advances in Percutaneous Management of Pulmonary Embolism

Jimmy Kerrigan
1   Department of Cardiology, Saint Thomas Health, Nashville, Tennessee
Michael Morse
1   Department of Cardiology, Saint Thomas Health, Nashville, Tennessee
Elias Haddad
1   Department of Cardiology, Saint Thomas Health, Nashville, Tennessee
Elisabeth Willers
2   Department of Pulmonary Medicine, Saint Thomas Health, Nashville, Tennessee
3   Department of Cardiothoracic Surgery, Saint Thomas Health, Nashville, Tennessee
› Author Affiliations


Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE with hemodynamic compromise (massive/high-risk PE). A significant number of patients are not candidates for systemic thrombolysis due to the bleeding risk associated with thrombolytics. Historically, surgical pulmonary embolectomy (SPE) was recommended for massive PE with hemodynamic compromise for these patients. In the last decade, catheter-directed thrombolysis (CDT) has largely replaced SPE in the patient population with intermediate risk PE (submassive), defined as right heart strain (as evidenced by right ventricle enlargement on echocardiogram and/or computed tomography, usually along with elevation of troponin or B-type natriuretic peptide). Use of CDT increased in the last few years due to high incidence of PE in hospitalized patients with coronavirus disease 2019 pneumonia, and the use of mechanical thrombectomy (initially reserved for those with contraindications to thrombolysis) has also grown. In this article, we discuss the value of the PE response team, our approach to management of submassive (intermediate risk) and massive (high risk) PE with systemic thrombolytics, CDT, mechanical thrombectomy, and surgical embolectomy.

Publication History

Article published online:
02 September 2022

© 2022. International College of Angiology. This article is published by Thieme.

