Treating large pulmonary emboli: do the guidelines guide us?

The diagnosis and management of patients with large pulmonary emboli can be confusing. This review will summarize available data and suggest the areas of certainty and uncertainty in the treatment of these patients.

Pulmonary emboli can be stratified according to patient prognosis. Risk-stratification of patients with submassive pulmonary emboli is still lacking. Similarly, although the treatment of low-risk pulmonary embolism is well established, and there is consensus regarding systemic thrombolysis for unstable patients with pulmonary embolism, the management of patients with submassive pulmonary embolism is still a matter of debate. The role of novel approaches such as low-dose thrombolysis, catheter-directed therapies and advanced cardiopulmonary support is yet to be determined. Although some patients in skilled centers may benefit from pulmonary embolectomy, patient selection has yet to be refined.

The treatment of massive and submassive pulmonary embolism has yet to be standardized. The complexity in choosing appropriate treatments for these patients is due to the lack of high-quality data compounded by an expanding arsenal of therapeutic options.