Acute pulmonary embolism: a paradigm shift in interventional treatment and interdisciplinary care?

Catheter-based recanalization procedures have long been standard of care in treating myocardial infarction and stroke. Interventional treatments for pulmonary embolism (PE), however, have only been performed occasionally as second-line strategies until recently. Current guidelines still recommend systemic thrombolysis, which may halve the mortality risk in patients with high-risk pulmonary embolism but is underused outside experienced centers. Novel devices for thrombectomy have significantly changed clinical practice and potentially fill a treatment gap in intermediate and high-risk pulmonary embolism. Observational data are encouraging and randomized controlled trials are underway to prove safety and efficacy, which requires the adaptation of current treatment paradigms. Interdisciplinary pulmonary embolism response teams are needed to provide individualized care, and interventional radiologists are suited to play a pivotal role given their expertise in both diagnostic imaging and invasive procedures. To live up to this challenge, interventional radiologists must familiarize themselves with both the pathophysiology of acute PE as well as with the principles of care provided by other team members. KEY POINTS: Question The recommended treatment of high-risk pulmonary embolism is systemic thrombolysis. New devices for percutaneous aspiration thrombectomy aim to change treatment paradigms and need critical review. Findings Observational data suggests both safety and efficacy of novel thrombectomy devices, randomized controlled trials are underway. The added value of catheter-directed thrombolysis is unclear. Clinical relevance Systemic thrombolysis reduces mortality in patients with high-risk pulmonary embolism but is disproportionately rarely used outside of experienced centers. Percutaneous large-bore pulmonary thrombectomy holds great potential for filling a treatment gap in intermediate and high-risk pulmonary embolism and changing guidelines.