
==== Front
JACC Adv
JACC Adv
JACC: Advances
2772-963X
Elsevier

S2772-963X(24)00474-5
10.1016/j.jacadv.2024.101243
101243
Letters
To the Editor
Systemic Thrombolysis and Catheter-Based Therapies in Acute Pulmonary Embolism
Coelho Mariana Caetano marianalcc.coelho@gmail.com
a∗
Teixeira Rita a
Nobre Carla b
Thomas Boban c
Lacerda Teixeira Barbara d
a Hospital Santa Marta, Lisbon, Portugal
b ULS Arco Ribeirinho, Setúbal, Portugal
c University Hospital Kerry, Tralee, Republic of Ireland
d University of California-San Diego, La Jolla, California, USA
∗ Cardiology Center, Hospital Santa Marta ULS de São José, Rua de Santa Marta 50, 1169-024 Lisboa, Portugal. marianalcc.coelho@gmail.com
12 9 2024
10 2024
12 9 2024
3 10 101243© 2024 The Authors
2024
https://creativecommons.org/licenses/by/4.0/ This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Key words

acute pulmonary embolism
chronic thromboembolic pulmonary hypertension
systemic thrombolysis
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pmc Already you know many things for yourself, and you will know others slowly.

— Pablo Neruda in Ode to Federico Garcia Llorca

We read with keen interest the Viewpoint by Rozenbaum regarding systemic thrombolysis (ST) in acute pulmonary embolism (PE) and disagree with the opinion expressed that the use of ST is becoming unethical because of low rates of major complications with catheter-based therapies (CBTs), such as percutaneous aspiration devices.1

There are no robust data supporting the use of CBTs in high-risk PE. In the FLowTriever for Acute Massive Pulmonary Embolism study in the “context arm” patients received diverse therapies, with a significant proportion (23%) of these high-risk PE patients being treated with anticoagulation alone, while being compared to the device.2

Although the FlowTriever All-Comer Registry for Patient Safety and Hemodynamics (FLASH) registry3 showed some promising results regarding the safety profile of one type of percutaneous aspiration devices, with low mortality and procedure-related complications, this study has limitations inherent to single-arm registries and is subject to many biases. Direct comparisons to other treatment options, especially ST, cannot be made, as only a minority (7.9%) of patients were considered high risk. Furthermore, the patient population in this registry was selected by each treating physician based on their judgment of suitability for mechanical thrombectomy, leading to potential selection bias and limiting the applicability of the results to the general PE population. Moreover, the characterization of the risk stratification is lacking.

Numerous options for CBTs for acute PE exist with none clearly superior to the other.4 Most of these devices do not have formal regulatory approval presently.

Primary percutaneous coronary intervention for ST-elevation myocardial infarction is not universally available throughout the world and ST is still used in resource-constrained and limited settings. Analogously, the widespread adoption of CBTs for acute PE worldwide is impractical and ST is a valuable resource. Reduced dose thrombolysis is being evaluated against standard anticoagulation in Pulmonary Embolism International THrOmbolysis (PEITHO)-3 study.

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
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References

1 Rozenbaum Z. Revisiting systemic thrombolysis in acute pulmonary embolism JACC Adv 3 5 2024 100923
2 Silver M.J. Gibson C.M. Giri J. Outcomes in high-risk pulmonary embolism patients undergoing FlowTriever mechanical thrombectomy or other contemporary therapies: results from the FLAME study Circ Cardiovasc Interv 16 10 2023 e013406
3 Toma C. Jaber W.A. Weinberg M.D. Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism EuroIntervention 18 14 2023 1201 1212 36349702
4 Finocchiaro S. Mauro M.S. Rochira C. Percutaneous interventions for pulmonary embolism EuroIntervention 20 7 2024 e408 e424 38562073
