Evidence-Based Management of Massive and Submassive Pulmonary Embolism

Acute pulmonary embolism (PE) can lead to life-threatening complications, such as shock due to right ventricular failure and death. PE cases can be stratified as low, intermediate, or high-risk. Intermediate-risk and high-risk PE present with right ventricular dysfunction and elevated cardiac troponins, but only high-risk PE is associated with hemodynamic instability. Although low-risk PE management is well-defined, that is not the case with intermediate and high-risk PEs. All PEs are initially managed with anticoagulation; systemic thrombolysis is the treatment of choice for high-risk ones. Treatment modalities such as reduced-dose thrombolysis, catheter-directed therapy (catheter-directed thrombolysis and mechanical thrombectomy), and surgical pulmonary embolectomy were explored in various trials. Despite this arsenal of treatments for PE, each modality carries risks and complications that further complicate PE management. Supportive care measures such as fluid management, vasopressors and inotropes, oxygen therapy, mechanical ventilation, and extracorporeal membrane oxygenation can mitigate clinical deterioration and hemodynamic collapse, especially in high-risk PE. This review provides an overview of acute PE presentation, diagnosis, risk stratification, and management while putting an emphasis on the diverse modalities of treatment and the studies exploring each.