Optimizing pulmonary embolism response team functionality: Outcomes of mechanical thrombectomy by interventional radiology and vascular surgery

Abstract

Background:

Pulmonary embolism response teams (PERTs) are multidisciplinary care teams that perform rapid assessment and recommendations for patients with pulmonary embolism (PE). Challenges in creating and maintaining a PERT include physician buy-in and availability at all hours. One potential solution is to share PE interventions across specialty services.

Methods:

Patients with acute PE who received a PERT consultation and subsequent mechanical thrombectomy (MT) were included in this single-center, retrospective study. Patients from January 2021 to June 2024 were divided into two cohorts: one that received MT from interventional radiology (IR) and another that received MT from vascular surgery (VS). Outcomes included 30-day mortality, bleeding, 6-minute follow-up walk distance, time to intervention, total procedure time, and complication rates.

Results:

A total of 76 patients were included in this analysis. IR and VS performed 61.8% (n = 47) and 38.2% (n = 29) of MTs, respectively. Of patients treated with MT, 46.1% (n = 35) had high-risk status and 53.9% (n = 41) had intermediate-high-risk status. In patients who received MT from IR, there was a 6.4% (three of 47) 30-day mortality rate compared to 6.9% (two of 29) from VS (p = 0.938). The occurrence of complications after MTs performed by IR and VS were 4.3% (two of 47) and 6.9% (two of 29), respectively (p = 0.792). Major procedure-related adverse events were 4.3% (two of 47) for IR and 6.9% (two of 29) for VS (p = 0.792).

Conclusion:

Outcomes of PE thrombectomy did not differ by whether the proceduralist was IR or VS. Intervention-sharing among different provider groups within PERTs could alleviate provider burden and make response team implementation more feasible.

Keywords

interventional radiology medical specialty pulmonary embolism (PE)thrombectomy venous thromboembolism (VTE)

Background

Acute pulmonary embolism (PE) affects upwards of 350,000 Americans annually and has devastating morbidity and mortality.^1–3 To help with the challenges associated with stratifying patients and constructing a management plan, pulmonary embolism response teams (PERTs) were developed.^3–10 The goal of a PERT is to utilize a rapid, centralized multidisciplinary diagnostic and therapeutic approach to complex PE care.^10–12 Members of the team can include interventional radiology, cardiology, pulmonary critical care, vascular surgery, cardiothoracic surgery, emergency medicine, hematology, and others.¹² Unique to the PERT at Barnes Jewish Hospital (BJH), is that both interventional radiology (IR) and vascular surgery (VS) perform the same catheter-directed therapies (CDTs), specifically pulmonary artery mechanical thrombectomy (MT), on alternating days.

As more PERTs are incorporated into hospital systems worldwide, additional research investigating team composition can benefit patients and hospitals by providing more evidence on how interdisciplinary collaboration affects patient outcomes.¹¹ The current literature demonstrates that PERT implementation has been associated with shorter hospital stay and higher utilization of advanced therapies; however, evidence for whether the increase in utilization of interventional therapies is beneficial or not is conflicting.^10,13 However, PERT composition and procedures are not fully standardized across hospitals.¹¹ The variation of PERTs across different sites invites investigation into ways to optimize PERTs, as well as to explore ways various specialties may contribute to the team to maximize patient care and physician participation in the PERT.

In some centers, including at BJH, physicians from more than one medical specialty but with appropriate training and expertise contribute to the delivery of MT procedures to treat patients with PE. The aim of this study is to investigate if there are differences in MT outcomes among IR and VS services that participate in the institutional PERT.

Methods

Patient selection

Adult patients with acute PE who received PERT consultation in the university-based hospital and underwent MT for PE were included in this retrospective cohort study. This study was approved by the Washington University in St Louis institutional review board. Patient data from January 2021 to June 2024 were extracted from a REDCap database that was maintained for quality improvement purposes. Patients were divided into two cohorts by whether they received MT from IR or VS. Regardless of the cohort, patients received systemic anticoagulation in the form of unfractionated heparin, low-molecular weight heparin, or bivalirudin.

Patients were stratified based on severity as either high-risk or intermediate-high-risk PE per European Society of Cardiology (ESC) guidelines. Low-risk and intermediate-low-risk patients were excluded owing to few interventions in these groups. Patients were also excluded if they received surgical pulmonary artery embolectomy, catheter-directed thrombolysis, or systemic thrombolysis. Patients included in this study were restricted to intermediate-high-risk and high-risk patients who were selected for MT after PERT discussion, whereas those who received primary or adjunctive therapy with systemic thrombolysis were excluded.

