Synopsis
Select patients who may benefit from catheter-directed or surgical thrombus removal, understand procedural trade-offs, and recognise when anticoagulation or systemic reperfusion remains appropriate.
- For PE with shock, assess fibrinolysis eligibility explicitly: use systemic thrombolysis when permitted; if lysis is contraindicated, urgent alternatives are catheter aspiration or mechanical thrombectomy without lytic exposure, or surgical embolectomy—not catheter-directed thrombolysis.
- Do not routinely thrombolyse haemodynamically stable PE, including patients with right-ventricular dysfunction; monitor higher-risk stable patients and prepare rescue escalation.
- For symptomatic iliofemoral DVT, consider catheter-directed thrombolysis only when symptoms have lasted under 14 days, functional status is good, life expectancy is at least 1 year and bleeding risk is low; do not offer thrombus-removal procedures for femoral, popliteal or calf-vein DVT. All intervention choices require multidisciplinary assessment and local capability.
Key red flags
Cardiac arrest, persistent hypotension, rising lactate or worsening organ perfusion indicates high-risk PE requiring immediate reperfusion assessment.
Recent intracranial haemorrhage, active major bleeding, intracranial neoplasm or recent major surgery may make thrombolytic exposure unacceptable.
Phlegmasia, threatened limb perfusion or severe iliofemoral DVT symptoms despite treatment needs urgent vascular review for selected thrombus-removal strategies.
New neurological change, access-site expansion, haemoglobin fall, pericardial signs or abrupt respiratory deterioration after intervention suggests a major complication.
Massive swelling, cyanosis, severe pain, sensory change or impaired arterial inflow suggests phlegmasia and requires urgent venous and arterial assessment.
Investigation priorities
Determine whether urgent reperfusion is needed and which methods remain safe.
Management branches
Confirmed or near-certain PE is causing shock, persistent hypotension or cardiac arrest.
- Provide expert-led resuscitation, continuous monitoring and anticoagulant assessment while activating critical care, interventional radiology or cardiology, and cardiothoracic surgery without serial referral delay.
- Decide fibrinolysis eligibility explicitly. Use systemic thrombolysis when indicated and permissible; if lysis is contraindicated or has failed, choose catheter aspiration or mechanical thrombectomy without thrombolytic exposure, or surgical embolectomy, according to anatomy, time and expertise.
A monitored normotensive patient develops hypotension, worsening hypoperfusion or escalating respiratory failure.