Evolving paradigm of thrombolysis in pulmonary embolism: Comprehensive review of clinical manifestations, indications, recent advances and guideline

Thrombolytic therapy has been the mainstay for patients with pulmonary embolism (PE). Despite being linked to a higher risk of significant bleeding, clinical trials demonstrate that thrombolytic therapy should be used in patients with moderate to high-risk PE, in addition to hemodynamic instability symptoms. This prevents the progression of right heart failure and impending hemodynamic collapse. Diagnosing PE can be challenging due to the variety of presentations; therefore, guidelines and scoring systems have been established to guide physicians to correctly identify and manage the condition. Traditionally, systemic thrombolysis has been utilized to lyse the emboli in PE. However, newer techniques for thrombolysis have been developed, such as endovascular ultrasound-assisted catheter-directed thrombolysis for massive and intermediate-high submassive risk groups. Additional newer techniques explored are the use of extracorporeal membrane oxygenation, direct aspiration, or fragmentation with aspiration. Because of the constantly changing therapeutic options and the scarcity of randomized controlled trials, choosing the best course of treatment for a given patient may be difficult. To help, the Pulmonary Embolism Reaction Team is a multidisciplinary, rapid response team that has been developed and is used at many institutions. Hence to bridge the knowledge gap, our review highlights various indications of thrombolysis in addition to the recent advances and management guidelines.