1. Date of download: 6/21/2016 Copyright © The American College of Cardiology. All rights reserved. From: Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach J Am Coll Cardiol. 2016;67(8):991-1002. doi:10.1016/j.jacc.2015.12.024 PERT Protocol Example of an intensive PE management pathway utilizing a single phone call to the PE team leader. Further review with PERT members can occur while the patient is transferred to the critical care unit, interventional laboratory, or operating room. Adapted with permission from Bloomer et al. (6). CT = computed tomography; PE = pulmonary embolism; PERT = pulmonary embolism response team. Figure Legend:

2. Date of download: 6/21/2016 Copyright © The American College of Cardiology. All rights reserved. From: Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach J Am Coll Cardiol. 2016;67(8):991-1002. doi:10.1016/j.jacc.2015.12.024 ER PE Protocol Utilizing PERT Consultation and sPESI Score ∗ Simplified pulmonary embolism severity index (sPESI) score = 1 point for age >80 years, cancer, chronic heart failure or chronic pulmonary disease, heart rate >110 beats/min, SBP <100 mm Hg, or O2 saturation <90%. Adapted with permission from Bloomer et al. (6). Echo = echocardiography; ER = emergency room; IV = intravenous; PE = pulmonary embolism; PERT = pulmonary embolism response team; RV = right ventricular; SBP = systolic blood pressure. Figure Legend:

3. Date of download: 6/21/2016 Copyright © The American College of Cardiology. All rights reserved. From: Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach J Am Coll Cardiol. 2016;67(8):991-1002. doi:10.1016/j.jacc.2015.12.024 AngioVac Device (A) AngioVac cannula. (B) Diagram of AngioVac insertion and reinfusion circuit. The cannula has been inserted into the right internal jugular vein. Blood and thrombus is aspirated through the filter canister, allowing clot capture utilizing a centrifugal pump canister, prior to return of blood to the patient via the reinfusion cannula placed into the femoral vein. (C) Example of thrombus captured in the filter canister. Figure Legend:

4. Date of download: 6/21/2016 Copyright © The American College of Cardiology. All rights reserved. From: Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach J Am Coll Cardiol. 2016;67(8):991-1002. doi:10.1016/j.jacc.2015.12.024 FlowTriever Device (A) The flow restoration catheter (FRC) is used to enmesh clots and is pulled through the aspiration guide catheter (AGC) utilizing (B) the retraction aspirator device (RAD). Figure Legend:

5. Date of download: 6/21/2016 Copyright © The American College of Cardiology. All rights reserved. From: Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach J Am Coll Cardiol. 2016;67(8):991-1002. doi:10.1016/j.jacc.2015.12.024 Penumbra Indigo Aspiration System (A) The 6- to 8-F straight or angled aspiration catheter (CAT6 or CAT8, respectively) is advanced to the thrombus and aspiration performed with the (B) ACER pump. Separator wires may be inserted into the catheter and utilized in a gentle back-and-forth motion to clear the catheter of thrombus. Figure Legend:

6. Date of download: 6/21/2016 Copyright © The American College of Cardiology. All rights reserved. From: Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach J Am Coll Cardiol. 2016;67(8):991-1002. doi:10.1016/j.jacc.2015.12.024 Example of a PE Treated With CDF (A and B) CT angiogram of a patient with acute submassive PE, with thrombi seen in bilateral main PAs extending into the lower branches (yellow arrows). (C) Pulmonary angiography of the same patient, demonstrating hand injection of contrast into the lower left PA branches, with thrombus noted by the orange arrow. (D) Infusion catheters noted in both PAs. Manual injection of contrast agent performed through the left catheter (orange arrows), documenting that the catheter is imbedded in the clot. Note EkoSonic catheter markers in the right PA (red arrow). CDF = catheter-directed fibrinolysis; CT = computed tomography; PA = pulmonary artery; PE = pulmonary embolism. Figure Legend:

7. Date of download: 6/21/2016 Copyright © The American College of Cardiology. All rights reserved. From: Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach J Am Coll Cardiol. 2016;67(8):991-1002. doi:10.1016/j.jacc.2015.12.024 EkoSonic Endovascular Device The 5.2-F infusion catheter (A), which contains 3 lumens: 1 each for the inner ultrasound cable, drug infusion, and normal saline as a coolant. The inner cable (B) is shown with ultrasound crystals (arrows). Ultrasound energy separates fibrin strands, allowing for enhanced thrombus penetration of fibrinolytic agent. Figure Legend: