Hemodynamic and Respiratory Instability During Percutaneous Pulmonary Thrombectomy in Pulmonary Embolism: Mechanisms, Timing, and Clinical Impact

Pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality worldwide and represents the third leading cause of cardiovascular death. Patients with high-risk or intermediate-high-risk PE may develop significant hemodynamic compromise due to acute right ventricular overload and impaired pulmonary circulation. While anticoagulation remains the cornerstone of treatment, reperfusion therapies are recommended in selected patients, including systemic thrombolysis, catheter-directed therapies, and surgical embolectomy.

Percutaneous pulmonary thrombectomy has emerged as an increasingly used reperfusion strategy, particularly in patients with contraindications to thrombolysis or in whom rapid hemodynamic improvement is required. Despite its growing use, the intraprocedural course of these patients is not fully understood. During thrombectomy, mechanical manipulation within the pulmonary arteries, transient increases in pulmonary vascular resistance, and the effects of anesthesia and positive pressure ventilation may contribute to hemodynamic and respiratory instability. These complications may manifest as hypotension, shock, hypoxemia, need for vasopressor support, endotracheal intubation, cardiopulmonary resuscitation, or the requirement for extracorporeal membrane oxygenation (ECMO).

Currently, there is limited evidence regarding the incidence, timing, and underlying mechanisms of intraprocedural hemodynamic and respiratory deterioration during percutaneous pulmonary thrombectomy. In addition, the potential influence of procedural factors, such as the type of thrombectomy device used, has not been fully elucidated. The FlowTriever® (Inari Medical) and Indigo® (Penumbra) systems are among the most commonly used devices, yet comparative data regarding their safety profiles in terms of intraprocedural instability are scarce.

Furthermore, biomarkers reflecting right ventricular strain, such as N-terminal pro-B-type natriuretic peptide (NT-proBNP), may provide prognostic information in acute PE. However, their role in predicting intraprocedural instability during thrombectomy remains unclear and warrants further investigation.

This prospective observational study aims to comprehensively evaluate the incidence, causes, and timing of hemodynamic and/or respiratory instability during percutaneous pulmonary thrombectomy in patients with high-risk or intermediate-high-risk PE. The primary outcome is a composite of intraprocedural events including significant hypotension, escalation of vasopressor support, need for mechanical ventilation or intubation, cardiopulmonary resuscitation, and/or initiation of ECMO. The temporal relationship between instability and different procedural phases will also be analyzed.