Acute pulmonary embolus: the next frontier in venous thromboembolic interventions

Submassive pulmonary embolism (PE) represents a patient population that is under-recognized and under-treated. Recent clinical trials demonstrated the hemodynamic benefit of IV thrombolytic therapy among these patients; however, it came at the cost of a significantly increased risk of major, particularly intracranial, hemorrhage. Catheter-based treatment modalities have garnered considerable clinical interest in recent years. In particular, ultrasound accelerated thrombolysis, a catheter-based technology that enhances the process of thrombolytic delivery into the thrombus, has emerged as a treatment modality with an increasing number of single-center studies, as well as randomized, controlled clinical trials. Results from these experiences are consistent in achieving outcomes of thrombus resolution and hemodynamic recovery with a low dose thrombolytic infusion protocol, but without the high risk of bleeding complications associated with IV thrombolysis. The clinical data will hopefully be impactful to the development of the next edition of the treatment guidelines, in support of overall recommendations for catheter-based interventions. When available and with appropriate expertise, this modality should be considered as the preferred treatment of both massive and submassive PE.