Intermediate-risk PE with RV strain and a bleeding history — systemic lysis versus catheter versus anticoagulation, consent, and the long-term picture

Examiner prompts and model answers

What band is he in, and how was the diagnosis secured? He is intermediate-risk: normotensive with right-ventricular dysfunction on imaging plus myocardial injury — the PEITHO enrolment phenotype, not the shocked massive embolus and not the strain-free embolus that takes anticoagulation alone.^[30] His workup follows the validated sequence: clinical probability with D-dimer gating (low probability plus negative D-dimer reaches 99.5% negative predictive value), then CT — which finds embolism in one-fifth of suspected patients with 1.3% 3-month VTE after a negative scan and a decision in 97.9%.^[2][4]

Anticoagulate, filter, or both — with his bleed 3 weeks ago? Start therapeutic anticoagulation now: a fixed-dose single-drug regimen is noninferior to enoxaparin-warfarin for symptomatic PE (2.1 versus 1.8%) with major bleeding halved (1.1 versus 2.2%).^[14] Do not add a filter while he is anticoagulable: retrievable filters plus anticoagulation give 3-month recurrent PE 3.0 versus 1.5% with anticoagulation alone (relative risk 2.00, non-significant) — no support for filters in patients who can be anticoagulated.^[27] If bleeding forces anticoagulation off, filter with a retrieval date: real-world retrieval is attempted in only 25.3% at median 51 days, and over a third of filters go in for perioperative stops — so date it at insertion.^[28]

Lysis, catheter, or thinners — with the trial numbers? Price systemic lysis first: tenecteplase prevents death-or-decompensation (2.6 versus 5.6%, odds ratio 0.44) but day-30 deaths tie (2.4 versus 3.2%), extracranial bleeding rises to 6.3 versus 1.2%, and stroke hits 2.4 versus 0.2% with ten haemorrhagic — and his 3-week-old gastrointestinal bleed makes him the patient those strokes warn about.^[30] The older alteplase story agrees: escalation falls (24.6 versus 10.2%) with mortality tied and no fatal or cerebral bleeding in 256 patients — decompensation, not death, is what lysis buys.^[29] Offer the catheter where the team owns it: 10–20 mg catheter alteplase over 15 hours drops RV-to-LV by 0.30 versus 0.03 with no major bleeding in 59 patients, and the stopped-early CANARY trial shows fewer 72-hour RV-to-LV above 0.9 (27.0 versus 52.1%) with one gastrointestinal major bleed.^[31][32] Name the surgical bailout: emergency embolectomy takes contraindicated, failed or shocked emboli at 6% operative mortality with 86% 1-year survival.^[33]

Consent him the way the examiner wants to hear it. Quote the lysis trade: decompensation prevented in roughly 3 per 100 at a stroke price of 2.4% (mostly haemorrhagic) with no survival gain at 30 days.^[30] Quote the long-term honesty: at median 37.8 months mortality ties at 20.3 versus 18.0%, one-third report persistent dyspnoea or limitation either way, and chronic thromboembolic pulmonary hypertension is confirmed in only 2–3% — lysis changes no late outcome.^[34] Then choose aloud: anticoagulate with RV monitoring given his recent bleed, escalate to catheter-directed lysis on deterioration where available, and keep surgical embolectomy for failed or contraindicated lysis — with a dated filter only if anticoagulation must stop.^[14][31][33]