National Coverage Analysis (NCA) View Public Comments

Transvenous (Catheter) Pulmonary Embolectomy

Public Comments

Commenter Comment Information
(NCHR), National Center for Health Research Organization: National Center for Health Research
Date: 09/10/2021
Comment:

We are writing on behalf of the National Center for Health Research (NCHR) to express our views on the discussion paper regarding the proposed change to the National Coverage Determination for transvenous (catheter) pulmonary embolectomy (TPE).

NCHR is a nonprofit think tank that conducts, analyzes, and scrutinizes research on a range of health issues, with particular focus on which prevention strategies and treatments are most effective for which patients and consumers. We do

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Beasley, MD, FSIR, FSCAI, Robert E. Title: Interventional Radiologist
Organization: Mount Sinai Medical Center
Date: 09/09/2021
Comment:

Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Re: Proposed Decision Memo for Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

Dear Ms. Brooks-LaSure:

My name is Dr. Robert Beasley. I am a practicing Interventional Radiologist in Florida, where my team and I have treated hundreds of VTE patients. I support CMS’s decision to retire NCD 240.6 for pulmonary

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Bourgeois, Austin Title: Interventional Radiologist
Organization: Huntsville Hospital
Date: 09/08/2021
Comment:

Administrator Chiquita Brooks-LaSure
The Centers for Medicare & Medicaid Services
7500 Security Blvd
Baltimore, MD 21244

Ms. Brooks-LaSure

Hello, my name Dr. Austin Bourgeois, and I’m a Vascular and Interventional Radiologist at a busy practice in Huntsville, AL. My team sees thousands of patients with various forms of vascular disease annually, and one of the most serious and life-threatening conditions we treat is Pulmonary Embolisms

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Bunte, Matthew Title: Director of Vascular Medicine
Organization: Saint Luke's Mid America Heart Institute
Date: 08/24/2021
Comment:

To Whom It May Concern:

I am a practicing Interventional Cardiologist and a Vascular Medicine Specialist with Saint Luke's Mid America Heart Institute in Kansas City, MO. I serve as Director of Vascular Medicine for Saint Luke’s Physician Group and co-Director of Saint Luke's Hospital Vascular Center of the Saint Luke’s Health System.

Thank you for CMS’s work in reviewing the evidence supporting pulmonary embolectomy. I agree with the analysis of the published data, that

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Cartagena, Sarah Title: Associate Director, Coverage and Research Policy
Organization: American College of Cardiology
Date: 09/09/2021
Comment:

The American College of Cardiology is submitting comments on the proposed decision memo of the national coverage decision (NCD) for Transvenous (Catheter) Pulmonary Embolectomy. The ACC envisions a world where innovation and knowledge optimize cardiovascular care and outcomes. As the professional home for the entire cardiovascular care team, the mission of the College and its more than 54,000 members is to transform cardiovascular care and to improve health. The ACC bestows credentials upon

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Crews, Sean Title: VP of Reimbursement
Organization: Penumbra, Inc.
Date: 08/20/2021
Comment:
We agree with the CMS proposal to remove the National Coverage Determination (NCD) for Transvenous (Catheter) Pulmonary Embolectomy (NCD 240.6), permitting Medicare coverage determinations for Transvenous (Catheter) Pulmonary Embolectomy to be made by Medicare Administrative Contractors (MACs) under §1862(a)(1)(A) of the Social Security Act (the Act).
Crishock, Patricia L Organization: The Society for Vascular Surgery (SVS)
Date: 09/09/2021
Comment:

The Society of Vascular Surgery (SVS) and the American Venous Forum (AVF) are two of the pre-eminent professional societies in the US, representing surgeons and other practitioners who provide vascular care to CMS recipients throughout the country. Our members regularly provide care for patients with pulmonary embolism as well as diseases in other vascular beds throughout the body.

