Evolution of advanced revascularization strategies for high-risk pulmonary embolism: a physiology-guided single-center experience

Management of pulmonary embolism (PE) has evolved substantially over the past several decades, yet optimal integration of emerging therapies remains challenging. This Perspective describes our 4 decade, single-center experience reflecting the transition from systemic thrombolysis to catheter-directed therapies (CDT) and, more recently, large bore mechanical thrombectomy supported by interventional cardiology with ECMO back-up. Our approach has increasingly focused on physiologic assessment including right ventricular function, pulmonary artery pressures, and cardiac output in the face of the patient's age, underlying cardiopulmonary disease and presence of proximal deep vein thrombosis. This evolution has been characterized by progressive adoption of CDT, reassessment, and refinement of therapies in response to both clinical experience, emerging evidence and participation in clinical trials. The development of a pulmonary embolism response team (PERT) and more recently integration of artificial intelligence detection systems have further improved early recognition of intermediate and high-risk PE cases and coordination of care. Our experience over four decades highlights key lessons and the importance of early physiologic recognition of severity, selective use of reperfusion therapies, and the critical role of a dedicated multidisciplinary system of care.