ESC Guidelines and Society Consensus

Although there has been significant development in our ability to prevent, diagnose and treat acute pulmonary embolism, it remains a significant cause of morbidity and mortality.¹

This has been the rationale for finding new approaches and options for managing patients at intermediate-high and high-risk of pulmonary embolism (PE). The field has been rapidly evolving, opening up new treatment options beyond standard anticoagulation and fibrinolysis.

Indeed, if PE can be diagnosed and the appropriate therapy started, the mortality can be reduced from approximately 30% to less than 5%.^2,3

In 2019, the European Society of Cardiology (ESC) updated their guidelines on the use of catheter-directed treatment as an alternative to rescue thrombolytic therapy for patients who deteriorate haemodynamically, bringing their recommendations from Class IIb to Class IIa.⁴

A new clinical development has been shared by the European Society of Cardiology (ESC) and by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) around the treatment of pulmonary embolism.

The consensus data formulated by the associations and authored by PE expert leaders has been designed to describe the currently available catheter directed therapies, complementary to the formal guidelines, to treat acute pulmonary embolism.

The paper reviews the standardization of patient selection, the timing and the technique of the procedures as well as protocols of anticoagulations regimes, considered crucial during the treatment.

The consensus serves as a practical guide for interventional Cardiologists, Interventional Radiologists, and Vascular Surgeons and it aims to describe and propose a standardised 12 steps protocol for catheter directed therapies including relevant information around timing, imaging before the intervention and the procedural objectives when treating a high-risk and intermediate-high risk PE patient.

In November 2023, the German Society of Cardiology (Deutsche Gesellschaft für Kardiologie, DGK) published a consensus5 related to the improvement of PE management through the multidisciplinary approach and catheter directed therapies (CDT). It was written by experts from several working groups of the specialist society.

Based on a critical literature review, the authors took a stand on eleven key statements related to the questions that are currently clinically relevant. They considered the reperfusion therapy of PE, as technology and knowledge in this area largely evolved since the last publication of the PE guidelines from the European Society of Cardiology.

Two of the eleven statements are highlighted below: the one related to Catheter Directed Therapies and the one related to Pulmonary Embolism Response Teams (PERT).

• Key statement 5: The indication for catheter-directed treatment of acute pulmonary embolism requires, as is also the case for intravenous thrombolysis, a manifest or impending haemodynamic instability. This is therefore an acute situation, meaning that the reperfusion therapy (in analogy to acute ST segment elevation myocardial infarction) should be started as quickly as possible after indication. In addition, the transfer of the patient to a hospital with the possibility for intervention may be considered/discussed.
• Key statement 9: It is recommended that multidisciplinary pulmonary embolism teams should be established in German hospitals (class IIa). They have the overarching aim of coordinating and accelerating treatment decisions and the implementation thereof for acute, potentially life-threatening pulmonary embolisms (high and intermediate-high risk). In this case, optimum use must be made of the expertise and resource available at the hospital in question and if necessary, cooperation partners (e.g., virtual conference) must be identified or the criteria for transfer to a suitable centre must be defined.