Decision-making and treatment allocation

After PERT evaluation, treatment decisions were made based on an assessment of factors including patient status, clot burden, comorbidities, bleeding risk, contraindications to thrombolytics, and institutional expertise. No strict metrics-based algorithm was applied; however, hemodynamic instability, right ventricular (RV) dysfunction, oxygen requirements, and clinical deterioration were considered when determining treatment.

Procedural technique

Although more detailed procedural techniques have been published, the general procedure for both IR and VS is described here. Common femoral venous access was achieved under ultrasound guidance. A large-bore sheath was then advanced to the pulmonary arteries under fluoroscopy, followed by angiography to visualize filling defects and targets. The FlowTriever (Inari Medical, Irvine, CA, USA) or Indigo Aspiration System (Penumbra, Inc., Alameda, CA, USA) was deployed for MT. With the FlowTriever System, a 20-French aspiration guide catheter was advanced over a 0.035-inch guidewire to a position proximal to the thrombus, followed by advancement of the FlowTriever catheter. Similarly, with the Indigo Aspiration System, the aspiration catheter was introduced over a 0.035-inch guidewire and advanced to a position proximal to the thrombus. Multiple aspirations were performed to try to achieve a combination of significant thrombus removal with improvement in hemodynamic variables, including resolution of tachycardia, and/or oxygenation requirements. In addition, mean pulmonary artery pressure was measured before and after intervention, when possible.

Outcomes and statistical analysis

Outcomes assessed were 30-day all-cause mortality, 6-minute walk distance at first follow-up (between 3 and 6 months), time to intervention from PERT consultation, total procedure room time, and complication rates. Data were collected and analyzed using Microsoft Excel (Microsoft Corp., V 16.95.4) and SPSS Statistics (IMB Corp., V 30.0.0), respectively. Chi-squared analyses and odds ratios (ORs) were utilized to determine association between variables where appropriate. A two-tailed p < 0.05 was considered statistically significant.

In categorization and discussion of PERT metrics, intraprocedural complications were defined as immediate complications that occur during the procedure itself (e.g., because of device manipulation, vascular access, or intraprocedural physiology). Minor procedural complications, such as access-site complications that had no significant clinical impact, were not recorded in the database. Major adverse events (AEs) related to the procedure were defined as clinically significant deterioration at least in part related to the procedure, but not during the procedure.

Results

Baseline patient characteristics

Table 1 shows baseline characteristics. Prior to exclusion, there were 434 total patients consulted by the PERT during the period of the study. Nine patients within the intermediate-high-risk and high-risk categories who received systemic thrombolysis in addition to anticoagulation were excluded; 78% (seven of nine) of these patients had a high-risk classification and 22% had an intermediate-high-risk classification. Of the remaining excluded patients, one received pulmonary embolectomy, 10 were low risk, and 79 were intermediate-low-risk. Therefore, 76 patients were treated with MT plus anticoagulation and met the study’s inclusion criteria. The IR service performed 61.8% (n = 47) of MTs, whereas the VS service performed 38.2% (n = 29). Of the patients treated with MT, 46.1% (n = 35) had a high-risk classification and 53.9% (n = 41) had an intermediate-high-risk classification. Of the patients treated by IR, 46.8% (22 of 47) were high-risk and 53.2% (25 of 47) were intermediate-high risk patients; of those treated by VS, 44.8% (13 of 29) were high-risk and 55.2% (16 of 29) were intermediate-high-risk patients (p = 0.794).

Table 1.

Patient baseline characteristics.

