High- and intermediate-risk pulmonary embolism in pediatric tertiary care centers in the Netherlands

Background: Pulmonary embolism (PE) response teams are increasingly used in adult care to improve severe PE management. Understanding the epidemiology, treatment, and outcomes of severe PE in children is crucial to assessing the need for pediatric PE response teams in the Netherlands. Objectives: To evaluate the incidence, management, and short-term outcomes of severe PE in Dutch pediatric patients. Methods: This retrospective cohort study included children (0-18 years) diagnosed with high- and intermediate-risk PE between 2012 and 2022 across 6 pediatric tertiary care centers in the Netherlands. Results: Among 172 PE patients, 17 (10%) had high-risk PE and 19 (11%) had intermediate-risk PE. The annual PE incidence was estimated at 1.0 case per million children, predominantly affecting adolescents. Common symptoms included dyspnea (90%) and tachypnea (75%). Major risk factors were oral contraceptive use (57%) and congenital thrombophilia (39%). In the high-risk group, 100% underwent reperfusion therapy, including systemic thrombolysis (n = 13), surgical thrombectomy (n = 3), and catheter-directed therapy (CDT; n = 1). Four systemic thrombolysis failures required further intervention (3 CDT and 1 surgical thrombectomy). Major bleeding occurred in 2 patients (12%), and 2 (12%) suffered PE-related deaths. Among intermediate-risk patients, 42% received reperfusion therapy (7 systemic thrombolysis and 1 CDT), with major bleeding in 2 (11%) and no deaths. Postdischarge treatment included low-molecular-weight heparin (n = 10), vitamin K antagonists (n = 7), and direct oral anticoagulants (n = 17). Conclusion: Severe PE is rare in Dutch children. The variation in indications and reperfusion strategies highlights the need for national, multidisciplinary care pathways to standardize management and improve outcomes.