We read the letter by Pampín-Huerta et al regarding our article1 with interest. According to the existing evidence, systemic thrombolysis is the treatment of choice for massive pulmonary embolism (PE). Our series included patients with an absolute contraindication and, under these circumstances, the guidelines recommend 2 alternative options: surgical or percutaneous embolectomy, depending on the experience and facilities in each center. Given that the means for surgical treatment are seldom available, even in our center, which is a major hospital in Madrid, Spain, a percutaneous intervention was performed.
Although there are no absolute contraindications for thrombolysis in critical situations, routine clinical practice demonstrates the opposite to be true. In fact more than 60% of the patients with massive PE do not receive this treatment,2 perhaps because the risk of major bleeding is over 20%, including the 3% risk of intracranial bleeding, and increases exponentially in those patients who are most unstable.3 Thus, although the evidence on transcatheter treatment is limited, at the present time, it is the only valid alternative in patients with massive PE in whom thrombolysis is contraindicated or who are at high risk for bleeding.
Common sense tells us, and different registries demonstrate,4 that 1 fourth or 1 fifth of the in situ systemic dose in the thrombus is associated with a minor bleeding risk; this, added to the fact that the percutaneous approach enables the fragmentation and aspiration of the thrombus, may prove to be vital in cases of central PE.
At the present time, it is unusual for a single physician to assess the indication and decide on the systemic thrombolysis dose in a case of intermediate- to high-risk PE. The current trend in final decision-making concerning thrombolytic, percutaneous, or surgical treatment involves urgent consensus on the part of a multidisciplinary team in which an interventional cardiologist or radiologist plays an important role.5,6
CONFLICTS OF INTERESTA. Sánchez-Recalde is Associate Editor of Revista Española de Cardiología.