Complications, Limitations

Although some studies have shown promising safety profiles for these interventions, more robust trials are needed as these techniques still carry complications such as access site bleeding, arrhythmias, pulmonary artery dissection, and tamponade.¹² In addition to complications, limitations to the implementation of EKOS and Inari FlowTriever include the fact that use requires technical expertise to navigate pulmonary vasculature and resources that not every facility is equipped with.⁷ Aside from equipment and device costs, use of these therapies usually requires multidisciplinary involvement from specialties like pulmonology, interventional cardiology, vascular surgery, interventional radiology, and more, to which smaller institutions may not have access.

The clinical presentation and effect of acute PE are highly variable and make management decisions, which include weighing risks and benefits of certain interventions, difficult and complex. How and whether to perform a catheter-based intervention is a multidisciplinary decision initiated in the emergency department, which factors in the patients’ clinical picture, bleeding risk, available personnel, expertise, and devices. Targeted approaches such as EKOS and Inari FlowTriever, appear promising because they reduce bleeding complications by lowering or eliminating the overall systemic dose of the thrombolytic delivered.

Given the rapid ability to restore favorable hemodynamics with catheter-directed intervention for PE, patients who display signs of RV dysfunction, myocardial injury, severe hypoxia, or hemodynamic instability are now considered for early intervention using these methods. Furthermore, these techniques provide a useful alternative in patients who fail systemic thrombolysis or those with relative or absolute contraindications to thrombolysis. Although the popularity of these techniques has grown, limitations of their clinical use must still be considered. With more devices and techniques being developed and approved for use in managing PE, it remains important to continue exploring their efficacy, accessibility, and safety profiles.

Dr. Ghanim is a third-year emergency medicine resident physician at the Baylor College of Medicine in Houston,Texas.

Dr. McArthur is a board-certified emergency medicine physician and assistant professor at the Baylor College of Medicine in Houston, Texas.

References

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