Mechanical Thrombectomy Versus Systemic Thrombolysis in Hemodynamically Unstable High-Risk Pulmonary Embolism Requiring Vasopressors: A Propensity-Matched Outcomes Analysis From TriNetX Network

Background High-risk pulmonary embolism (PE) is associated with high mortality. Optimal reperfusion strategy remains debated. Systemic thrombolysis (ST) is traditionally used but carries a high risk of intracranial bleeding. Catheter-directed or mechanical thrombectomy (MT) may be safer, but real-world data are limited. We compared thrombectomy vs thrombolysis using a multicenter data network. Methods We conducted a retrospective cohort study on the TriNetX Research Network across 107 healthcare organizations. Adults with hemodynamically unstable PE on vasopressors from January 2016 to September 2025 who received MT (n = 1064) or thrombolysis (n = 3325) within 1 day of diagnosis were included. We excluded patients with COVID-19, malignancy, obstetric conditions, trauma, and burns. Propensity matching (1:1) for Pulmonary Embolism Severity Index variables and other baseline characteristics yielded 1052 per group. Results Mortality was lower with MT (RR: 0.53; 95% CI, 0.44-0.63). Kaplan-Meier analysis showed better survival in the matched MT group (79.4% vs 61.3%; P < .001). Hemorrhagic stroke (RR: 0.71; 95% CI: 0.41-1.22) and ischemic stroke (RR: 0.80; 95% CI: 0.57-1.13) were also reduced in the thrombectomy group. Conclusions Thrombectomy was associated with lower mortality and fewer strokes vs thrombolysis. Thrombectomy appears safer and more effective for high-risk PE. This finding is hypothesis generating. Large randomized controlled trials, although difficult to conduct, are needed to validate these findings.