Barriers to guideline implementation in intermediate- and high-risk Pulmonary Embolism: insights from a real-world cohort study.

Background: Pulmonary embolism (PE) presents significant challenges due to its wide clinical spectrum, associated right ventricular failure, and high mortality rates. Despite guideline recommendations for systemic thrombolysis in high-risk PE, its implementation remains suboptimal due to safety concerns. This study investigates barriers to guideline implementation in treating intermediate- and high-risk PE and assesses catheter-based thrombectomy (CBT) as an alternative treatment.

Methods: A single centre retrospective cohort study analyzed medical records of all PE-diagnoses between January 2022 and June 2023 . Patients with central, lobar, or segmental PE and Pulmonary Embolism Severity Index scores of III - V were included. A subgroup of patients received CBT. Data on patient characteristics, treatment, outcomes, and eligibility for CBT were collected.

Results: Of the 124 intermediate- and high-risk patients, thrombolysis was administered to only 17% of high-risk patients. Within the conventional treatment group, barriers to thrombolysis included contra-indications in 72% of intermediate-risk and 80% of high-risk patients, leaving a significant number eligible for CBT. Additionally, 20% of high-risk PE patients who did not received thrombolysis had no contra-indications and should have been treated with thrombolysis. In-hospital mortality was 50% among high-risk patients. Eleven patients received CBT, with no mortality at 30 days.

Conclusions: Guideline-recommended thrombolysis is underutilized in high-risk PE, due to safety concerns and contra-indications. CBT demonstrates a promising alternative with a favourable safety profile and low mortality rates, highlighting the need for prospective studies. Multidisciplinary approaches, such as Pulmonary Embolism Response Teams, may help to standardize care and to improve outcomes.