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  • References

  • 1 Barco S, Valerio L, Ageno W. et al. Age-sex specific pulmonary embolism-related mortality in the USA and Canada, 2000-18: an analysis of the WHO Mortality Database and of the CDC Multiple Cause of Death database. Lancet Respir Med 2021; 9 (01) 33-42
  • 2 Kabrehal C, Rosovsky R, Channick R. et al. A multidisciplinary pulmonary embolism response team: initial 30-month experience with a novel approach to delivery of care patients with submassive or massive pulmonary embolism. Chest 2016; 150 (02) 384-393
  • 3 Stein PD, Matta F. Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med 2012; 125 (05) 465-470
  • 4 Meyer G, Vicaut E, Danays T. et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
  • 5 Kearon C, Akl EA, Comerota AJ. et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2, Suppl): e419S-e496S
  • 6 Bloomer TL, El-Hayek GE, McDaniel MC. et al. Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: results of a multicenter registry and meta-analysis. Catheter Cardiovasc Interv 2017; 89 (04) 754-760
  • 7 Arora S, Panaich SS, Ainani N. et al. Comparison of in-hospital outcomes and readmission rates in acute pulmonary embolism between systemic and catheter-directed thrombolysis (from the National Readmission Database). Am J Cardiol 2017; 120 (09) 1653-1661
  • 8 Naidu SG, Knuttinen MG, Kriegshauser JS, Eversman WG, Oklu R. Rationale for catheter directed therapy in pulmonary embolism. Cardiovasc Diagn Ther 2017; 7 (Suppl 3): S320-S328
  • 9 Owens CA. Ultrasound-enhanced thrombolysis: EKOS EndoWave infusion catheter system. Semin Intervent Radiol 2008; 25 (01) 37-41
  • 10 Braaten JV, Goss RA, Francis CW. Ultrasound reversibly disaggregates fibrin fibers. Thromb Haemost 1997; 78 (03) 1063-1068
  • 11 Kucher N, Boekstegers P, Müller OJ. et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 2014; 129 (04) 479-486
  • 12 Piazza G, Hohlfelder B, Jaff M. et al. A Prospective, Single-Arm, Multicenter Trial of Ultrasound-Facilitated, Catheter-Directed, Low-Dose Fibrinolysis for Acute Massive and Submassive Pulmonary Embolism. J Am Coll Cardiol Intv 2015; 8 (10) 1382-1392
  • 13 Tapson VF, Sterling K, Jones N. et al. 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 2018; 11 (14) 1401-1410
  • 14 Avgerinos ED, Saadeddin Z, Abou Ali AN. et al. A meta-analysis of outcomes of catheter-directed thrombolysis for high- and intermediate-risk pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2018; 6 (04) 530-540
  • 15 Liang NL, Avgerinos ED, Marone LK, Singh MJ, Makaroun MS, Chaer RA. Comparative outcomes of ultrasound-assisted thrombolysis and standard catheter-directed thrombolysis in the treatment of acute pulmonary embolism. Vasc Endovascular Surg 2016; 50 (06) 405-410
  • 16 Rothschild DP, Goldstein JA, Ciacci J, Bowers TR. Ultrasound-accelerated thrombolysis (USAT) versus standard catheter-directed thrombolysis (CDT) for treatment of pulmonary embolism: a retrospective analysis. Vasc Med 2019; 24 (03) 234-240
  • 17 Graif A, Grilli CJ, Kimbiris G. et al. Comparison of ultrasound-accelerated versus pigtail catheter-directed thrombolysis for the treatment of acute massive and submassive pulmonary embolism. J Vasc Interv Radiol 2017; 28 (10) 1339-1347
  • 18 Lee MS, Singh V, Wilentz JR, Makkar RR. AngioJet thrombectomy. J Invasive Cardiol 2004; 16 (10) 587-591
  • 19 Garcia MJ, Lookstein R, Malhotra R. et al. Endovascular management of deep vein thrombosis with rheolytic thrombectomy: final report of the prospective multicenter PEARL (Peripheral Use of AngioJet Rheolytic Thrombectomy with a Variety of Catheter Lengths) Registry. J Vasc Interv Radiol 2015; 26 (06) 777-785 , quiz 786
  • 20 Schultz J, Andersen A, Kabrhel C, Nielsen-Kudsk JE. Catheter-based therapies in acute pulmonary embolism. EuroIntervention 2018; 13 (14) 1721-1727
  • 21 Sista AK, Horowitz JM, Tapson VF. et al; EXTRACT-PE Investigators. Indigo Aspiration System for treatment of pulmonary embolism: results of the EXTRACT-PE trial. JACC Cardiovasc Interv 2021; 14 (03) 319-329
  • 22 National Library of Medicine (U.S.). Study of the Long-Term Safety and Outcomes of Treating Pulmonary Embolism with the Indigo Aspiration System. March 2021. Identifier NCT04798261. Accessed August 11, 2022, at:
  • 23 Accessed August 11, 2022, at:
  • 24 Tu T, Toma C, Tapson VF. et al; FLARE Investigators. A prospective, single-arm, multicenter trial of catheter-directed mechanical thrombectomy for intermediate-risk acute pulmonary embolism: the FLARE study. JACC Cardiovasc Interv 2019; 12 (09) 859-869
  • 25 National Library of Medicine (U.S.). FlowTriever All-Comer Registry for Patient Safety and Hemodynamics (FLASH). December 2018. Identifier NCT03761173. Accessed August 11, 2022, at:
  • 26 Toma C, Bunte MC, Cho KH. et al. Percutaneous mechanical thrombectomy in a real-world pulmonary embolism population: interim results of the FLASH registry. Catheter Cardiovasc Interv 2022; 99 (04) 1345-1355
  • 27 Toma C. Acute and long-term improvements following FlowTriever mechanical thrombectomy in pulmonary embolism patients: six-month results from the FLASH registry. Presented at: TCT 2021, October 27, 2021
  • 28 National Library of Medicine (U.S.). FLowTriever for Acute Massive Pulmonary Embolism (FLAME). March 2021. Identifier NCT04795167. Accessed August 11, 2022, at:
  • 29 National Library of Medicine (U.S.). The PEERLESS Study (PEERLESS). November 2021. Identifier NCT05111613. Accessed August 11, 2022, at:
  • 30 U.S. Food and Drug Administration. 510(k) K182835, WOLF Thrombectomy Device. Accessed August 11, 2022, at:
  • 31 Accessed August 11, 2022, at:
  • 32 Accessed August 11, 2022, at:
  • 33 Accessed August 11, 2022, at:,
  • 34 Accessed August 11, 2022, at:
  • 35 Accessed August 11, 2022, at:
  • 36 McCarthy FH, McDermott KM, Kini V, Gutsche JT, Wald JW, Xie D, Szeto WY, Bermudez CA, Atluri P, Acker MA, Desai ND. Trends in U.S. Extracorporeal Membrane Oxygenation Use and Outcomes: 2002-2012. Semin Thorac Cardiovasc Surg 2015 Summer;27(2):81-8. doi: 10.1053/j.semtcvs.2015.07.005. Epub 2015 Jul 22. PMID: 26686427; PMCID: PMC4780346
  • 37 Meneveau N, Guillon B, Planquette B. et al. Outcomes after extracorporeal membrane oxygenation for the treatment of high-risk pulmonary embolism: a multicentre series of 52 cases. Eur Heart J 2018; 39 (47) 4196-4204