Pulmonary embolism thromboreductive strategies

Associate Editors-in-Chief: Ujjwal Rastogi, MBBS [mailto:urastogi@perfuse.org]

Overview
Presence of a residual thrombus doubles the risk of recurrent venous thromboembolism and Post-thrombotic syndrome. Rapid clot lysis may prevent:
 * Valvular reflux
 * Venous obstruction
 * Recurrent VTE
 * Post-thrombotic syndrome

Types

 * Systemic Thrombolysis
 * Catheter-Directed Thrombolysis (CDT)/ Pharmacomechanical CDT (PCDT)
 * Percutaneous Mechanical, and Pharmacomechanical Thrombolysis,
 * Thrombolysis in Pediatric Patients

ACC/AHA Guidelines-Recommendations for Endovascular Thrombolysis and Surgical Venous Thrombectomy (DO NOT EDIT)
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Class I
1. CDT or PCDT should be given to patients with IFDVT associated with limb-threatening circulatory compromise (ie, phlegmasia cerulea dolens) (Level of Evidence: C).

2. Patients with IFDVT at centers that lack endovascular thrombolysis should be considered for transfer to a center with this expertise if indications for endovascular thrombolysis are present (Level of Evidence: C).

Class IIa
3. CDT or PCDT is reasonable for patients with IFDVT associated with rapid thrombus extension despite anticoagulation (Level of Evidence: C) and/or symptomatic deterioration from the IFDVT despite anticoagulation (Level of Evidence: B).

4. CDT or PCDT is reasonable as first-line treatment of patients with acute IFDVT to prevent PTS in selected patients at low risk of bleeding complications (Level of Evidence: B).

Class IIb
5. Surgical venous thrombectomy by experienced surgeons may be considered in patients with IFDVT (Level of Evidence: B).

Class III
6. Systemic fibrinolysis should not be given routinely to patients with IFDVT (Level of Evidence: A).

7. CDT or PCDT should not be given to most patients with chronic DVT symptoms (>21 days) or patients who are at high risk for bleeding complications (Level of Evidence: B)}}.

Guidelines Resources

 * Guidelines on the management of Pulmonary embolism: Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension