In a registry of 488 unstable patients reported in Chest who underwent thrombolysis for pulmonary embolism, 8.2% failed treatment, as evidenced by persistent hemodynamic instability and echocardiographically defined right ventricular dysfunction. Those patients were then subjected (not randomly, but at the discretion of their attending physicians) to either surgical thrombectomy or repeat thrombolysis. Outcomes were better in the surgical group (statistically significantly fewer recurrent PEs and a non statistically significant improvement in mortality). 79% of surgically treated patients had an uneventful subsequent hospital course.
The accompanying editorial points out that although high level studies are lacking, this report, adding as it does to the recorded experience in treating such patients, provides some practical lessons. Surgical rescue is feasible. Clinicians should have contingency plans for failed thrombolysis based on resources available at their respective hospitals.