Characteristic	All patients(N = 76)	IR(n = 47)	VS(n = 29)	p-value
Age	57.9 (± 15.2)	58.8 (± 15.4)	56.5 (± 15.0)	0.652
Race				0.147
White	43 (56.6)	23 (48.9)	20 (70.0)
Black	30 (39.5)	22 (46.8)	8 (27.6)
Asian	1 (1.3)	1 (2.1)	0 (0)
Pacific Islander	1 (1.3)	1 (2.1)	0 (0)
American Indian	1 (1.3)	0 (0)	1 (3.4)
BMI, kg/m²	34.94 ± 9.4	35.83 ± 9.6	33.63 ± 9.3	0.339
PE severity				0.794
High-risk PE	35 (46.1)	22 (46.8)	13 (44.8)
Intermediate-high-risk PE	41 (53.9)	25 (53.2)	16 (55.2)
Location of PE				0.442
Saddle	52 (68.4)	34 (72.3)	18 (62.1)
DVT presence	56 (73.7)	32 (68.1)	24 (83.8)	0.791
Comorbidities
HTN	43 (56.6)	29 (61.7)	14 (48.2)	0.28
DM	21 (27.4)	14 (29.7)	7 (24.1)	0.926
CVA	2 (2.6)	2 (4.3)	0 (0)	0.694
COPD	4 (5.3)	3 (6.4)	1 (3.4)	0.971
Active malignancy	18 (23.7)	11 (23.4)	7 (24.1)	> 0.99
2+ comorbidities	30 (39.5)	20 (42.6)	10 (34.5)	0.622
Charlson Comorbidity Score	3.0 (± 2.8)	3.3 (± 2.9)	2.8 (± 2.7)	0.476
History of COVID-19	6 (8.2)	4 (8.9)	2 (7.1)	> 0.99
Vitals and studies
Pro-BNP at diagnosis, pg/mL	3598.4 ± 5298	3889.2 ± 6085	3113.1 ± 3782	0.58
Troponin I at diagnosis, ng/mL	386.6 ± 571	402.7 ± 613	351.5 ± 484	0.763
HR over 100 at diagnosis	58 (76.7)	34 (75.6)	24 (78.6)	> 0.99
Presence of RV strain on CT	73 (96.4)	45 (95.7)	28 (96.6)
Presentation location				0.175
BJH ER	36 (47.4)	24 (51.1)	12 (41.1)
OSH ER	25 (34.2)	15 (33.3)	10 (35.7)
Inpatient	10 (13.7)	4 (8.9)	6 (21.4)
Direct admission	2 (2.7)	2 (4.4)	0 (0)

All values are displayed as n (%) or mean ± SD, unless otherwise noted.

BJH, Barnes Jewish Hospital; BMI, body mass index; COPD, chronic obstructive pulmonary disease; CT, computed tomography; CVA, cerebrovascular accident; DM, diabetes mellitus; DVT, deep vein thrombosis; ER, emergency room; HR, heart rate; HTN, hypertension; IR, interventional radiology; OSH, outside hospital; PE, pulmonary embolism; pro-BNP, pro-B-type natriuretic peptide; RV, right ventricular; VS, vascular surgery.

The average body mass index (BMI) of patients in this study was 34.94 ± 9.4. The self-reported race of patients is shown in Table 1, with no significant differences in race between the IR and VS groups. The average Charlson Comorbidity Score was 3 ± 2.8 for all participants, indicating a moderate severity of comorbidity burden. Between the IR and VS services, differences in any of the patient comorbidities were not statistically significant. Average pro-b-type natriuretic peptide (pro-BNP), troponin, number of patients with a heart rate (HR) of over 100 at presentation, location of patient presentation, and location of embolus are also included in Table 1.

Patient-centered outcomes

A total of 59 patients received monitored anesthesia care (MAC) and 16 received general endotracheal anesthesia (GA), with one patient converting from MAC to GA (see Table 3). Table 2 shows the comparison of patient-centered outcomes between groups that received MT by IR or VS. The use of GA was highest during the first 2 years of data recording, with five cases using GA each year during the years 2021 and 2022. In 2023 and 2024, GA was used in three cases per year. Among those who received MT by IR, there was a 6.4% (three of 47) 30-day mortality rate compared to a 6.9% (two of 29) 30-day mortality rate in those who received MT by VS (Figure 1). All five patients who died within 30 days were high-risk patients. The difference in 30-day mortality between groups was not statistically significant (OR = 0.93, 95% CI: 0.15–5.93, p = 0.938). Neither group had any occurrence of 30-day postprocedure bleeding.

Table 2.

Comparison of patient mortality and readmission, bleeding, recurrence, and functional improvement between interventional radiology and vascular surgery.

