Novel Pharmacomechanical Thrombolysis for Treating Intermediate-Risk Acute Pulmonary Embolism: The Bashir Endovascular Catheter

Abstract

Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death.1 Although there is little debate about how to manage low-or high-risk acute PE, therapeutic strategies for patients who have intermediate-risk acute PE are continuously evolving. This condition is associated with a substan-tial risk of death at 90 days and with possible progression to acute hemodynamic decompensation. In the Fibrinolysis for Patients with Intermediate Risk Pulmonary Embolism (PEITHO) trial,2 normotensive patients were divided into 2 groups: one group was given tenecteplase plus heparin, and the other, placebo plus heparin. In the anticoagulation-only group, 28 of 499 patients (5.6%) died or progressed to hemodynamic decompensation, compared with 13 of 506 (2.6%) in the tenecteplase group; however, the rates of major bleeding and stroke were significantly higher in the tenecteplase group. The investigators recommended great caution in considering fibrinolytic therapy for hemodynamically stable patients with intermediate-risk PE, right ventricular (RV) dysfunction, and elevated cardiac troponin levels.2 Systemic fi-brinolytic therapy reduced the risk of hemodynamic decompensation but significantly increased the risk of stroke and intracranial hemorrhage (ICH).2 Patients with acute PE and RV strain have a low cardiac reserve and are subject to sudden decompensation. The therapeutic goal in patients with intermediate-risk PE, particularly in those at high intermediate risk, is to improve symptoms while lower-ing the risk classification or preventing near-term hemodynamic decompensation. Minimizing the risk of severe hemorrhagic complications while accelerating thrombus resolution is guiding new therapies for intermediate-risk acute PE.