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Management of Acute Pulmonary Embolism

Variant: 1   Adult. Extensive acute bilateral central pulmonary emboli. Sustained hypotension for more than 15 minutes. Initial therapy.
Procedure Appropriateness Category
Anticoagulation Usually Appropriate
Systemic thrombolysis Usually Appropriate
Catheter-directed therapy pulmonary artery Usually Appropriate
Surgical embolectomy pulmonary artery Usually Appropriate
Extracorporeal membrane oxygenation May Be Appropriate

Variant: 2   Adult. Acute bilateral pulmonary emboli. RV/LV ratio greater than 0.9 on CTA. Evidence of right heart strain on echocardiogram. Elevated troponin level. No hypotension. Initial therapy.
Procedure Appropriateness Category
Anticoagulation Usually Appropriate
Catheter-directed therapy pulmonary artery Usually Appropriate
Surgical embolectomy pulmonary artery May Be Appropriate (Disagreement)
Systemic thrombolysis Usually Not Appropriate
Extracorporeal membrane oxygenation Usually Not Appropriate

Variant: 3   Adult. Acute bilateral pulmonary emboli. RV/LV ratio less than 0.9 on CTA. No right heart strain on echocardiogram. Normal troponin level. No hypotension. Initial therapy.
Procedure Appropriateness Category
Anticoagulation Usually Appropriate
Catheter-directed therapy pulmonary artery Usually Not Appropriate
Extracorporeal membrane oxygenation Usually Not Appropriate
Surgical embolectomy pulmonary artery Usually Not Appropriate
Systemic thrombolysis Usually Not Appropriate

Variant: 4   Adult. Acute saddle pulmonary embolism. Normal RV/LV ratio on CTA. Normal troponin level. No hypotension. Initial therapy.
Procedure Appropriateness Category
Anticoagulation Usually Appropriate
Catheter-directed therapy pulmonary artery Usually Not Appropriate
Systemic thrombolysis Usually Not Appropriate
Extracorporeal membrane oxygenation Usually Not Appropriate
Surgical embolectomy pulmonary artery Usually Not Appropriate

Variant: 5   Adult. Acute bilateral central pulmonary emboli. Evidence of right heart failure on echocardiogram. Sustained a syncopal event with head trauma and acute intracranial hemorrhage. Initial therapy.
Procedure Appropriateness Category
Catheter-directed therapy pulmonary artery Usually Appropriate
Extracorporeal membrane oxygenation May Be Appropriate
Surgical embolectomy pulmonary artery May Be Appropriate (Disagreement)
Anticoagulation May Be Appropriate
Systemic thrombolysis Usually Not Appropriate

Variant: 6   Adult. Acute thromboembolism in transit. Thrombus in the right atrium. Sustained hypotension for more than 15 minutes. Initial therapy.
Procedure Appropriateness Category
Anticoagulation Usually Appropriate
Catheter-directed therapy right heart Usually Appropriate
Surgical embolectomy right heart Usually Appropriate
Systemic thrombolysis May Be Appropriate
Extracorporeal membrane oxygenation May Be Appropriate