	All patients	IR	VS	p
30-Day mortality
All PE	6.6 (5 of 76)	6.4 (3 of 47)	6.9 (2 of 29)	0.938
High-risk PE	14.3 (5 of 35)	13.6 (3 of 22)	15.4 (2 of 13)	0.854
Intermediate-high-risk PE	0.0 (0 of 41)	0.0 (0 of 25)	0.0 (0 of 16)	> 0.99
Secondary outcomes
30-Day readmission	10.5 (8 of 76)	12.8 (6 of 47)	6.9 (2 of 29)	0.706
30-Day bleeding	0.0 (0 of 76)	0.0 (0 of 47)	0.0 (0 of 29)	> 0.99
Recurrent VTE	6.9 (5 of 72)	4.4 (2 of 45)	11.1 (3 of 27)	0.579
6-Minute walk distance, ft	1089 ± 389(n = 30)	1040 ± 423(n = 15)	1139 ± 354(n = 15)	0.497

All values are displayed as % (n of total) or mean ± SD, unless otherwise noted.

p-values obtained with chi-squared analyses were utilized for comparison of outcomes and characteristics.

Note – Fewer total patients in each category reflects patients lost to follow-up or death.

IR, interventional radiology; PE, pulmonary embolism; VS, vascular surgery; VTE, venous thromboembolism.

Figure 1.

Patient mortality and complications: 30-day mortality represents the percent of patients treated by each service who died within a 30-day period for any reason; major adverse events related to the procedure represent postprocedure patient events; and procedural complications represent complications that occurred during the procedure.

Thirty patients (15 in each cohort) received a follow-up measurement of 6-minute walk distance at the first visit after discharge, which ranged in timing from 3 to 6 months, with an average of 5.3 months postdischarge. The average distance was 1040 ± 423 ft in those who received CDT from IR and 1139 ± 354 ft in those who received CDT from VS (p = 0.497) (Table 2). An initial follow-up echocardiogram for 18 patients, conducted between 3 and 6 months postdischarge, showed that only two patients had evidence of RV strain; both had an intermediate-high-risk status.

There was an intraprocedural complication rate of 4.3% (two of 47) in the IR cohort and 6.9% (two of 29) in the VS cohort (OR = 0.60, 95% CI: 0.08–4.6; Table 3). All four intraprocedural complications were related to cardiac injury. We defined procedural complications as events that caused clinically significant deterioration at least in part related to the procedure, but not necessarily during the procedure. The first patient experienced two episodes of pulselessness during cannulation of the left main pulmonary artery, resulting in death. The second patient experienced fatal hemopericardium during catheter advancement in the RV outflow tract. The third patient experienced ventricular tachycardia likely due to catheter manipulations in the RV. The fourth patient experienced cardiovascular collapse after anesthesia induction. In four patients different from those who experienced procedural complications, there were major AEs related to the procedure (Table 3). One patient with respiratory failure (high-risk status) and another patient with refractory cardiogenic shock and cardiac arrest (intermediate-high-risk status) both survived past 30 days. Conversely, two patients died within 30 days: one patient with hemopericardium which developed 20 hours after the procedure requiring intubation (high-risk status) and another patient with hypotension and cardiac arrest requiring intubation (high-risk status). Differences in AEs related to the procedure were not statistically significant between the groups and were found to be 4.3% (two of 47) for the IR group and 6.9% (two of 29) for the VS group (OR = 1.3, 95% CI: 0.2–7.4).

Table 3.

Comparison of procedural characteristics between interventional radiology and vascular surgery.

	All(N = 76)	IR(n = 47)	VS(n = 29)	p
Major adverse events	5.2	4.3	6.9	0.792
Procedural complications	5.2	4.3	6.9	0.792
Anesthesia type				0.234
MAC	77.6	82.3	68.9
General	21.0	14.9	27.6
Time measures (minutes)
Time to intervention	129.4 ± 171	101.9 ± 136	176.9 ± 215	0.076
Time in room	181.6 ± 57	169.0 ± 47	202.6 ± 67	0.017

All values are displayed as % or mean ± SD.

Statistically significant p-values are bolded; p-values obtained with chi-squared analyses were utilized for comparison of outcomes and characteristics.

IR, interventional radiology; MAC, monitored anesthesia care; VS, vascular surgery.

Pulmonary embolism response team (PERT) metrics

Time analysis was conducted between the IR and VS services (Figure 2). The first analysis explored the time from the PERT consultation to the beginning of the intervention. The average time to intervention was 101.9 ± 136 minutes for the IR service and 176.9 ± 215 minutes for the VS service (p = 0.076). The second analysis focused on total patient time in the procedure suite. The average total time in the room for MTs performed by IR was 169.0 ± 47 minutes and 202.6 ± 67 minutes for MTs performed by VS (p = 0.017).

