When the heart struggles to breathe: a case of pulmonary embolism

Abstract

Pulmonary embolism (PE) is a highly fatal acute cardiovascular syndrome caused by pulmonary arterial obstruction and resulting right ventricular pressure overload, which can lead to hemodynamic instability and shock. In patients with high-risk or intermediate-to-high-risk PE, especially those with contraindications to systemic thrombolysis or an inadequate response to anticoagulant therapy, interventional radiology procedures in the hemodynamic setting are an effective treatment option, increasingly supported by clinical evidence. The care pathway begins in the Emergency Department with diagnostic confirmation by CT pulmonary angiography and prognostic stratification based on clinical, laboratory, and echocardiographic parameters. In selected cases, the Pulmonary Embolism Response Team (PERT) is activated, ensuring a timely multidisciplinary assessment and, if necessary, referral for endovascular treatment, with transfer to the cath lab. Vascular access is generally achieved via the femoral vein under fluoroscopy or ultrasound guidance. Among the main techniques available, thromboaspiration and mechanical thrombectomy allow direct removal of the thrombus from the pulmonary circulation. Dedicated systems such as the FlowTriever and Indigo System use large-bore catheters with active aspiration, allowing for rapid reduction of the thrombotic load without the use of fibrinolytics. Our center has developed consolidated experience with the FlowTriever technique. Available data demonstrate significant improvement in hemodynamic parameters and right ventricular function, with a favorable safety profile. The therapeutic strategy must be individualized based on clinical risk and the center's expertise.