Could thrombolysis for acute pulmonary embolism become safer and more personalised in the ICU?

A recent single-centre randomised feasibility trial explored ClotPro-guided, low-dose, prolonged systemic thrombolysis for high- and intermediate-high-risk acute pulmonary embolism patients in the ICU.

Instead of giving every patient the standard 100 mg rtPA over 2 hours, the viscoelastometry-guided group received an individualised infusion adjusted according to real-time coagulation and fibrinolysis results, alongside repeated echocardiography to monitor right ventricular recovery.

The results are encouraging:

✅ Median rtPA dose was reduced to 32 mg

 ✅ Protocol adherence for viscoelastic testing was 95%

 ✅ Right ventricular dysfunction resolved in all patients in the guided group

 ✅ Severe thrombolysis-induced coagulopathy appeared reduced

 ✅ Fibrinogen supplementation could be targeted when needed

 ✅ Coagulation recovery after stopping thrombolysis appeared faster than with standard dosing

For ICU patients, this approach may offer a major advantage: effective reperfusion while preserving haemostatic reserve. That is especially important in patients at high bleeding risk, where standard thrombolysis can be difficult to justify.

The study also highlights the value of specific ClotPro assays:

ECA test: the most sensitive assay for detecting tPA-related fibrinolytic activity, helping clinicians identify excessive or residual fibrinolysis in real time.

TPA test: useful for assessing whether the patient’s clotting system is responsive to tPA and for excluding fibrinolysis resistance.

This points toward an important future direction: precision-guided thrombolysis rather than fixed-dose thrombolysis.A promising step for safer, more individualised PE management in critical care. #clotpro #multiclot

read the article here: https://link.springer.com/article/10.1186/s40635-026-00903-7