Figure 2.

Time comparison between interventional radiology (IR) and vascular surgery (VS). Time to intervention represents the time from the initial pulmonary embolism response team (PERT) consultation to the beginning of mechanical thrombectomy. Time in room indicates the total time a patient spends in the procedure room, which can be influenced by procedure duration and anesthesia type.

Additionally, extracorporeal membrane oxygenation (ECMO) was used in five patients, four of whom held a high-risk status and one who held an intermediate-high-risk status. All five patients were within the VS treatment arm. Considering device utilization within the IR cohort, in instances where the device type was recorded in the database, 86.7% (39 of 45) of MT cases were performed with the FlowTriever (Inari Medical), with the remaining 13.3% (six of 45) performed with the Flash Indigo System (Penumbra, Inc.). Within the VS cohort, 75% (15 of 20) of cases were performed with the FlowTriever and 25% with the Flash Indigo System (five of 20).

Discussion

PERTs have been shown to enhance certain clinical outcomes for patients with PE, including a shorter hospital length of stay (LOS), whereas improvement of other outcomes, such as short-term (i.e., 30-day) mortality has not been clearly demonstrated.^10–12 Alongside the potential benefits of PERTs, several challenges need to be addressed. These challenges primarily revolve around individual physician and specialty buy-in. PERT participation often demands increased time and effort from physicians, including extended 24-hour on-call responsibilities.¹¹ Physician recruitment can be further diminished due to the difficulty of securing supplemental reimbursement for each team member.¹¹ It is also important to consider that participation in the PERT can impose additional challenges on physicians in the realm of medical decision making. For instance, there may be added difficulty in achieving consensus among multiple specialties, compared with reaching an agreement within a single specialty.

Although challenges vary across institutions, introducing more flexibility within PERTs could alleviate provider burden and make PERT implementation more feasible. One potential solution is to share PE interventions across physicians from different specialties. At our institution, both VS and IR perform a broad array of vascular procedures (arterial and venous). Within the past two decades, IR and VS have substantially modified training pathways to achieve greater independence and relevance to clinical needs, with heavy integration of vascular disease management and image-guided intervention into both specialty training pathways. Each group learned to perform PE thrombectomy procedures separately, without any inter-specialty training or proctoring. IR and VS services alternate on-call days for performing MTs that are deemed appropriate after PERT consultation. This rotation reduces the workload on both specialties by allowing shared on-call responsibilities. Although this approach benefits PERT providers, it is crucial to understand if comparable care quality is provided across specialty groups, and to understand and mitigate any deficiencies or tradeoffs that are identified.

The results of this study indicate no statistically significant differences in patient outcomes between MTs performed by IR and VS physicians, including 30-day mortality, major AEs, and procedural complications. The observed 30-day mortality rate of 6.6% for both specialties should be viewed in the context of a study population in which nearly half of the patients had high-risk PE, which is traditionally associated with very high mortality rates.

The 5.2% AE related to the procedure and 5.2% procedural complication rate are on par and slightly lower compared to rates reported in the literature.¹⁴ In our study, the average Charlson Comorbidity Score was 3, which suggests a moderate level of comorbid conditions, increasing the risk of mortality. Most patients in our study were obese (average BMI = 34.94), with an average age of 57.9 years. Additionally, a significant number of patients had a known malignancy, diabetes, and hypertension, all of which may contribute to the complication and AE rate. In fact, the average Charlson Comorbidity Score of the four patients who experienced a major AE related to the procedure was 5.25, signifying a higher risk of mortality due to multiple severe comorbid conditions.¹⁵ Similarly, the four patients who experienced a procedural complication had an average Charlson Comorbidity Score of 4.8.

Because two distinct specialties share a single procedure, it was essential to examine procedural characteristics such as total room time, the interval from PERT consultation to intervention, and type of anesthesia used. The study found no significant difference in the time interval from PERT consultation to intervention. It should be acknowledged that time to intervention may be influenced by the decision of the PERT to delay intervention in favor of an initial approach with more conservative care. However, there was a larger number of patients treated with MT by IR (n = 47) compared to VS (n = 29), even though call responsibilities are equally shared. This may be for several reasons, including variation in PERT consultation rates across the study period or higher rates of recommendation for MT by IRs. The use of other CDTs or surgical embolectomy is, however, unlikely to be responsible for the differences in MT performed between specialties due to minimal utilization of both procedures within the database.

