From anticoagulation to intervention: The expanding role of percutaneous therapies in pulmonary embolism

Table 1 Contemporary catheter-based options for acute pulmonary embolism

Device/system	Primary mechanism	Key technical characteristics	Typical venous access	PE indication status	Main advantages	Main limitations/risks
Pigtail catheters/peripheral balloon catheters	Mechanical clot disruption (fragmentation ± balloon maceration)	Small profile catheters (historically used); manual rotation over a wire; can be paired with local lytic infusion	Femoral or jugular	Not applicable	Simple, widely available, low cost; may provide rapid partial recanalization as a bridge	Fragmentation can push clot distally and potentially worsen obstruction; largely replaced by dedicated systems
Cragg-McNamara infusion catheter (Medtronic)	CDT	Multi-side-hole infusion catheter; multiple working lengths and infusion segments	Femoral	Yes	Dedicated infusion design; reliable local delivery without need for complex mechanical components	Requires prolonged infusion (commonly 12-24 hours); bleeding risk still present
Fountain infusion catheter (Merit Medical)	CDT	Multi-side-hole infusion system; variable infusion lengths	Femoral	No	Practical and relatively cost-efficient	Less robust PE-specific clinical evidence compared with some alternatives
Uni-Fuse (AngioDynamics)	CDT	Multi-side-hole infusion catheter; multiple infusion segment lengths	Femoral	Yes	Broad and uniform thrombolytic dispersion through side holes	Requires monitored infusion over many hours; bleeding risk persists
Pulse-spray infusion catheter (AngioDynamics)	CDT (pulsed delivery)	Side-hole catheter allowing bolus/pulsed lytic administration; can be used with fragmentation	Femoral	No	Can enhance drug penetration and shorten initial delivery phase	Limited PE-specific outcome data; still requires thrombolytic exposure
Bashir catheter (Thrombolex)	Hybrid: Mechanical clot disruption + local lytic delivery	Expandable basket with multiple micro-infusion points to distribute lytic within thrombus	Femoral	No	Multi-point drug delivery directly inside thrombus; may improve penetration	Limited clinical dataset and adoption; still involves thrombolytic use
EkoSonic (Boston Scientific)	Ultrasound-assisted CDT (USAT)	Dual-lumen catheter: Ultrasound core + thrombolytic infusion lumen; multiple treatment-zone lengths	Femoral or jugular	Yes	Ultrasound energy may loosen fibrin architecture, improving lytic penetration; allows lower-dose/shorter regimens	Higher cost; incremental clinical advantage vs standard CDT remains debated
Aspirex (Becton Dickinson)	Mechanical fragmentation + aspiration	Aspiration catheter designed for thrombus extraction (more often peripheral use)	Femoral	Yes, in European Union, not in United States	Straightforward concept; avoids systemic thrombolysis	May be less effective for organized/older thrombus; PE-specific evidence limited
AngioJet (Boston Scientific)	Rheolytic thrombectomy ± “power pulse” lytic injection	High-pressure saline jets fragment thrombus and create suction (Bernoulli effect); can be combined with local lytic injection	Femoral or jugular	Yes, in European Union; FDA boxed warning for PE	Rapid debulking with option for pharmacomechanical approach	Bradyarrhythmias, hemolysis, hemodynamic instability; safety concerns led to boxed warning in the United States
AngioVac (AngioDynamics)	Aspiration with extracorporeal veno-venous bypass	Large-bore aspiration cannula connected to external filtration and reinfusion circuit; requires perfusion support	Femoral + jugular (dual access)	No	Allows aspiration with reinfusion and limited net blood loss; useful for RA/IVC thrombus	Not designed for pulmonary artery thrombectomy; requires perfusion team; limited role in acute PE
AlphaVac (AngioDynamics)	Large-bore aspiration without extracorporeal support	Manual aspiration system; no bypass circuit; deliverable cannula with multiple configurations	Femoral or jugular	No	Avoids perfusion team; less complex than AngioVac	Clinical experience still limited; not established for chronic PE
FlowTriever (Inari Medical)	Large-bore aspiration ± mechanical extraction	Large aspiration catheters; nitinol mesh discs for clot engagement; optional blood filtration/reinfusion (FlowSaver)	Femoral or jugular	Yes	Effective for high clot burden; avoids thrombolytics; strong prospective trial and registry evidence	Large and relatively stiff system can limit distal branch reach; requires operator experience
Indigo aspiration system (Penumbra)	Aspiration + mechanical thrombus disruption	Continuous suction pump + separator wire; smaller, more flexible catheters; optional Lightning Suction-Control Technology	Femoral or jugular	Yes	Better navigation into distal pulmonary branches; automated suction control may reduce blood loss	No blood reinfusion/filtering; effectiveness may be lower for highly organized clot

CDT: Catheter-directed thrombolysis; USAT: Ultrasound-assisted thrombolysis; FDA: Food and Drug Administration; PE: Pulmonary embolism; RA: Right atrium; IVC: Inferior vena cava.