Early hemodynamic and safety profile of pigtail catheter-directed thrombolysis in acute pulmonary embolism

Abstract Background Pulmonary embolism (PE) is a major cardiovascular emergency with high morbidity and mortality. In intermediate-high and high-risk patients, right ventricular (RV) dysfunction and hemodynamic compromise are common. Systemic thrombolysis can improve outcomes but carries a high risk of major and intracranial bleeding, limiting its use. Catheter-directed thrombolysis (CDT) with a pigtail catheter allows localized delivery of fibrinolytics at reduced doses, potentially achieving rapid improvement while minimizing systemic complications. Purpose To evaluate the safety and early efficacy of CDT using a pigtail catheter in patients with intermediate-high and high-risk PE who had contraindications to systemic thrombolysis, focusing on clinical, hemodynamic, and echocardiographic changes at 48 hours. Methods We conducted a prospective, observational study including consecutive patients with confirmed intermediate-high or high-risk PE between 2022 and 2025. All patients underwent in situ thrombolysis with a pigtail catheter. Clinical, hemodynamic, and echocardiographic data were collected at baseline and 48 hours. Safety outcomes included bleeding, vascular complications, recurrent PE, and in-hospital mortality related to PE. Results Fifteen patients were included; the mean age was 56±14 years and 46.7 % were women. Following in-situ thrombolysis with a pigtail catheter, heart rate fell from 118±15 to 86±14 beats per minute (p 0.001), while mean arterial pressure remained unchanged (87±17 vs 89±9 mmHg, p = 0.69). Echocardiography showed marked RV recovery at 48 h: the RV/LV ratio decreased from 1.22±0.11 to 0.92±0.13 (p 0.001), tricuspid annular plane systolic excursion (TAPSE) rose from 11.2±2.7 to 20.6±3.9 mm (p 0.001), S′ wave from 7.7±1.0 to 13.3±3.3 cm/s (p 0.001) and fractional area change from 20.7±6.4 % to 32.2±6.7 % (p 0.001). Pulmonary pressures improved; the tricuspid regurgitation velocity (TRV) fell from 3.20±0.33 to 2.57±0.49 m/s and estimated pulmonary artery systolic pressure (PASP) from 54.9±8.5 to 36.1±10.4 mmHg (p 0.001), while the TAPSE/PASP ratio increased from 0.21±0.05 to 0.59±0.14 (p 0.001). Minor complications were uncommon: one patient (6.7%) developed a local access-site hematoma, and another (6.7%) experienced a gastrointestinal bleed requiring transfusion; there were no intracranial haemorrhages, recurrent pulmonary emboli or deaths. Major CDT series report major bleeding in roughly 0–10% of patients, so our complication rate lies within this range. Conclusion In situ thrombolysis with a pigtail catheter was associated with rapid improvement in clinical, hemodynamic, and echocardiographic parameters within 48 hours, with a favourable safety profile and a low-cost advantage compared to other CDT techniques. This approach represents a safe, effective, and economically accessible therapeutic alternative for intermediate-high and high-risk PE patients with contraindications to systemic thrombolysis.PASP, TRV, RV/LV, TAPSE: baseline vs 48hFor image description, please refer to the figure legend and surrounding text. S′ wave, TAPSE/PASP, FAC & complicationsFor image description, please refer to the figure legend and surrounding text.