From anticoagulation to intervention: The expanding role of percutaneous therapies in pulmonary embolism

Abstract

Pulmonary embolism remains a major cause of cardiovascular morbidity and mortality, with management guided by risk stratification and the balance between thrombotic burden, right ventricular dysfunction and bleeding risk. Although anticoagulation remains the cornerstone of therapy, percutaneous catheter-based interventions have emerged as important alternatives or adjuncts in selected intermediate-risk and high-risk patients, particularly when systemic thrombolysis is contraindicated, has failed, or carries an unacceptable bleeding risk. These approaches include catheter-directed thrombolysis, ultrasound-assisted thrombolysis, mechanical thrombectomy, aspiration embolectomy and hybrid techniques, all aiming to achieve rapid hemodynamic improvement while limiting systemic thrombolytic exposure. Available trial and registry data suggest favorable effects on right ventricular function and pulmonary hemodynamics, with an acceptable safety profile in experienced centers, although recent comparative evidence for hard clinical endpoints remains limited. This review summarizes the current evidence, technical considerations and patient-selection principles for percutaneous therapies in acute pulmonary embolism and discusses their potential integration into evolving treatment algorithms and future research directions.

Keywords: Pulmonary embolism; Percutaneous interventions; Catheter-directed thrombolysis; Mechanical thrombectomy; Aspiration embolectomy; Endovascular therapy; Risk stratification; Bleeding risk

Core Tip: Pulmonary embolism remains a leading cause of cardiovascular mortality, and optimal management, particularly in intermediate-risk and high-risk patients, continues to evolve. This review critically appraises the expanding role of percutaneous catheter-based therapies, including catheter-directed thrombolysis and mechanical thrombectomy, as alternatives or adjuncts to systemic thrombolysis and anticoagulation. We synthesize contemporary randomized and registry data, discuss patient selection and procedural strategy and examine the emerging concept of a “primary percutaneous pulmonary intervention” approach as a potential paradigm shift in acute pulmonary embolism care.