The SVS and AVF submitted comments to CMS in May 2021 advocating removal of the Transvenous

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Elmasri, MD, Fakhir Title: Interventional Radiologist
Organization: Lakeland Vascular Institute
Date: 09/09/2021
Comment:

Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Re: Proposed Decision Memo for Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

Dear Ms. Brooks-LaSure:

My name is Dr. Fakhir Elmasri. I am a practicing Interventional Radiologist in Florida, where my team and I have treated hundreds of VTE patients. I support CMS’s decision to retire NCD 240.6 for pulmonary

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Fernandes, Timothy Title: M.D., M.P.H. Associate Professor of Medicine UCSD
Organization: University of California, San Diego
Date: 09/09/2021
Comment:

CMS Coverage and Analysis Group,

I am a pulmonologist treating patients in San Diego County, CA, and an Associate Professor of Medicine for UCSD. Our care team has saved the lives of patients by performing catheter based pulmonary embolectomy, and I support of your decision to consider pulmonary embolectomy a covered benefit for Medicare beneficiaries. I do believe this is a medically necessary procedure, and that the clinical experts should have the ability to treat their

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Fortuna, MD, Gerald Organization: Washington University Physicians
Date: 09/09/2021
Comment:

Chiquita Brooks-LaSure
Centers for Medicare and Medicaid Services

Dear Ms. Brooks-LaSure,
I agree with CMS’s analysis of the published data that supports pulmonary embolectomy as reasonable and medically necessary, and agree that it should be recognized as a covered physician service for patients suffering from a Pulmonary Embolism (PE).

I fully support CMS’ decision to remove this old NCD, and at the same time, provide a detailed overview of the clinical

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Garg, MD, Karan Title: Associate Professor of Surgery
Organization: New York University Langone Medical Center
Date: 09/09/2021
Comment:

Dear Ms. Brooks-LaSure,

My name is Dr. Karan Garg and I am a vascular surgeon practicing at NYU Langone Medical Center. Thank you for accepting public comments in regard to efforts toward officially retiring NCD 240.6.

Since innovation and advances in this life-saving procedure for the treatment of patients with pulmonary embolism have been clinically significant over the last 38 years since this policy was originally created, I whole-heartedly agree with the proposed

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Giri, Jay Title: Interventional Cardiologist
Organization: University of Pennyslvania
Date: 09/09/2021
Comment:

Chiquita Brooks LaSure, Administrator
Centers for Medicare and Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244

Dear Administrator Brooks LaSure:

I am a practicing Interventional Cardiologist in Philadelphia, and I would like to submit comments supporting the removal of NCD 240.6.

I am the Director of Peripheral Intervention at the Hospital of the University of Pennsylvania and Director of the Cardiovascular Catheterization

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Gonsalves, Carin Title: Doctor
Organization: Thomas Jefferson University Hospitals
Date: 09/08/2021
Comment:

Chiquita Brooks-LaSure
CMS Administrator
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Administrator Brooks-LaSure,

My name is Dr. Carin Gonsalves. I am an Interventional Radiologist at Thomas Jefferson University Hospitals in Philadelphia, PA. I am also the Co-Founder and Co-Director of our Pulmonary Embolism Response Team (PERT). Over the past several years, our PERT physicians have saved the lives

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Henry, MD, MSCAI, Timothy D. Title: President
Organization: Society for Cardiovascular Angiography and Interventions
Date: 08/30/2021
Comment:

August 30, 2021

Chiquita Brooks-LaSure
CMS Administrator
Centers for Medicare and Medicaid Services
Attention C4-26-05
7500 Security Blvd.
Baltimore, MD 21244-8016

Re: Proposed Decision Memo For Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R

Dear Ms. Brooks-LaSure:

SCAI is a non-profit professional association with over 4,500 members representing the majority of practicing interventional cardiologists and cardiac

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Hoffman, Bill Title: CEO
Organization: Inari Medical
Date: 09/10/2021
Comment:

Submitted Electronically September 10th, 2021

The Honorable Chiquita Brooks-LaSure
Administrator
The Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244-8016

RE: “Proposed Decision Memo for Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)”

Dear Administrator Brooks-LaSure,

Inari Medical, Inc. appreciates the opportunity to submit comments in support of CMS’s proposal to retire NCD 240.6 for

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Horowitz MD, James Organization: NYU Langone Hospital
Date: 09/09/2021
Comment:

Dear Ms. Brooks-LaSure,

My name is Dr. James Horowitz and I am a cardiologist at NYU Langone Hospital who, as part of the Pulmonary Embolism Advanced Care team, have extensive experience treating pulmonary embolism.

