Imaging-Driven Risk Stratification and Endovascular Decision Pathways in Acute Pulmonary Embolism.

Area of Science:

• Cardiology
• Radiology
• Pulmonary Medicine

Background:

• Acute pulmonary embolism (PE) management is shifting towards a dynamic risk continuum.
• Identifying intermediate-high-risk normotensive patients with potential right ventricular (RV) dysfunction is crucial.
• Standardized imaging parameters are increasingly integrated into PE severity categorization.

Purpose of the Study:

• To review how imaging-derived markers impact risk stratification and therapeutic decisions in PE.
• To examine the role of imaging in guiding escalation timing and endovascular strategies.
• To assess the influence of contemporary imaging on contemporary PE management.

Main Methods:

• Structured narrative review of literature from January 2020 to January 2026.
• Searched PubMed/MEDLINE, Scopus, and Web of Science for relevant studies.
• Focused on imaging-based risk assessment, catheter-based reperfusion, trials, registries, and guidelines.

Main Results:

• Catheter-directed therapies (CDTs) rapidly improve RV imaging surrogates and hemodynamics in PE.
• Short-term mortality benefits are minimal in normotensive PE cohorts.
• CDTs reduce early clinical deterioration, need for rescue escalation, and healthcare resource utilization.

Conclusions:

• Standardized imaging reporting of RV strain should be integrated into PE escalation algorithms.
• Imaging acts as a trigger for escalation in multidisciplinary PE care pathways.
• CDTs modulate PE patient trajectories, particularly in intermediate-risk cases, rather than solely reducing mortality.