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High-risk pulmonary embolism with contraindication to thrombolysis — SCE Respiratory MCQ

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HardVenous ThromboembolismHigh-risk pulmonary embolism with contraindication to thrombolysisSCE Respiratory

A 59-year-old man develops sudden hypoxaemia and cardiovascular collapse 8 days after craniotomy for resection of a meningioma. CT pulmonary angiography shows large bilateral central pulmonary emboli. His blood pressure is 78/48 mmHg despite cautious fluid resuscitation, and noradrenaline is required. Serum lactate is 4.6 mmol/L. Echocardiography shows severe right ventricular dilatation and impaired systolic function. The neurosurgical team advises that any thrombolytic treatment carries an unacceptable risk of intracranial haemorrhage, but agrees that intravenous unfractionated heparin can be given with close monitoring. An experienced cardiothoracic team is immediately available and considers him suitable for surgical embolectomy. Percutaneous mechanical thrombectomy is also technically available under the hospital's special governance arrangements, but the patient is not enrolled in a research study. Which definitive reperfusion strategy is most appropriate?

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Correct answer: C — Emergency surgical pulmonary embolectomy

This is high-risk pulmonary embolism: persistent hypotension requiring vasopressor support, raised lactate and severe right ventricular dysfunction demonstrate obstructive shock. Anticoagulation alone is therefore inadequate if an effective reperfusion option is available. Systemic thrombolysis is normally the preferred reperfusion treatment for high-risk PE, but recent intracranial surgery creates a prohibitive haemorrhagic risk. Catheter-directed thrombolysis still administers a fibrinolytic agent and does not remove that decisive contraindication. Surgical pulmonary embolectomy is the best answer because thrombolysis is contraindicated and an experienced surgical team has confirmed that an immediately available, suitable alternative exists. European respiratory guidance supports surgical embolectomy or catheter-directed treatment when thrombolysis is contraindicated, but current NICE guidance adds an important UK discriminator: for high-risk PE, percutaneous thrombectomy may be used with special governance arrangements when thrombolysis and other suitable alternatives are unavailable or have failed. When an alternative such as surgical embolectomy is suitable, percutaneous thrombectomy should be undertaken only in research. This patient is not enrolled in a study. Unfractionated heparin and haemodynamic support remain appropriate adjuncts, but they do not replace urgent reperfusion in established shock.

Reference: Percutaneous thrombectomy for intermediate-risk or high-risk pulmonary embolism: Recommendations (Published 29 November 2023; last reviewed 27 April 2026) — https://www.nice.org.uk/guidance/HTG705/chapter/1-recommendations Percutaneous thrombectomy for intermediate-risk or high-risk pulmonary embolism: The condition, current treatments and procedure (29 November 2023) — https://www.nice.org.uk/guidance/HTG705/chapter/2-the-condition-current-treatments-and-procedure 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (2019) — https://publications.ersnet.org/index.php/content/erj/54/3/1901647