Treatment of Pulmonary Embolism

Treatment of acute pulmonary embolism is typically provided in a hospital, where your condition can be closely monitored. The goal of treatment is to primarily prevent the clot from growing and if symptoms are severe remove the clot to prevent shock, cardiac arrest or death. A secondary goal is to to reduce the severity of long-term pulmonary hypertension (shortness of breath, exercise intolerance).

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The standard of care in the management of pulmonary embolism is blood thinners (anticoagulation). Modern minimal invasive techniques can nowadays be offered (in addition to blood thinners) in selected patients with severe symptoms. These techniques involve immediate clot removal (“clot-busters” - thrombolysis). Mechanical cardiopulmonary support and open surgery to physically remove the clot are last resort treatment alternatives when other techniques have failed or are contraindicated.

Anticoagulants (Blood thinners)

Although anticoagulants do not remove the existing clots, they may keep them from growing.

This therapy relies on the body to "dissolve" the clot. In the acute period patients will receive heparin (intravenous or under the skin (subcutaneous) and they will then need transition to warfarin (Coumadin) that is taken orally.

Treatment with blood thinners may last from three to six months, but depending on your medical history it may need to be lifelong.

A major disadvantage of Coumadin is its interaction with certain foods (mainly green vegetables) and the need for frequent blood tests to check the appropriateness of the dosage (too little increases your clot risk, too much increases your risk for bleeding).

New medications are currently available (e.g. dabigatran (Pradaxa), apixaban (Eliquis), rivaroxaban (Xarelto)) that may not have these disadvantages; they may however carry other risks (e.g. no antidote available to cease bleeding in case of injury).

The most common side effect of all blood-thinners is bleeding. You should discuss these options with your doctor.

Thrombolysis

Blood thinners alone, do not remove the clot but allow time to the body to dissolve the clot. Unfortunately, in cases of life threatening (massive) pulmonary embolism there is no time to wait and more aggressive measures are needed.

Thrombolytics ("clot busters") can dissolve a clot quickly, over a period of a few hours. These clot busters can be administered either through a peripheral arm vein (systemic thrombolysis) at the intensive care unit bedside or through a long catheter (thin tube) that delivers them directly into the lung clot (catheter directed thrombolysis).

A major risk of this treatment is the risk of bleeding as any other clot within the body will be also busted. For this reason it cannot be applied to all patients e.g. those with active bleeding, recent surgery or trauma.

Systemic thrombolysis is currently the standard of care for massive pulmonary embolism, however as the thombolytic drug is not delivered directly into the clot, high dose is needed and the rate of bleeding complications including brain bleed (stroke) is relatively high, still though can be justified given the life threatening nature of the disease.

The use of catheter-directed thrombolysis is emerging as an effective alternative in patients with high risk pulmonary embolism.

As the drug is administered directly into the clot, lower dose is needed and the major complication rate seems to be lower.

This treatment alternative is invasive and needs to be done in a surgical environment, under local anethesia.

The procedure involves a puncture (no incision) usually at the groin or the neck. Under x-ray guidance wires and catheters are navigated to the lung.

A catheter will be positioned into the clot and thrombolytic drip will be initiated. You will be transferred to the bedside and the drug will be delivered slowly over the course of 12-24 hours, until the heart and lung function have improved.

Modern techniques will even allow break up the clot into pieces or removal with suction through the catheter. As with any operation, catheter directed techniques have risks, mainly this of bleeding.

Surgery

Vena Cava Filter

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Inferior vena cava filtersare used when you cannot take any of the blood thinners, or if you are taking blood thinners and continue to develop clots. Inferior vena cava is the large vein which is formed when the two large leg veins (iliac veins) merge in the pelvis.

The vena cava transfers the blood back to the heart and lungs. The vena cava filter can catch blood clots that move from the leg veins to the lung and prevent a recurrent pulmonary embolism.

During a small surgical procedure, the filter is inserted through a puncture in the groin or neck veins.

Under x-ray guidance a catheter is navigated into the vena cava and the filter is deployed.

This treatment will help prevent a pulmonary embolism, but will not prevent the development of more clots.

Contemporary filters are retrievable and as soon as the risk period is over, your vascular surgeon will remove it, again with a small minimally invasive procedure.

Compression Stockings

Graduated compression stockings are essentialto reduce the swelling associated with venous thrombosis that may accompany a pulmonary embolism.

The swelling often occurs because the valves in the leg veins have become damaged or the vein remains blocked from the blood clot.

Compression “squeezes” the blood out of the leg back to the heart, preventing it from pooling.

The stockings have no effect on reducing the clot but may help prevent a new clot. Most compression stockings are worn just below the knee.

These stockings are tight at the ankle and become looser as they go up the leg. This causes gentle external compression (or pressure) on your leg.

It is recommended that the compression pressure is 30-40 mmHg and they should be worn daily, if possible, for at least 2 years to prevent post-thrombotic syndrome.

Prevention of Recurrent Pulmonary Embolism

If you have had pulmonary embolism once, you are more likely to have it again. Your vascular surgeon will recommend ways to prevent pulmonary embolisms in the future:

Stay active and exercise regularly
Wear elastic compression stockings, particularly if you need to sit or stand for long periods.
Use anticoagulants during times when you have limited mobility, like during surgery or prolonged bed rest. Discuss this with your doctor.
Being fitted with a sleeve-like device on your legs during surgery. This device compresses your legs regularly to help blood keep flowing through your veins until you can walk again
Walk or flex and stretch your legs every hour on long plane or car trips.
If you can’t walk around due to bed rest, recovery from surgery or extended travel, move your arms, legs and feet for a few minutes each hour
Drink plenty of fluids, like water and juice, but avoid excess alcohol and caffeine.
Do not smoke
Maintain and optimal weight