Cost-Effectiveness of Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis for Intermediate-Risk Pulmonary Embolism: A PEERLESS Randomized Controlled Trial Post Hoc Analysis

Background This study evaluates the cost-effectiveness of large-bore mechanical thrombectomy (LBMT) compared with catheter-directed thrombolysis (CDT) for the treatment of intermediate-risk pulmonary embolism (PE). Methods A combined decision tree and Markov model was developed to estimate lifetime health care costs, quality-adjusted life years (QALY), and net monetary benefit from the perspective of the United States health care system. Event probabilities during PE management were derived from the PEERLESS randomized controlled trial. Resource utilization, costs, and long-term event probabilities were established from published literature. Scenario analyses and probabilistic sensitivity analyses were performed to characterize uncertainty. Results In the base case analysis, LBMT was cost-saving to CDT (ie, lower costs and higher QALY), with a net monetary benefit of $5850 for the willingness-to-pay threshold of $120,000/QALY for LBMT when compared to CDT. In the PE management phase, LBMT yielded a net $4755 cost-saving and 0.009 QALY gained per patient vs CDT, driven in large part by reduced intensive care unit utilization (–$6454), shorter hospital stay (–$2217), avoided thrombolytic costs (–$4068), and fewer 30-day readmissions (–$1134). The long-term care phase yielded a total of $32,012 additional costs per patient over the lifetime with no incremental difference in costs or QALY between groups. These additional costs were driven by venous thromboembolism–related death ($12,377), chronic thromboembolic pulmonary hypertension diagnosis and treatment ($8080), postacute anticoagulation management ($4512), and recurrent venous thromboembolism ($3289). LBMT remained cost-saving across scenarios evaluating CDT cost assumptions and device-specific chronic thromboembolic pulmonary hypertension rates. Probabilistic sensitivity analyses confirmed the robustness of these findings across multiple parameter ranges. Conclusions Intervention with LBMT in intermediate-risk PE patients in the United States is economically attractive when compared with CDT, resulting in reduced costs and marginally improved patient benefit.