Massive PE: thrombolysis versus embolectomy — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 70-year-old man had an elective hip replacement 9 days ago. He now has acute PE confirmed on CTPA. His systolic blood pressure has been 76-84 mmHg for 25 minutes despite adequate filling, with no arrhythmia, bleeding or sepsis; he is confused and oliguric with a raised lactate. Bedside TTE shows a dilated, hypokinetic RV. The hospital has on-site cardiothoracic surgery and a catheter-directed PE service, each with appropriate expertise and resources.^[1][2]

1. How does ESC 2019 define the haemodynamic instability that delineates high-risk PE? (2)^[1]
2. List four absolute contraindications to fibrinolysis in ESC 2019 Table 10, and say which applies to him. (2)^[1]
3. Which reperfusion options does ESC 2019 recommend for him, with class and level? (2)^[2]
4. Give the AHA/ACC 2026 rows for surgical embolectomy and mechanical thrombectomy in Category E1, with COR and LOE. (2)^[3]
5. He needs to go to the operating theatre. Give one AHA/ACC 2026 row on sedation and intubation, and the risk it addresses. (2)^[3]

Model answers — SAQ 1

1. ESC 2019 Table 4 defines the haemodynamic instability that delineates acute high-risk PE as any one of three clinical manifestations at presentation: cardiac arrest (need for cardiopulmonary resuscitation), obstructive shock (systolic BP <90 mmHg or vasopressors needed to keep BP ≥90 mmHg despite adequate filling, with end-organ hypoperfusion) or persistent hypotension (1 mark).^[1] Persistent hypotension means systolic BP <90 mmHg or a drop of ≥40 mmHg, lasting longer than 15 min and not caused by new-onset arrhythmia, hypovolaemia or sepsis (1 mark).^[1]
2. Any four of: history of haemorrhagic stroke or stroke of unknown origin; ischaemic stroke in the previous 6 months; CNS neoplasm; major trauma, surgery or head injury in the previous 3 weeks; bleeding diathesis; active bleeding (1 mark).^[1] His hip replacement 9 days ago is major surgery within the previous 3 weeks (1 mark).^[1]
3. Surgical pulmonary embolectomy is recommended for high-risk PE in whom thrombolysis is contraindicated or has failed, if appropriate expertise and resources are available on-site (ESC 2019, Class I, Level C) (1 mark).^[2] Percutaneous catheter-directed treatment should be considered for high-risk PE in whom thrombolysis is contraindicated or has failed, with the same expertise proviso (ESC 2019, Class IIa, Level C) (1 mark).^[2]
4. Surgical embolectomy compared with anticoagulation alone is reasonable in Category E1 to prevent further clinical decompensation and acute mortality (AHA/ACC 2026, COR 2a, LOE B-NR) (1 mark).^[3] MT plus anticoagulation is reasonable over anticoagulation alone in Category E1 to prevent further clinical decompensation and acute mortality (AHA/ACC 2026, COR 2a, LOE B-NR) (1 mark).^[3]
5. AHA/ACC 2026: in Categories C-E needing sedation for intubation, vasopressors, inotropes and/or VA-ECMO should be available in case the patient becomes unstable (COR 1, LOE C-LD); deep sedation and mechanical ventilation should not be performed unless clinically indicated, to avoid haemodynamic collapse (COR 3: Harm, LOE C-LD) (1 mark).^[3] The risk is haemodynamic collapse: removing the compensatory rise in heart rate and SVR, for example with most anxiolytic and analgesic drugs, can cause or worsen decompensation (1 mark).^[3]

SAQ 2 (10 marks)

Practice scenario. A 58-year-old woman has acute PE. Her blood pressure is 124/78 mmHg and heart rate 108 beats per minute. CTPA shows RV dilatation, TTE confirms RV dysfunction, the troponin is raised and her sPESI is 1. She has no contraindication to anticoagulation or fibrinolysis.^[2][1]

1. Into which ESC 2019 risk class does she fall, and on what findings? (2)^[2]
2. What does ESC 2019 say about routine primary systemic thrombolysis for her, with class and level, and why? (2)^[2][1]
3. What did PEITHO show for tenecteplase in patients like her? (2)^[10]
4. On day 2 she becomes hypotensive on anticoagulation. What does ESC 2019 recommend, with class and level? (2)^[2]
5. Give the AHA/ACC 2026 rows on systemic thrombolysis and on catheter-directed thrombolysis for Category C3 at presentation. (2)^[3]

Model answers — SAQ 2

1. Intermediate-high risk (ESC 2019 Table 8) (1 mark).^[2] No haemodynamic instability, with both RV dysfunction on TTE or CTPA and elevated cardiac troponin, and a positive clinical-severity score (sPESI ≥I) (1 mark).^[2]
2. Routine use of primary systemic thrombolysis is not recommended in intermediate- or low-risk PE (ESC 2019, Class III, Level B) (1 mark).^[2] ESC 2019 text: the risk of potentially life-threatening bleeding appears too high for the expected benefit (1 mark).^[1]
3. Death or haemodynamic decompensation within 7 days fell from 5.6% with placebo to 2.6% with tenecteplase (odds ratio 0.44; P=0.02) (1 mark).^[10] Extracranial bleeding rose (6.3% vs 1.2%) and stroke rose (2.4% vs 0.2%) (1 mark).^[10]
4. Rescue thrombolytic therapy is recommended for haemodynamic deterioration on anticoagulation (ESC 2019, Class I, Level B) (1 mark).^[2] As an alternative for haemodynamic deterioration on anticoagulation, surgical embolectomy or percutaneous catheter-directed treatment should be considered if appropriate expertise and resources are available on-site (ESC 2019, Class IIa, Level C) (1 mark).^[2]
5. Category C3, acceptable bleeding risk, advanced therapy being considered: the use of systemic thrombolysis and anticoagulation over anticoagulation alone to prevent further clinical deterioration is uncertain (AHA/ACC 2026, COR 2b, LOE C-LD) (1 mark).^[3] Categories C2-3: the benefit of CDL plus anticoagulation compared with anticoagulation alone for short-term fatal/nonfatal deterioration and long-term mortality, functional capacity and quality of life is unclear (AHA/ACC 2026, COR 2b, LOE C-LD) (1 mark).^[3]