Panel Members
Sara Plett, MDa; Nicholas Fidelman, MDb; Mikhail C.S.S. Higgins, MD, MPHc; Resmi Charalel, d; Kavi Devulapalli, MDe; Sanjeeva P. Kalva, f; Brent Keeling, MDg; Christopher S. King, MDh; Yilun Koethe, MDi; Sharon W. Kwan, MD, MSj; Alexander Lam, MDk; Rajeev Suri, MD, MBAl; Ricky T. Tong, MD, PhDm; Jason W. Pinchot, MDn.
Summary of Literature Review
Introduction/Background
Initial Therapy Definition
Discussion of Procedures by Variant
Variant 1: Adult. Extensive acute bilateral central pulmonary emboli. Sustained hypotension for more than 15 minutes. Initial therapy.
Variant 1: Adult. Extensive acute bilateral central pulmonary emboli. Sustained hypotension for more than 15 minutes. Initial therapy.
A. Anticoagulation
Variant 1: Adult. Extensive acute bilateral central pulmonary emboli. Sustained hypotension for more than 15 minutes. Initial therapy.
B. Catheter-directed therapy pulmonary artery
Variant 1: Adult. Extensive acute bilateral central pulmonary emboli. Sustained hypotension for more than 15 minutes. Initial therapy.
C. Extracorporeal membrane oxygenation
Variant 1: Adult. Extensive acute bilateral central pulmonary emboli. Sustained hypotension for more than 15 minutes. Initial therapy.
D. Surgical embolectomy pulmonary artery
Variant 1: Adult. Extensive acute bilateral central pulmonary emboli. Sustained hypotension for more than 15 minutes. Initial therapy.
E. Systemic thrombolysis
Variant 2: Adult. Acute bilateral pulmonary emboli. RV/LV ratio greater than 0.9 on CTA. Evidence of right heart strain on echocardiogram. Elevated troponin level. No hypotension. Initial therapy.
Variant 2: Adult. Acute bilateral pulmonary emboli. RV/LV ratio greater than 0.9 on CTA. Evidence of right heart strain on echocardiogram. Elevated troponin level. No hypotension. Initial therapy.
A. Anticoagulation
Variant 2: Adult. Acute bilateral pulmonary emboli. RV/LV ratio greater than 0.9 on CTA. Evidence of right heart strain on echocardiogram. Elevated troponin level. No hypotension. Initial therapy.
B. Catheter-directed therapy pulmonary artery
Variant 2: Adult. Acute bilateral pulmonary emboli. RV/LV ratio greater than 0.9 on CTA. Evidence of right heart strain on echocardiogram. Elevated troponin level. No hypotension. Initial therapy.
C. Extracorporeal membrane oxygenation
Variant 2: Adult. Acute bilateral pulmonary emboli. RV/LV ratio greater than 0.9 on CTA. Evidence of right heart strain on echocardiogram. Elevated troponin level. No hypotension. Initial therapy.
D. Surgical embolectomy pulmonary artery
Variant 2: Adult. Acute bilateral pulmonary emboli. RV/LV ratio greater than 0.9 on CTA. Evidence of right heart strain on echocardiogram. Elevated troponin level. No hypotension. Initial therapy.
E. Systemic thrombolysis
Variant 3: Adult. Acute bilateral pulmonary emboli. RV/LV ratio less than 0.9 on CTA. No right heart strain on echocardiogram. Normal troponin level. No hypotension. Initial therapy.
Variant 3: Adult. Acute bilateral pulmonary emboli. RV/LV ratio less than 0.9 on CTA. No right heart strain on echocardiogram. Normal troponin level. No hypotension. Initial therapy.
A. Anticoagulation
Variant 3: Adult. Acute bilateral pulmonary emboli. RV/LV ratio less than 0.9 on CTA. No right heart strain on echocardiogram. Normal troponin level. No hypotension. Initial therapy.
B. Catheter-directed therapy pulmonary artery
Variant 3: Adult. Acute bilateral pulmonary emboli. RV/LV ratio less than 0.9 on CTA. No right heart strain on echocardiogram. Normal troponin level. No hypotension. Initial therapy.
C. Extracorporeal membrane oxygenation
Variant 3: Adult. Acute bilateral pulmonary emboli. RV/LV ratio less than 0.9 on CTA. No right heart strain on echocardiogram. Normal troponin level. No hypotension. Initial therapy.
D. Surgical embolectomy pulmonary artery
Variant 3: Adult. Acute bilateral pulmonary emboli. RV/LV ratio less than 0.9 on CTA. No right heart strain on echocardiogram. Normal troponin level. No hypotension. Initial therapy.
E. Systemic thrombolysis
Variant 4: Adult. Acute saddle pulmonary embolism. Normal RV/LV ratio on CTA. Normal troponin level. No hypotension. Initial therapy.
Variant 4: Adult. Acute saddle pulmonary embolism. Normal RV/LV ratio on CTA. Normal troponin level. No hypotension. Initial therapy.
A. Anticoagulation
Variant 4: Adult. Acute saddle pulmonary embolism. Normal RV/LV ratio on CTA. Normal troponin level. No hypotension. Initial therapy.
B. Catheter-directed therapy pulmonary artery
Variant 4: Adult. Acute saddle pulmonary embolism. Normal RV/LV ratio on CTA. Normal troponin level. No hypotension. Initial therapy.
C. Extracorporeal membrane oxygenation
Variant 4: Adult. Acute saddle pulmonary embolism. Normal RV/LV ratio on CTA. Normal troponin level. No hypotension. Initial therapy.
D. Surgical embolectomy pulmonary artery
Variant 4: Adult. Acute saddle pulmonary embolism. Normal RV/LV ratio on CTA. Normal troponin level. No hypotension. Initial therapy.
E. Systemic thrombolysis
Variant 5: Adult. Acute bilateral central pulmonary emboli. Evidence of right heart failure on echocardiogram. Sustained a syncopal event with head trauma and acute intracranial hemorrhage. Initial therapy.
Variant 5: Adult. Acute bilateral central pulmonary emboli. Evidence of right heart failure on echocardiogram. Sustained a syncopal event with head trauma and acute intracranial hemorrhage. Initial therapy.
A. Anticoagulation
Variant 5: Adult. Acute bilateral central pulmonary emboli. Evidence of right heart failure on echocardiogram. Sustained a syncopal event with head trauma and acute intracranial hemorrhage. Initial therapy.
B. Catheter-directed therapy pulmonary artery
Variant 5: Adult. Acute bilateral central pulmonary emboli. Evidence of right heart failure on echocardiogram. Sustained a syncopal event with head trauma and acute intracranial hemorrhage. Initial therapy.
C. Extracorporeal membrane oxygenation
Variant 5: Adult. Acute bilateral central pulmonary emboli. Evidence of right heart failure on echocardiogram. Sustained a syncopal event with head trauma and acute intracranial hemorrhage. Initial therapy.
D. Surgical embolectomy pulmonary artery
Variant 5: Adult. Acute bilateral central pulmonary emboli. Evidence of right heart failure on echocardiogram. Sustained a syncopal event with head trauma and acute intracranial hemorrhage. Initial therapy.
E. Systemic thrombolysis
Variant 6: Adult. Acute thromboembolism in transit. Thrombus in the right atrium. Sustained hypotension for more than 15 minutes. Initial therapy.
Variant 6: Adult. Acute thromboembolism in transit. Thrombus in the right atrium. Sustained hypotension for more than 15 minutes. Initial therapy.
A. Anticoagulation
Variant 6: Adult. Acute thromboembolism in transit. Thrombus in the right atrium. Sustained hypotension for more than 15 minutes. Initial therapy.
B. Catheter-directed therapy right heart
Variant 6: Adult. Acute thromboembolism in transit. Thrombus in the right atrium. Sustained hypotension for more than 15 minutes. Initial therapy.
C. Extracorporeal membrane oxygenation
Variant 6: Adult. Acute thromboembolism in transit. Thrombus in the right atrium. Sustained hypotension for more than 15 minutes. Initial therapy.
D. Surgical embolectomy right heart
Variant 6: Adult. Acute thromboembolism in transit. Thrombus in the right atrium. Sustained hypotension for more than 15 minutes. Initial therapy.
E. Systemic thrombolysis
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
References
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.