Comparative Effectiveness and Safety of Catheter-Directed Thrombolysis Techniques in Acute versus Subacute Lower-Extremity Deep Vein Thrombosis: A Systematic Review and Bayesian Network Meta-analysis

Current guidelines restrict catheter-directed thrombolysis (CDT) for lower-extremity deep vein thrombosis (DVT) to patients presenting within 14 days—a consensus-based threshold. No network meta-analysis (NMA) has compared CDT modalities in acute (≤14 days) versus subacute (15–28 days) DVT or tested whether duration modifies efficacy. The objectives of this study are to compare technical success, thrombus clearance, and safety of CDT modalities (standard CDT, ultrasound-assisted thrombolysis [USAT], pharmacomechanical thrombectomy [PMT], hybrid) versus anticoagulation across both strata and test the pre-registered duration × modality interaction. Systematic review and Bayesian NMA (PRISMA-NMA 2020) were conducted. MEDLINE, Embase, Cochrane CENTRAL, and Web of Science (1990–2025) were searched. Eight-node network was defined: four modalities × two strata; gemtc R package; SUCRA (Surface Under the Cumulative Ranking Curve); GRADE-NMA. The protocol was registered in PROSPERO: CRD-420261392029. Fifteen studies (10 randomized controlled trials, 5 observational; n = 2,531) were included. Technical success was significantly higher with CDT than anticoagulation in the acute (odds ratio [OR]: 5.81, 95% Bayesian credible interval [CrI]: 3.42–9.87; I2 = 28%; high certainty) and subacute stratum (OR: 2.34, 95% CrI: 1.18–4.63; I2 = 39%; moderate certainty). The duration × modality interaction was significant (p = 0.003). SUCRA favored PMT (79%) and USAT (71%) over standard CDT (44%) in the subacute stratum. Major bleeding did not differ significantly. Postthrombotic syndrome was reduced in the acute stratum (OR: 0.52, 95% CrI: 0.34–0.79). CDT significantly improves technical success across both strata without increasing major bleeding. The significant duration × modality interaction confirms symptom duration modifies CDT efficacy, with mechanical modalities demonstrating superior rankings in subacute disease. These findings provide the first comparative evidence for the 14-day guideline boundary and support preferential use of PMT or USAT in patients presenting at 15 to 28 days.