I agree with the proposed decision memo’s thorough review of the published clinical evidence and agree pulmonary embolectomy is a reasonable and medically necessary service for Medicare beneficiaries.

Thank you.

Sincerely,
James

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Huff, MD, Dr. Christopher M. Title: Interventional Cardiology
Organization: OhioHealth Riverside Methodist Hospital
Date: 09/09/2021
Comment:

Chiquita Brooks-LaSure
CMS Administrator
U.S. Department of Health & Human Services

RE: Proposed Decision Memo for Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

Dear Ms. Brooks-LaSure:

My name is Dr. Chris Huff and I am a board certified Interventional Cardiologist at OhioHealth Riverside Methodist Hospital in Columbus, Ohio. Although I treat a spectrum of cardiovascular diseases, I have a special interest in catheter directed therapy

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Jaber, MD, Dr. Wissam A. Title: Interventional Cardiology
Organization: Emory Healthcare
Date: 09/08/2021
Comment:

Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

RE: Retirement of Medicare NCD 240.6 Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

Dear Administrator Brooks-LaSure:

My name is Dr. Wissam Jaber and I am a practicing Interventional Cardiologist in the state of Georgia. My hospital has treated thousands of patients with DVT and PE, so we know first-hand how

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Jolly, MD, Dr. Michael A. Title: Interventional Cardiology
Organization: OhioHealth Riverside Methodist Hospital
Date: 09/09/2021
Comment:

Chiquita Brooks-LaSure
CMS Administrator
U.S. Department of Health & Human Services
200 Independence Avenue, S.W.
Washington, DC 20201

RE: Proposed Decision Memo for Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

Dear Administrator Brooks-LaSure,

My name is Dr. Michael A. Jolly and I am a practicing Interventional Cardiologist in Columbus, Ohio. My work focuses on complex coronary intervention, acute pulmonary embolism, acute

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Kado, Herman Organization: Beaumont Health System
Date: 09/08/2021
Comment:

Chiquita Brooks-LaSure
CMS Administrator
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Administrator Brooks-LaSure,

My name is Dr. Herman Kado and I’m an Interventional Cardiologist at Beaumont Health in Michigan. Our team has saved hundreds of lives using pulmonary embolectomy as first line therapy to treat patients with a Pulmonary Embolism, and we are thrilled to see CMS finally retiring NCD

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Khalsa, Bhavraj Title: MD
Organization: Vascular and Interventional Specialists of Orange County
Date: 09/09/2021
Comment:

Ms. Chiquita Brooks-LaSure,

My name is Bhavraj Khalsa, and I am a Board-Certified Interventional Radiologist practicing in Orange County, CA. As a disclosure, I do serve as a Consultant and Advisory Board member for medical device companies that manufacture catheters used in pulmonary embolism procedures. I agree with CMS’s review of the data supporting pulmonary embolectomy as both reasonable and medically necessary.

I also agree that pulmonary embolectomy should be

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Khanna M.D., M.S., DABR, Pavan Title: Medical Director of Interventional Radiology
Organization: Dignity Health St. Joseph’s Medical Center
Date: 09/10/2021
Comment:

Administrator Chiquita Brooks-LaSure,

My name is Dr. Pavan Khanna, and I am the Medical Director of the Interventional Radiology Department at Dignity Health St. Joseph’s Medical Center in Stockton, CA. I am encouraged that after considering the advances in medicine during the Coverage and Analysis Group’s review of the evidence supporting pulmonary embolectomy, they have proposed to retire NCD 240.6. I am grateful they are proposing pulmonary embolectomy as a covered defined

