Outcomes of EKOS (ultrasound-assisted thrombolysis) for intermediate–high-risk pulmonary embolism: A PERT-guided cohort study

Objectives Acute intermediate–high-risk pulmonary embolism (PE) is associated with right-ventricular (RV) dysfunction, biomarker elevation, and risk of early clinical deterioration. Ultrasound-assisted catheter-directed thrombolysis (USAT) using the EKOS system is increasingly used in selected patients; however, real-world data on physiological response and clinically relevant in-hospital outcomes remain limited. Methods We conducted a retrospective single-center analysis of 128 consecutive patients with acute intermediate–high-risk PE treated with EKOS-guided USAT within a structured Pulmonary Embolism Response Team (PERT) pathway between August 2017 and December 2023. Changes in RV/LV ratio, B-type natriuretic peptide (BNP), and cardiac troponin before and after intervention were assessed. A composite endpoint of death, extracorporeal membrane oxygenation (ECMO), renal replacement therapy, or invasive mechanical ventilation captured clinically meaningful deterioration. Multivariable logistic regression identified determinants of the composite endpoint. Results RV/LV ratio and biomarkers improved significantly after intervention. Median RV/LV ratio decreased from 1.6 to 1.0, and B-type natriuretic peptide (BNP) declined from 2365 to 877 pg/mL (both p < 0.001). Clinically meaningful in-hospital deterioration requiring escalation of organ support occurred in a subset of patients and was predominantly associated with baseline disease severity. Short-term survival remained favorable (60-day probability 96.9%). Conclusions In this real-world, PERT-guided cohort, EKOS was associated with rapid physiological improvement and favorable short-term survival in patients with intermediate–high-risk PE. These findings should be interpreted as descriptive single-center experience.