To date, no study has ever assessed the management of failed thrombolysis in the setting of acute massive PE. Our study, based on a single-center prospective registry, is the first study to report the immediate clinical course as well as the long-term outcome of acute PE patients who had undergone either rescue embolectomy or repeat thrombolysis after not responding to initial thrombolysis. Patients who were unresponsive to thrombolysis were prospectively defined as patients with both persistent clinical instability and echocardiographic criteria of RV dysfunction. Source
We found that approximately 8% of patients do not respond to thrombolysis. In this situation, rescue surgical embolectomy should be preferred over repeat thrombolysis. The in-hospital course of patients who had undergone rescue embolectomy was significantly better than that of patients who were treated with a second thrombolysis. This early benefit is the result of a significant reduction in the number of recurrent PEs, which was associated with more recurrent PE. Interestingly, patients who were operated on had a more severe initial profile (shock was present in 36% vs 15% among repeat-thrombolysis patients).
The in-hospital mortality rate of 28% observed in the overall study population is much higher than that usually reported after thrombolysis in patients who have experienced acute massive or submassive PE, but is comparable to the mortality rate reported in the MAPPET registry in patients presenting with cardiogenic shock. In the repeat-thrombolysis group, the in-hospital mortality rate reached 38%, and one third of these deaths were caused by recurrent PE, thus confirming that the thromboembolic process is responsible for a higher degree of early mortality than previously believed.’ In contrast, patients who underwent rescue surgical embolectomy had a very low in-hospital mortality rate of 7% and experienced no recurrent PE. Hence, the significant reduction of recurrent PE observed in patients who had been treated surgically may be related to systematic perioperative vena caval filter insertion, as previously suggested.