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Knox, MD, FACR, Michael Organization: Advanced Radiology Services
Date: 09/08/2021
Comment:

Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244

Proposed Decision Memo for Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

Dear Ms. Brooks-LaSure:

My name is Dr. Michael Knox. I am a practicing Interventional Radiologist in MI, where my team and I have treated thousands of VTE patients. I support CMS’s decision to retire NCD 240.6 for pulmonary

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Lake, Leslie Title: Board Chair
Organization: National Blood Clot Alliance
Date: 08/23/2021
Comment:

Dear Administrator Brooks-LaSure:

My name is Leslie Lake and I’m writing to you as Board Chair of the National Blood Clot Alliance (NBCA) and a survivor of a Pulmonary Embolism (PE). We are submitting comments in support of CMS’s proposed decision to retire NCD 240.6.

The National Blood Clot Alliance (NBCA) is a 501c(3), nonprofit, voluntary health organization dedicated to advancing the prevention, early diagnosis and successful treatment of life-threatening blood

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Leahey, Mark Title: President and CEO
Organization: Medical Device Manufacturers Association
Date: 09/08/2021
Comment:

September 6, 2021

** Via Electronic Submission **

Joseph Hutter, MD, MA, Lead Medical Officer
David Dolan, Lead Analyst
Coverage and Analysis Group
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244

RE: Comment in Support of the Proposed Decision Memorandum—Transvenous (Catheter) Pulmonary Embolectomy [CAG-00457R]

Dear Dr. Hutter

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Li, Jun Title: Medical Director, System-Wide Limb Salvage Program
Organization: University Hospitals Cleveland Medical Center
Date: 09/10/2021
Comment:

Chiquita Brooks-LaSure, Administrator
Centers for Medicare and Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244

Dear Ms. Brooks-LaSure

I hope this finds you well. My name is Dr. Jun Li, and I’m an Interventional Cardiologist with University Hospitals in Ohio. I submitted comments on NCD 240.6 during the National Coverage Analysis (NCA), and I want to thank CMS for finally retiring it and recognize pulmonary embolectomy as a covered physician

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Lindquist, Jonathan Title: MD
Organization: UCHealth
Date: 09/09/2021
Comment:

Ms. Brooks-LaSure,

I am an interventional radiologist in with UCHealth in Aurora, CO specializing in Vascular & Interventional Radiology. I was happy to see that after reviewing the newer FDA cleared devices and published evidence, that CMS is proposing to remove the old NCD 240.6 regarding transvenous (catheter) pulmonary embolectomy.

Due to the complex nature of this disease state, and the vast potential clinical co-morbidities and complications

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Maleki, Ashley Title: Manager of Coding and Reimbursement
Organization: Society of Interventional Radiology
Date: 08/27/2021
Comment:

RE: Request for Expediated Removal of National Coverage Determination (NCD) for Transvenous (Catheter) Pulmonary Embolectomy (240.6)

Dear Ms. Brooks-LaSure:

The Society of Interventional Radiology (SIR) is a nonprofit, professional medical society representing more than 8,000 practicing interventional radiology physicians, trainees, students, scientists and clinical associates, dedicated to improving patient care through the limitless potential of image-guided

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Misono, Alexander Title: M.D., M.B.A., R.P.V.I.
Organization: Hoag Hospitals
Date: 09/09/2021
Comment:

Dear Ms. Brooks-LaSure,

I am a Harvard/Mass General Hospital/Miami Vascular trained board-certified interventional radiologist specializing in Vascular & Interventional Radiology based in California with more than 50 scientific publications. I am writing to provide comment for the proposed decision to remove NCD 240.6 for Transvenous (Catheter) Pulmonary Embolectomy.

