Advanced Therapies for Acute Pulmonary Embolism: A Focus on Catheter-Based Therapies and Future Directions

Patients with acute pulmonary embolism (PE) present on a spectrum of clinical severity with a subset at risk for significant morbidity and mortality. Individuals without contraindications should be treated with systemic anticoagulation therapy; however, advanced therapies including systemic fibrinolysis, catheter-based approaches, surgical embolectomy, and mechanical circulatory support may be considered in the setting of hemodynamic instability or deterioration. Catheter-based therapies, categorized into lytic and non-lytic based approaches, have recently broadened treatment options, and may be of benefit to patients who are in intermediate- or high-risk categories. These approaches may allow for rapid improvement of right ventricular function and have the potential to lower the risk of bleeding complications compared to systemic fibrinolytic therapy. Emerging strategies utilizing adjunctive mechanical circulatory support may improve outcomes in the highest risk patients, providing stabilization prior to definitive therapy and potentially obviating the need for invasive measures. To help navigate these rapidly evolving treatment paradigms, pulmonary embolism response teams (PERT) have been established. Further studies focusing on the safety and efficacy of novel therapies and impact of PERT will be crucial for advancement of the field. This review focuses on currently available therapies, recent advances, and future directions in the treatment of acute pulmonary embolism. Abbreviations: PE: pulmonary embolism; VTE; venous thromboembolism; CBT: catheter-based therapy; RV: right ventricle; AHA: American Heart Association; ACCP: American College of Chest Physicians; ESC: European Society of Cardiology; PESI: pulmonary embolism severity index; LV: left ventricle; DOAC: direct oral anticoagulant; FDA: Food and Drug Administration; tPA: tissue plasminogen activator; CTEPH: chronic thromboembolic pulmonary hypertension; USAT: ultrasound-assisted catheter-directed thrombolysis; VA-ECMO: veno-arterial extracorporeal membrane oxygenation; PERT: pulmonary embolism response team