Table 3.

Summary of guidance statements

Question	Guidance statement
(1) What are the major goals of thrombolytic therapy for DVT and PE?	The goals of thrombolytic therapy are to reduce thrombus burden and (a) for massive and submassive PE, to reduce mortality and recurrent PE, relieve symptoms, prevent CTEPH, preserve functional capacity, and improve quality of life; and (b) for acute iliofemoral DVT, to relieve symptoms, prevent PTS, improve quality of life, and in selected patients save life, limb, or organ
(2a) What are the risk stratification criteria for thrombolytic therapy for PE?	For adults, we suggest use of an integrated risk stratification algorithm that incorporates the clinical presentation with cardiac biomarkers, chest CT, and echocardiography (Fig. 1) to guide decisions on escalation to thrombolytic therapy, surgical embolectomy, or caval filter placement. In children, because prognostic factors for acute and long-term PE outcomes are not well-established and limited clinical trial data are available, we suggest that decision-making be based on individualized risk-benefit considerations and patient age, and that future prospective studies be conducted to inform future pediatric care
(2b) What are the risk stratification criteria for thrombolytic therapy for DVT?	Decisions on use of thrombolytic therapy for acute DVT must be highly individualized to patient circumstances. For the selection of symptomatic lower extremity acute proximal DVT patients for whom the benefits of thrombolysis are most likely to outweigh the risks, we suggest use of the risk stratification algorithm presented in Fig. 2
(3a) Is systemic thrombolytic therapy recommended for PE?	Systemic thrombolysis is a reasonable consideration for selected patients with acute PE who are hemodynamically unstable (massive PE) or who have evidence of RV dysfunction (submassive PE), and who do not have contraindications to the use of thrombolytic drugs. The benefit to risk ratio may be more favorable for patients with massive PE. For submassive PE, the decision to use systemic thrombolysis should be made on an individual patient basis, with careful consideration of the patient’s age, co-morbidities, severity of RV dysfunction, degree of biomarker elevation, respiratory status, bleeding risk, and likelihood of clinical deterioration based upon his/her observed clinical course
(3b) Is systemic thrombolytic therapy recommended for DVT?	Systemic thrombolysis is not recommended for DVT therapy
(4a) When and what types of catheter-directed thrombolysis are recommended for PE?	CDT may be reasonable to employ in centers with the available expertise for patients with acute PE who are hemodynamically unstable (massive PE) or who have evidence of right ventricular dysfunction (submassive PE), and who do not have contraindications to the use of thrombolytic drugs. CDT may enable the use of lower doses of thrombolytic drug than systemic thrombolysis. For patients with contraindications to thrombolytic drugs, either surgical thrombectomy or CDT may be considered, depending on the specific nature of the contraindication, the availability of local endovascular or surgical expertise, and the ability to rapidly activate the applicable procedure team
(4b) When and what types of catheter-directed thrombolysis are recommended for DVT?	When acute DVT is treated, the use of pharmacomechanical CDT is suggested over the use of infusion-only CDT since it is likely to reduce treatment time and thrombolytic dose. When rt-PA is used, weight-based administration of 0.01 mg/kg/hr, not to exceed 1.0 mg/hr, is recommended. The use of stand-alone PMT is strongly discouraged unless a patient with clinically severe DVT is felt to absolutely require therapy and fibrinolytic drugs cannot be given
(5) How can safety during thrombolytic infusions be optimized?	Safety during thrombolytic infusions can be optimized with rigorous patient selection, use of ultrasound guidance for venous punctures, and close patient monitoring.
(6) When should IVC filters be used with thrombolytic therapy?	The routine placement of IVC filters before infusion CDT is not recommended. Placement of a retrievable filter may be reasonable for patients at particularly high risk of major morbidity due to clinical PE during CDT, such as patients with poor cardiopulmonary reserve, especially if single-session PCDT or stand-alone PMT without pharmacologic CDT is being employed. Once thrombolysis is completed, IVC filters should ideally be removed as soon as the period of major PE risk has passed
(7) When should surgical embolectomy be considered?	Comparative data are limited, and it is not currently possible to make firm conclusions about when and in which patients embolectomy should be performed. Based on the limited data and if local surgical expertise is available, it is suggested that embolectomy be considered for massive or submassive PE patients who fail or cannot receive systemic thrombolysis but who have not suffered a cardiac arrest, especially if intra-cardiac thrombus (“in transit”) is present