Thank you for soliciting feedback on this decision. I anticipate an overwhelming

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Mouawad, Nicolas Title: Chief & Medical Director, Vascular & Endovascular
Organization: McLaren Health Care Bay Region - Heart and Vascular
Date: 09/08/2021
Comment:

Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Administrator Brooks-LaSure,

My name is Dr. Nicolas J. Mouawad, Chief of Vascular & Endovascular Surgery and co-director of the Pulmonary Embolism Response Team at McLaren Health System – Bay Region in Bay City, MI outside of Detroit.

I would like to wholeheartedly affirm CMS’s decision to retire National

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Nakagawa, MD, Dr. Nobuo Title: Vascular & Interventional Radiologist
Organization: Ascension St. Mary's of Michigan Hospital
Date: 09/10/2021
Comment:

Administrator Chiquita Brooks-LaSure
Centers for Medicare and Medicaid Services
U.S. Department of Health and Human Services
200 Independence Avenue
Washington, DC 20201

RE: Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

Dear Ms. Brooks-LaSure:

My name is Dr. Nobuo Nakagawa and I’m a practicing Vascular & Interventional Radiology Specialist with Ascension St. Mary's of Michigan Hospital in MI.

I fully support

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Nukala, Melanie Title: Vascular Surgeon
Organization: BJC Health Care
Date: 09/08/2021
Comment:

Administrator Chiquita Brooks-LaSure
Centers for Medicare and Medicaid Services
Department of Health and Human Services
7500 Security Boulevard
Baltimore, MD 21244

Dear Ms. Brooks-LaSure,

My name is Dr. Melanie Nukala, a practicing Vascular Surgeon outside of St. Louis. I would like to offer comments supporting the retirement of NCD 240.6 for pulmonary embolectomy.

I submitted comments on May 6 2021 regarding this old non-coverage

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Redberg, Rita Title: Professor of Medicine
Organization: Division of Cardiology, Department of Medicine, University of California, San Francisco School of Medicine
Date: 09/09/2021
Comment:

We strongly urge CMS to reconsider its decision to end the non-coverage National Coverage Determination for transvenous (catheter) pulmonary embolectomy and permit decisions by Medicare Administrative Contractors. Our recommendation is based on the fact that there are no published clinical outcome evidence supporting pulmonary embolectomy; we think that the current published evidence suggests pulmonary embolectomy remains an experimental procedure.

In its Proposed Decision Memo,

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Roesch, MD, Dr. Jeffrey M. Title: Interventional Radiologist
Organization: Vista Radiology, P.C.
Date: 09/10/2021
Comment:

Chiquita Brooks-LaSure
CMS Administrator
U.S. Department of Health & Human Services
200 Independence Avenue
Washington, DC 20201

RE: Proposed Decision Memo for Transvenous (Catheter) Pulmonary Embolectomy (CAG-00457R)

Dear Administrator Brooks-LaSure,

My name is Dr. Jeff Roesch, an Interventional Radiologist at Covenant Health in Knoxville, TN, who has treated many Medicare patients suffering from a Pulmonary Embolism. I am submitting

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Rundback MD, John Organization: Advanced Interventional & Vascular Services, LLP
Date: 09/09/2021
Comment:

Dear Ms. Brooks-LaSure,

I agree with the proposed decision memo’s thorough review of the published clinical evidence and support pulmonary embolectomy as a reasonable and medically necessary service for Medicare beneficiaries.

Thank you.

Sincerely,
John Rundback, MD
SAYED, Luay Title: MD
Organization: Troy Beaumont hospital
Date: 08/27/2021
Comment:

Chiquita Brooks-LaSure
Administrator, Centers for Medicare and Medicaid Services
7500 Security Blvd.
Baltimore, MD 21244

Ms. Brooks-LaSure,

My name is Dr. Luay Sayed, and I am an Interventional Cardiologist with Beaumont Health System in Michigan. I’m writing in support of the retirement of NCD 240.6 for Transvenous (Catheter) Pulmonary Embolectomy.

