In a recent editorial, stakeholders responded to the exclusion of vascular surgical societies from participating in developing updated clinical practice guidelines for the management of acute pulmonary embolism from the American Heart Association (AHA) and the American College of Cardiology (ACC).
The AHA and ACC recently provided updated Clinical Practice Guidelines (CPGs) for the Management of Acute Pulmonary Embolism (PE) in adults.1 They advocated for PE Response Teams (PERTs) to provide multidisciplinary care for acute PE, which include diverse medical and surgical specialties. Despite being mentioned as key stakeholders in PERTs, the AHA/ACC excluded vascular surgical societies from participating in developing their PE guidelines. The Society for Thoracic Surgery was invited but declined.
The AHA/ACC Guidelines feature a new clinical classification scheme titled “Acute Pulmonary Embolism Clinical Categories.” The scheme includes five risk categories — A through E, with E being the highest risk — and several subcategories. The categories build on previous risk schemes by incorporating clinical, hemodynamic and respiratory factors, along with biomarkers and assessment of right ventricular size and function. While the 2021 Chest guideline serves as a focused update on pharmacotherapy,3 the AHA/ACC Guidelines represent a shift toward integrated, severity-stratified, team-based care for acute PE, building on prior guidelines by highlighting new tools such as mechanical thrombectomy devices for precision management. Notably absent from the 2021 Chest guidelines, care delivery by a PERT is given a Class 1 recommendation in the new guidelines, emphasizing multidisciplinary care for patients with acute PE. The PERT collaborative strategy having the highest level of recommendation is not well reflected in the 2026 AHA/ACC Guidelines societal contributions solicited by the AHA and ACC and excludes vascular surgical societies and specialty as key stakeholders who care for and treat patients with acute venous thromboembolism disease.
Also concerning is the disagreement regarding advanced therapies in patients with sub-massive PE noted in other guidelines2,3 compared to patients with a category C PE in the new AHA/ACC Guidelines, where advanced catheter directed therapies are not recommended. Current ongoing randomized trials are underway to further define the indications for intervention in patients with sub-massive PE (Hi-Peitho, PE-tract) and will hopefully address outcomes of CDI compared to anticoagulation alone.
The current uncertainty exhibited across national and international guidelines may be exacerbated by the new AHA/ACC Guidelines, specifically recommendations for instituting CDI for only categories D and E. Selecting patients who will benefit most from CDI is unresolved since there is a notable lack of consensus among different guidelines and providers. The phrasing for class 2B recommendations in the new AHA/ACC Guidelines are open to interpretation, as exemplified by the ambiguous wording of “may/might be reasonable” and “may/might be considered.” Such vague language and conclusions may lead to unnecessary interventions or avoidance of appropriate interventions. While such classification provides a platform for future targeted clinical research and a tool for assessment of quality, it fails to remove uncertainty for CDI treatment by applying indecisive language.
Having uncertainty with CDI treatment for physiologically less severe PE (clinical PE categories B and C), emphasizes the need for additional robust clinical trial data to guide decision making and best treatments for patients. A diverse representation of the different interventional specialties including vascular surgical specialist and the surgical societies in association with the PERT consortium is essential to reflect the landscape of PE care across the United States and the world. Excluding a vital specialty of vascular surgeons who care for and treat patients with acute PE from the current 2026 AHA/ACC Guidelines can lead to a significant misrepresentation of key stakeholders, resulting in delayed referral/consultation by non-interventionalist providers, appropriate patient access to centers with PERT capabilities and lifesaving timely care.
The AHA/ACC Guidelines represent a shift toward integrated, severity-stratified, team-based care for acute PE. Establishing new PE guidelines by seeking opinion from different specialties managing PE patients would have been appropriate. Omission of input in the AHA/ACC Guidelines by surgical specialties, especially vascular surgeons and thoracic surgeons, is perplexing and not in the best interest of optimal patient care. If PE guidelines were published only by surgeons without input from cardiologists, hematologists and pulmonologists, others might consider them to be similarly narrow-sighted and ill-conceived.
The role of vascular surgeons and thoracic surgeons in the innovation of minimally invasive approaches to treat PE is well established for over 50 years when Dr. Greenfield introduced the pulmonary embolectomy catheter and the vena cava filter.4 Vascular surgeons have been leaders in clinical research and have contributed to almost all clinical IDE and NIH-sponsored trials in the interventional management of PE. A recent query of the Medicare database demonstrated 41% of mechanical thrombectomy cases for acute PE were performed by vascular surgeons.5 Excluding key operational stakeholders may lead to lack of nuance in guidelines, poor adoption rates and ultimately lack of cooperation across the interventional spaces in pivotal trial recruitment and administration. In the words of Dr. Mayo, “the needs of the patient come first” — and in the PE realm, this would involve inclusion of the boots on the ground vascular surgeons.
Optimal PE treatment involves a diverse selection of medical and surgical specialties who are well represented in the PERT consortium. A collaborative multispecialty comprised of committed providers with diverse skillsets should be reflected in composing the 2026 AHA/ACC Guidelines given the unique expertise and intellectual perspective vascular surgeons and thoracic surgeons provide and patients with acute PE deserve.
Rabih Chaer is the John J Ricotta Endowed Professor in vascular surgery and chief of the division of vascular surgery at Stonybrook University. Andrea Obi is an associate professor of vascular surgery at University of Michigan health. Charles Ross is a vascular surgeon at Piedmont Medical System. Mark Iafrati is president of the American Venous Forum. Keith Calligaro is president of the Society for Vascular Surgery.
References
- Creager MA, et al 2026AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN guideline for the evaluation and management of acute pulmonary embolism in adults: a report of the American College of Cardiology / American Heart Association Joint Committee on Clinical Practice Guidelines . J Am Coll Cardiol. 2026;10.1016/j.jacc.2025.11.005.
- Zuin M et al. International Clinical Practice Guideline Recommendations for Acute Pulmonary Embolism. Harmony, Dissonance, and Silence. JACC. 2024;84:1561–1577.
- Stevens SM et al. Antithrombotic Therapy for VTE Disease. Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021;160(6):e545-e608
- Greenfield LJ, Kimmell GO, McCurdy WC. Transvenous removal of pulmonary emboli by vacuum-cup catheter technique. J Surg Res 1969;9:347–352.
- https://rbrvs.ama-assn.org/#/ruc-home. Accessed 2/27/2026
