Pulmonary Embolism Lysis Team (PELT): Guiding thrombolysis in Sub-Massive PE (SMPE)

Introduction: The decision to thrombolyse patients with SMPE is difficult and there is no consensus on best practice. Thrombolysis reduces risk of haemodynamic collapse but increases risk of major haemorrhage 1 . The MOPETT trial introduced ‘safe dose thrombolysis’ (reduced dose tPA; 10mg bolus, 40mg/2hours) 2 but bleeding remains a concern. In order to assess patients who may benefit from thrombolysis multidisciplinary PELTs comprising specialists in respiratory medicine, ICU, haematology and interventional radiology were established in two closely linked hospitals with existing staffing. Aim: To review the safety outcomes of patients with SMPE referred to PELT in a teaching hospital and a district general hospital (DGH). Methods: After review by the PELT, patients were treated with either anticoagulation alone, systemic reduced-dose thrombolysis (SRDT) or catheter-directed thrombolysis (CDT) based on clinical judgment of the PELT and patients informed view. We reviewed the records of patients referred between 1/1/14 and 31/12/16. Results: 57 patients were assessed; 3 progressed to massive PE and received full thrombolysis, 13 underwent SRDT, 18 CDT and 23 received anticoagulation alone. Minor bleeding post-thrombolysis was common (37.5% systemic, 11.1% CDT) but there was no major or intracerebral haemorrhage. Mortality post-thrombolysis was 14.7% (12.5% systemic, 16.7% CDT) but no deaths were attributable to thrombolysis. Conclusions: When guided by a PELT, SRDT and CDT appear safe therapies which can be used in patients with high risk SMPE who are significantly compromised, at risk of haemodynamic collapse, or have not improved with anticoagulation. 1)NEJM2014;370:1402-11 2)AmJCardiol2013;111:273-277