I submitted comments previously requesting the removal of this outdated non-coverage

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Shishehbor, DO, MPH, PhD, Mehdi Title: Interventional Cardiologist
Organization: UH Cleveland Medical Center
Date: 09/09/2021
Comment:

Chiquita Brooks-LaSure
Centers for Medicare and Medicaid Services

Dear Ms. Brooks-LaSure,

My name is Dr. Mehdi Shishehbor and I am submitting comments in support of CMS’s decision to retire NCD 240.6.

I previously submitted comments on the National Coverage Analysis (CAG-00457R) for Transvenous (Catheter) Pulmonary Embolectomy back in May 2021.

The recently proposed decision memo by CMS clearly outlines pulmonary embolectomy is reasonable and

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Silver, Mitchell Title: Dr.
Organization: Society for Vascular Medicine
Date: 09/09/2021
Comment:

Chiquita Brooks-LaSure
CMS Administrator
Centers for Medicare and Medicaid Services
Attention C4-26-05
7500 Security Blvd.
Baltimore, MD 21244-8016
Re: NCD on Transvenous (Catheter) Pulmonary Embolectomy.

Dear Ms. Brooks-LaSure:

The Society for Vascular Medicine (SVM) is a non-profit professional association with over 500 members representing the majority of practicing vascular medicine specialties in the United States. Most of our members

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Toma, Catalin Date: 09/08/2021
Comment:

Chiquita Brooks-LaSure, Administrator
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Ms. Brooks-LaSure

I am an Interventional Cardiologist who has treated thousands of patients with Venous Thromboembolic disease, including PE.

I read CMS’s proposed decision to retire NCD 240.6, and I agree that this antiquated non-coverage policy should be removed. I also agree that these procedures meet the

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Trestman MD, Eric Date: 09/09/2021
Comment:

Chiquita Brooks-LaSure

Centers for Medicare and Medicaid Services

Dear Ms. Brooks-LaSure,

I am a vascular surgeon practicing in the Gulf Coast area of Texas, and was very pleased to learn that based on review of the literature, CMS concluded that pulmonary embolectomy is reasonable and medically necessary, and therefore is a covered physician service for patients suffering from a PE.

As a surgeon who has treated both PE and DVT, clinical experts

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Tullia, Kirsten Title: VP, Payment & Health Care Delivery Policy
Organization: Advanced Medical Technology Association
Date: 09/09/2021
Comment:

RE: Proposed Decision Memorandum to Remove Transvenous (Catheter) Pulmonary Embolectomy National Coverage Determination (NCD) (§240.6)

Dear Ms. Jensen,

The Advanced Medical Technology Association (AdvaMed) is writing to offer the following comments in support of the Centers for Medicare and Medicaid Services’ (CMS) proposed decision to remove the Transvenous (Catheter) Pulmonary Embolectomy National Coverage Determination (NCD) (§ 240.6).

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Waldmann, Daniel Title: EVP, Health Policy and Reimbursement
Organization: Medical Device Manufacturers Association
Date: 09/06/2021
Comment:

Submitted on behalf of Mark Leahey, President and CEO, Medical Device Manufacturers Association

RE: Comment in Support of the Proposed Decision Memorandum—Transvenous (Catheter) Pulmonary Embolectomy [CAG-00457R]

Dear Dr. Hutter and Mr. Dolan,

The Medical Device Manufacturers Association (MDMA), a national trade association representing the innovative sector of the medical device market, is submitting this letter to the Centers for Medicare and Medicaid

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Zlotnick MD, David Organization: Gates Vascular Institute/Univ of Buffalo
Date: 09/10/2021
Comment:

Chiquita Brooks-LaSure
Centers for Medicare and Medicaid Services

Dear Ms. Brooks-LaSure,

My name is Dr. David Zlotnick and I’m an Interventional Cardiologist at Gates Vascular Institute (GVI)/University of Buffalo in Buffalo, New York. I am also a founding member of the PERT Consortium, and built the PERT program here at GVI.

The Pulmonary Embolism Response Team (PERT) Consortium is designed to coordinate and expedite the treatment of pulmonary embolus

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