Rethinking Pulmonary Embolism Therapy in Hip Fracture Patients

To the editor:

We read with great interest the article by Atzmon et al, ¹ in which the authors examined the impact of pulmonary embolism (PE) in patients who had previously sustained a femoral neck fracture, reporting a 5-year mortality rate of 87%, compared with 59.7% among patients who did not experience PE. In the contemporary series by Lin et al, ² 3-month mortality following postoperative PE after hip fracture surgery reached 28.6%, underscoring the prognostic magnitude of this complication.

According to the European Society of Cardiology (ESC) guidelines, ³ the therapeutic management of PE is based on risk stratification using clinical, biochemical, and imaging parameters, allowing classification into low, intermediate-low, intermediate-high (IHR), and high-risk (HR) categories. Thus, IHR patients may be managed with anticoagulation, whereas HR patients are candidates for systemic fibrinolysis.

However, bleeding at the surgical site may limit the use of anticoagulation, and recent major orthopedic surgery—such as hip fracture repair—constitutes an absolute contraindication to systemic fibrinolysis. ³ In this context, catheter-directed interventions, particularly mechanical thrombectomy, play a key role as they avoid the use of fibrinolytic agents.

Evidence from prospective registries such as FLASH has shown a 30-day mortality below 1% ⁴ and less than 5% at 6 months in patients with intermediate-risk PE treated with mechanical thrombectomy, with sustained improvement in right ventricular function. Likewise, the FLAME study reported an in-hospital mortality rate under 2% in patients with high-risk PE. ⁵ Although these are non-randomized data, they support percutaneous mechanical thrombectomy as an effective and safe reperfusion strategy when fibrinolysis is contraindicated.

In this scenario, close collaboration between Traumatology and Cardiology specialists is essential. A joint assessment would allow integration of thromboembolic risk stratification with postoperative bleeding risk evaluation, optimizing patient selection for catheter-directed therapies and subsequent follow-up. In this regard, emerging risk scores such as RISA-PE, ⁶ which provide greater prognostic granularity, may help refine clinical decision-making. Furthermore, the implementation of multidisciplinary Pulmonary Embolism Response Teams could further enhance clinical outcomes.

In conclusion, the findings of Atzmon and colleagues highlight the prognostic significance of postoperative PE in hip fracture surgery. Mechanical thrombectomy emerges as a promising therapeutic alternative when fibrinolysis is not feasible. Promoting standardized management and follow-up protocols could contribute to reducing both short- and long-term mortality.

In light of the above, we would kindly ask the authors to clarify the following specific aspects:

• We would be interested to know whether PE risk stratification following ESC recommendations was available for these patients.

• Were any catheter-directed interventions considered or used in the management of PE?

• International guidelines (such as NICE ⁷ and AAOS ⁸ ) recommend initiating pharmacological thromboprophylaxis prior to surgery unless the procedure is expected within 12 hours. We would be interested to know the rationale for preferring non-pharmacological measures in this context.