Systemic Full Dose, Half Dose, and Catheter Directed Thrombolysis for Pulmonary Embolism. When to Use and How to Choose?

OPINION STATEMENT: Treatment of pulmonary embolism (PE) is variable amongst different and even the same institutions. With the introduction of different forms of thrombolysis, catheter based interventions, and new oral anticoagulants, the treatment and decision-making process has become more complex. The different forms of classification of PE into massive, submassive, severe, moderate, intermediate high risk, intermediate low risk, and low risk have only added to this complexity. The main two reasons for such classifications have been to aid in assessment of patient prognosis and in the intent to carefully select patients who are high risk and would benefit from thrombolysis. The literature supports the use of thrombolysis in high risk patients albeit at the risk of a higher bleeding rate. It has been suggested that survival can improve in both massive and submassive PE with thrombolysis. Studies have shown a reduced risk of bleeding with reduction of the doses of the thrombolytic and anticoagulant agents while imparting the same beneficial effects seen in full dose thrombolysis. The opinion of this author is that treatment of massive and submassive forms of PE can become standardized, safe, streamlined, and simplified by using a lower dose of systemic thrombolysis for both and an anticoagulation regimen without the necessity for expensive approaches such as invasive catheter placement in the pulmonary circulation.