The management of patients with acute massive pulmonary embolism (PE) who do not respond to fibrinolytic therapy remains unclear. This is partly due to the difficulty of defining “failed” thrombolysis in this setting, unlike the situation in patients with myocardial infarction, in whom the criteria and consequences of unsuccessful thrombolysis are well-established. In the setting of PE, the recovery of right ventricular (RV) function is an early marker of thrombolysis efficacy as well as a predictor of inhospital course. Furthermore, residual pulmonary vascular obstruction (> 30% at 10 days) after thrombolytic therapy is associated with adverse outcomes and increased long-term mortality. Despite this, there is no structured policy for the management of failed thrombolysis, and many physicians follow a conservative approach. However, optimizing early pulmonary revascularization could play a pivotal role in improving both the immediate and long-term evolution in patients with acute massive PE who do not respond to thrombolysis. further
The therapeutic options in patients with persistent hemodynamic instability who do not respond to thrombolysis rely on two different strategies comprising either rescue surgical embolectomy or repeat thrombolysis. However, both therapeutic options entail potential risks, and to date the question of the most appropriate management strategy for PE patients who do not respond to thrombolysis has never been addressed. Until the past few years, pulmonary embolectomy was confined to clinically desperate circumstances, while repeat thrombolysis was reported to lead to increased bleeding risks, especially intracranial hemorrhage. The aim of our study was to compare rescue surgical embolectomy and repeat thrombolysis in patients who have not responded to thrombolysis, based on a prospective single-center registry of PE patients who had undergone thrombolytic therapy.