Tough decisions in pulmonary embolism: thrombolysis or embolectomy?

Patients presenting with acute pulmonary embolism (PE) and persisting haemodynamic instability need to be considered for primary reperfusion therapy with, commonly, thrombolysis or even surgical embolectomy [1]. Both treatment options can pose significant risks to the patient, but are potentially life-saving when used appropriately. Absolute contraindications to thrombolysis include cases where there is high risk of haemorrhage including previous haemorrhagic stroke, recent major surgery or trauma, recent gastrointestinal bleeding, central nervous system neoplasm or known bleeding diathesis [2]. In the presence of such contraindications, surgical embolectomy can be considered for intermediate to high and high-risk PE [1]. In clinical practice, the treatment decision is not always clear-cut and the ‘European Society of Cardiology (ESC)’ offers guidelines especially in situations where therapeutic options might be open to contention [1].