Tough decisions in pulmonary embolism: thrombolysis or embolectomy?

Patients presenting with acute pulmonary embolism (PE) and persisting haemodynamic instability need to be considered for primary reperfusion therapy with, commonly, thrombolysis or even surgical embolectomy [1]. Both treatment options can pose significant risks to the patient, but are potentially lifesaving when used appropriately. Absolute contraindications to thrombolysis include cases where there is high risk of haemorrhage including previous haemorrhagic stroke, recent major surgery or trauma, recent gastrointestinal bleeding, central nervous system neoplasm or known bleeding diathesis [2]. In the presence of such contraindications, surgical embolectomy can be considered for intermediate to high and high-risk PE [1]. In clinical practice, the treatment decision is not always clear-cut and the ‘European Society of Cardiology (ESC)’ offers guidelines especially in situations where therapeutic options might be open to contention [1]. Two such cases recently published in the Journal provide an insight into the successful treatment of clinically challenging presentations of intermediate to high and high-risk PE, one using thrombolysis [3] and the other surgical embolectomy [4]. The first case, by Kostetskiy et al. [3], describes a fit and healthy 56-year-old gentleman undergoing surgical repair for an open fracture of his left tibia. Towards the final stages of the operation, the patient became hypoxic, tachycardic and profoundly hypotensive requiring ionotropic support. His electrocardiogram tracing revealed new atrial fibrillation, right bundle branch block and central venous pressure measured at 35mmHg. The main differential included PE and despite no imaging confirmation, the situation was ‘considered life-threatening’ and ‘due to high risk of death’ thrombolysis was undertaken [3]. The role of thrombolysis as a first-line treatment in massive PE is well established. It has been shown to improve haemodynamic stability with respect to right ventricular (RV) dysfunction and pulmonary arterial pressure in the short term [5, 6]. However, it is associated with an increased risk of major haemorrhage (10%) and intracranial bleeding (1.7%) compared to anticoagulation alone [7–9]. Although recent surgery is an absolute contraindication to thrombolysis, the ESC guidelines state that ‘most contraindications to thrombolysis should be considered relative in patients with life-threatening, high-risk PE’ [1]. Kostetskiy et al. had a challenging decision to make: undertake thrombolysis in a patient with an unconfirmed but most certainly large PE perioperatively, or simply watch and wait? They decided to proceed with thrombolysis and ensured appropriate measures to reduce thrombolysis-related blood loss were taken, notably by applying a femoral tourniquet proximal to the operative site. The patient was saved by their intervention, with haemodynamic stability achieved and only a total blood loss of 300ml, indicating that when no alternative therapy exists, thrombolysis even in patients with contraindications might be the appropriate life-saving therapy. The second case by Namana et al. [4] reports the case of a 47-year-old female with a saddle embolus extending into both main pulmonary arteries causing RV dysfunction without haemodynamic instability. A decision was made to proceed with surgical embolectomy, following which she recovered well, with improving RV function and discharged home 6 days later. Interestingly, the ESC guidelines state that surgical embolectomy should normally be reserved for high-risk PE and for selected patients with intermediateto high-risk PE when haemodynamic instability is imminent or if thrombolysis is contraindicated or has failed [1]. However, with improving outcomes following surgical embolectomy, clinicians are increasingly considering early surgical intervention [10–13]. This case