Systemic thrombolysis vs catheter-directed interventions for the treatment of high-risk pulmonary embolism. A comparative analysis of early outcomes and complications

Introduction High-risk pulmonary embolism (HR-PE) poses an immediate threat to life being related with 30-50% short-term mortality. The HR-PE patients may present with heterogenous symptoms such as persistent hypotension, obstructive shock or cardiac arrest. Systemic thrombolysis (ST) is the guideline-recommended life-saving treatment although associated with significant risk of bleeding complications. Thus catheter-directed embolectomy (CDE) has emerged as an alternative life-saving treatment strategy. Aim The study aimed to evaluate the early outcomes and complications among HR-PE treated with ST or CDE. Methods We evaluated medical records of HR-PE patients, defined in line with the current European Society of Cardiology Guidelines, from prospectively conducted registries of Pulmonary Embolism Response Teams (PERT) of tertiary cardiology centres. Clinical profile, treatment strategies and outcomes defined as in-hospital mortality, International Society of Thrombosis and Hemostasis (ISTH) major bleeding and a need for bailout therapy due to primary treatment strategy failure were compared. Results We identified 111 HR-PE patients (67 [52-74] years old; 48.6% females). There were 41 (36.9%) individuals who presented with cardiac arrest, and the remaining with obstructive shock or refractory hypotension. Absolute contraindications to ST were detected in 29 (26.1%) patients. All patients received pharmacological circulatory support and 4 (3.6%) also mechanical, all from CDE group. 53 (47.7%) patients were treated with ST and 58 (52,3%) with CDE. There were 26 (24.5%) in-hospital deaths. Patients treated with CDE had lower in-hospital mortality rate as compared to those treated with ST [4 (6.9%) vs 22 (45.8%) respectively, p<0.001]. The rate of major bleedings was greater in the ST group than in the CDE [9 (22.5%) vs 3 (5.1%) respectively, p=0.03]. Failure of the ST was reported in 4 (7.8%) patients. Eleven (21.6%) CDE procedures were followed by a low-dose local thrombolysis to optimize the therapeutic effect. Conclusions HR-PE is a severe medical condition associated with highly increased risk of early death. The use of CDE as a primary reperfusion strategy was associated with a favourable outcome and less frequent bleeding complications as compared to ST.