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

Table 2 Expected complications of catheter-based therapies for acute pulmonary embolism

Complication	Approximate frequency	Likely mechanism/trigger	Practical management
Acute hemodynamic decompensation (sudden hypotension/collapse)	Uncommon	Distal embolization after clot fragmentation increasing pulmonary vascular resistance; RV strain from prolonged catheter manipulation; arrhythmia or acute RV failure during intervention	Escalate vasopressors/inotropes; terminate or simplify catheter maneuvers; consider rescue thrombolysis if appropriate; mechanical support (e.g., VA-ECMO) when refractory
Mechanical injury to the tricuspid valve	Uncommon	Inadvertent aggressive valve crossing or repeated catheter passes causing acute tricuspid regurgitation or leaflet/chordal damage	Remove/withdraw catheter; echocardiographic evaluation; cardiac surgical consultation if severe structural injury
Cardiac perforation with pericardial tamponade	Rare	Guidewire or catheter perforation (RA/RV) during manipulation	Immediate pericardiocentesis; hemodynamic stabilization; surgical repair if persistent bleeding
Hemoptysis/pulmonary hemorrhage	Uncommon	Pulmonary artery branch injury (wire perforation or catheter trauma); reperfusion injury after rapid flow restoration; thrombolysis-related bleeding	Airway protection and ventilatory support (selective intubation if needed); stop/limit thrombolytics; reverse anticoagulation when required; endovascular measures (balloon tamponade, selective coiling) in focal injury
Pulmonary artery dissection (large branch)	Rare	Excessive catheter torque, stiff wire trauma, or device advancement in tortuous anatomy	Often conservative monitoring if stable; balloon angioplasty if flow-limiting; CTA follow-up when indicated
Systemic (paradoxical) embolization	Rare	Embolus passage through intracardiac shunt (e.g., PFO) or other right-to-left communication	Treat based on embolic territory (stroke/limb/visceral); multidisciplinary management; consider evaluation for shunt closure after stabilization
Non-pulmonary major bleeding	Uncommon	Thrombolytic exposure (CDT/USAT), excessive anticoagulation, or access-site bleeding	Stop thrombolysis; reverse heparin if necessary; manage bleeding source specifically (GI, GU, retroperitoneal, etc.)
Hemolysis and bradyarrhythmias (device-related)	Uncommon (device-dependent)	Mainly described with rheolytic systems (e.g., AngioJet): Hemolysis-mediated release of vasoactive mediators	Limit activation time; monitor rhythm closely; treat bradycardia/AV block; discontinue device if instability occurs
Vascular access complications (hematoma, pseudoaneurysm, venous injury)	Uncommon	Large-bore sheaths (especially thrombectomy platforms), inadequate ultrasound guidance, prolonged procedure	Ultrasound-guided access; closure/pressure; transfusion if needed; vascular surgery/interventional radiology when severe
Contrast-associated acute kidney injury	Uncommon	High contrast volume in unstable patients or baseline CKD	Minimize contrast; hydration if feasible; avoid nephrotoxins; monitor creatinine

RV: Right ventricle; RA: Right atrium; PFO: Patent foramen ovale; CDT: Catheter-directed thrombolysis; USAT: Ultrasound-assisted thrombolysis; CKD: Chronic kidney disease; VA-ECMO: Venoarterial extracorporeal membrane oxygenation; CTA: Computed tomography angiography; GI: Gastrointestinal; GU: Genitourinary; AV: Atrioventricular.