Indications

• Massive PE: Acute PE with sustained hypotension

• Submassive PE (more commonly requested): Acute PE without hypotension but with evidence of RV dysfunction or myocardial injury (cardiac enzymes)

• In general: Pts must have reserve to tolerate the procedure; can’t receive or have failed systemic thrombolysis; have multiple comorbidities or are poor surgical candidates

Contraindications

• Similar to DVT Thrombolysis on previous page.

• Pts with contraindications to tPA may undergo mechanical / suction thrombectomy.

• Left Bundle Branch Block: needs temporary pacing to prevent complete heart block.

Imaging Review

• Signs of Right Heart Dysfunction

  • • CT with RV:LV ratio >0.9

    • Echo (more sensitive and specific)

    • EKG (RV ischemia)

    • Lab (elevated trop or BNP)

Tips for Workup

• Submassive PE are often ideal candidates; those who are not yet unstable but could benefit from reduction in clot burden (preventing them from tipping into Massive category).

• Pt will need ICU bed for tPA monitoring post-op

• HIT or allergy to heparin? Discuss alternatives (argatroban, bivalrudin, etc)

• Consent:

  • • Hemorrhage: 2.4% major complications with catheter-directed tPA

    • Other: worsening distal PE burden, PA perforation, bradycardia, hemoptysis, infection, contrast nephropathy, access site complications.