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

S2772-963X(24)00477-0
10.1016/j.jacadv.2024.101246
101246
Letters
Reply to the Letter to the Editor
Reply
Systemic Thrombolysis and Catheter-Based Therapies in Acute Pulmonary Embolism
Rozenbaum Zach MD zachroze@gmail.com
@Rozenbaum_z
∗
∗ Department of Cardiology, Tulane University, 131 S. Robertson Street, New Orleans, Louisiana 70112, USA. zachroze@gmail.com@Rozenbaum_z
12 9 2024
10 2024
12 9 2024
3 10 101246© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
==== Body
pmcI thank Dr Coelho and colleagues for their interest in the viewpoint1 regarding the management of pulmonary embolism. The group disagrees with the opinion that the use of systemic thrombolysis is becoming unethical as first-line therapy. Nonetheless, their comment noting that part of the control arm (“context arm”) in the FLAME (FlowTriever for Acute Massive PE) study received only anticoagulation2 highlights the major shortcoming of systemic thrombolysis. Treatment with anticoagulation reflects real-world practice, as systemic thrombolysis is immensely underutilized in indicated cases due to the high bleeding risk and despite hemodynamic instability.3 The comparison of percutaneous aspiration devices to the conservative group as a whole is appropriate because it represents the true standard treatment and the challenges of managing unstable pulmonary embolism. PEITHO-3 (Pulmonary Embolism International THrOmbolysis) (NCT04430569) is mentioned in the reply, but the trial excludes patients who are hemodynamically unstable, and therefore the results will not support the usage of systemic thrombolysis in high-risk pulmonary embolism.

Dr Coelho and colleagues argue that data on the low rates of major complications with percutaneous aspiration devices are difficult to interpret compared to systemic thrombolysis. While it is difficult to draw generalized conclusions on the effectiveness of percutaneous aspiration devices in high-risk pulmonary embolism from the heterogenous FLASH (FlowTriever All-Comer Registry for Patient Safety and Hemodynamics) registry, the high rates of technical success with low rates of device-related complications4 are reproducible in centers that are utilizing the technology.

Dr Coelho and colleagues rightfully state that percutaneous aspiration devices are not available in all medical centers. Efforts to increase the availability of newer therapies are essential. The option of transferring patients for primary percutaneous coronary intervention is one example of limited resources concentrated to tertiary hospitals. Considering that systemic thrombolysis is, in practice, only used in a minority of patients, widespread adaptation of catheter-based therapies to an updated flowchart of acute pulmonary embolism management5 is required to bridge this treatment gap.

Dr Rozenbaum has received speaker fees and research funding from AngioDynamics for a previous project.

The author attests they are in compliance with human studies committees and animal welfare regulations of the author’s institution and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
==== Refs
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 Sedhom R. Megaly M. Elbadawi A. Contemporary National trends and outcomes of pulmonary embolism in the United States Am J Cardiol 176 2022 132 138 35637010
4 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
5 Rozenbaum Z. Gnall E. Percutaneous cardiac chambers and pulmonary artery aspiration Curr Cardiol Rep 25 7 2023 681 691 37166556