In our practice, nearly all MT procedures were performed with anesthetic support, most commonly MAC, with a minority of cases utilizing GA. This reflects the need to safely perform procedures in patients who are frequently hemodynamically unstable or are at high likelihood of decompensation, are unable to tolerate prolonged supine positioning or breath-holding, or require airway and ventilatory support. It is acknowledged that the use of GA induction and positive-pressure ventilation may precipitate hemodynamic deterioration in patients with significant RV strain, and therefore GA is avoided when feasible. In this cohort of patients, the use of GA represents case selection and a case-by-case clinical decision based on the risks and benefits of its use in the context of the multidisciplinary care team. There were no statistically significant differences in the rate of use of GA between the two specialties. This trend may demonstrate a parallel between clinical practice at this institution and an understanding of the risks of GA in patients who are hemodynamically compromised.

Similarly, although procedure room time for MTs performed by IR was 33.6 minutes shorter on average (p = 0.017), there was no difference in clinical outcomes. It should be noted that factors outside of the physician’s control—such as clot burden, location, and patient status—may impact the time it takes to perform the MT safely and successfully. We were not able to discern if this difference was due to shorter MT procedure time (i.e., time from venipuncture to MT completion) or due to faster periprocedure workflow in the IR suite versus the surgical operating room. Even with these considerations, the minimal differences in these metrics suggest there are no major distinguishing features between how these services perform this procedure in the context of our institution’s PERT.

The results of this study are supportive of the concept that sharing MT between IR and VS in the context of a PERT does not harm patient outcomes. Instead, sharing MT allows two separate services to share call time and consultations, reducing the workload on both services. Strengths of our analysis include multispecialty participation in the collection and analysis of the data, the capture of a comprehensive set of outcome data, and the fact that the nonprocedural aspects of care (i.e., PERT function) were similar between the two groups. However, there are several limitations of this study. First, its retrospective nature is an inherent limitation. Second, the study was conducted at a single institution, potentially limiting the generalizability of the results to other institutions with different PERT policies and availability of specialties that can perform catheter-based therapies. It is also important to acknowledge that variations in operator experience within the IR or VS services were not accounted for; specifically, data regarding the number of unique operators within each service and their years of experience were not collected. Furthermore, the study was modest in size, which could preclude the detection of small-to-moderate differences. In addition, there was no interventional cardiology (IC) arm included in the study, as this specialty does not perform this procedure within the institutional PERT, which may limit generalizability to teams in which IC performs a significant amount of MT for PE. This is notable, as there are institutional PERTs in which IC will perform a significant number of MTs for PE. Finally, a detailed description of procedural complications (e.g., at what point during the procedure the complication occurred) is unavailable, as data were limited to what was recorded in the REDCap database.

Conclusion

Our findings suggest that IR and VS physicians can provide substantially equivalent outcomes in the delivery of MT in institutions that utilize a PERT. Sharing call responsibilities between IR and VS within the BJH PERT does not compromise patient outcomes, but instead allows both services to share on-call time for emergent PE thrombectomy. Models that include multispecialty participation in MT delivery are reasonable to consider in other institutions looking to implement a PERT or to increase physician participation in an existing PERT. Further research is needed to confirm these findings in larger, multicenter cohorts and to explore additional strategies for optimizing PERTs, incorporating new ways of multidisciplinary collaboration, and improving overall PE care.

Footnotes

Acknowledgements

An editorial by Sreepathy et al.¹⁶ accompanies this article.

Declaration of conflicting interests

The authors disclosed the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Maanasi Samant is a consultant for Bayer Healthcare Pharmaceuticals, Johnson and Johnson, and United Therapeutics. Westley Ohman is a consultant for Cook Medical, Globus Medical, and Terumo Cardiovascular Systems. Nathan Droz is a consultant for Penumbra. Pavan Kavali is a consultant for AngioDynamics, Penumbra, and Surmodics and reports participation on the Data and Safety Monitoring Board for Advarra and Nanobiotics. The remaining authors have no conflicting interests.

Funding

This project was supported by the Mallinckrodt Institute of Radiology Summer Research Program.

ORCID iDs

Ryan Nolan

Suresh Vedantham

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