Massive pulmonary embolism

Last revised by Liz Silverstone on 15 Oct 2023

A massive pulmonary embolism (PE) represents the most severe manifestation of venous thromboembolic disease and causes acute right ventricular outflow obstruction which can be fatal. The source is sometimes a clinically silent free-floating lower limb thrombus originating from the soleal intramuscular venous sinuses 9.

Massive PE is usually characterized by an acute pulmonary embolism accompanied by one or more of the following 1,6

  • sustained systemic hypotension (systolic blood pressure <90 mmHg) for at least 15 minutes or which requires inotropic support

  • pulselessness

  • persistent and profound bradycardia

    • defined by the presence of a heart rate <40 bpm associated with signs of end-organ hypoperfusion

Massive pulmonary embolism carries a high mortality rate despite advances in diagnosis and therapy.

Reversal of the associated hypotension and hypoxia with supplemental oxygen and inotropes/vasopressors should be performed to prevent circulatory collapse. As with other forms of venous thromboembolism, anticoagulation is usually initiated 8.

Intravenous administration of systemic thrombolytics, such as recombinant tissue type plasminogen activator (rtPA), may be considered. Systemic administration may be preferable to catheter-directed thrombolysis, although this remains controversial. Thrombolytic administration may reduce the clot burden, resulting in an improvement in hemodynamics; however, there is an attendant risk of major arterial bleeding. Absolute contraindications to systemic thrombolytic administration include the following: 7

  • structural intracranial lesions

  • history of intracranial hemorrhage

  • recent (within 3 months) ischemic stroke

  • active bleeding

  • presence of a bleeding diathesis

  • recent spine or brain surgery

  • recent traumatic brain injury

Failure of systemic thrombolytics to resolve hemodynamic instability may warrant surgical or catheter-assisted embolectomy. These may also be considered when thrombolytic administration is contraindicated due to an unacceptably high risk of bleeding.

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Cases and figures

  • Case 1: probable massive pulmonary embolism
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  • Case 2: with watershed cerebral infarction on top
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