Long‐Term Outcomes After Catheter‐Directed Thrombolysis or Mechanical Thrombectomy in Intermediate‐High–Risk Pulmonary Embolism: A Propensity‐Matched Analysis From a TriNetX Database

ABSTRACT Catheter‐directed thrombolysis (CDL) and mechanical thrombectomy (MT) are increasingly used for intermediate–high–risk pulmonary embolism (PE), yet comparative long‐term outcomes remain uncertain. We aimed to compare the effectiveness and safety of CDL versus MT in real‐world clinical practice. Using the multi‐institutional TriNetX network, we identified adults with acute intermediate–high–risk PE treated with CDL or MT. One‐to‐one propensity score matching was performed across demographics, comorbidities, and laboratory variables. Outcomes were assessed up to 2 years post‐index. The primary outcome was all‐cause mortality, while secondary outcomes included hospitalization, major adverse cardiovascular events (MACE), pulmonary hypertension (PH), and bleeding. After matching, 1290 patients remained in each group with balanced baseline characteristics, with a median follow‐up of approximately 1.5 years. Long‐term mortality was similar between CDL and MT (3.1% vs. 3.5%; p = 0.061). MACE rates were comparable (5.2% vs. 4.6%; p = 0.933), with no significant difference in PH (3.0% vs. 3.24%; p = 0.352). CDL was associated with higher hospitalization rates (2.2% vs. 0.9%; p = 0.026), while bleeding events were low and similar between groups. In this large real‐world cohort of patients with intermediate–high–risk PE, CDL and MT demonstrated broadly comparable long‐term outcomes, suggesting no clear superiority of either strategy and supporting ongoing clinical equipoise. Ongoing randomized trials are needed to further inform optimal management.