Key result
LBMT linked to ~25-point lower in-hospital mortality vs systemic thrombolysis in high-risk PE.
Why the study?
Early mortality in high-risk PE remains high under current guidelines recommending first-line systemic thrombolysis. Large-bore mechanical thrombectomy might improve outcomes, but comparative data against systemic thrombolysis are scarce.
Does primary large-bore mechanical thrombectomy reduce in-hospital mortality and major bleeding compared to primary systemic thrombolysis in patients with high-risk pulmonary embolism eligible for both treatments?
Observational (n=181)
Yes
Does primary large-bore mechanical thrombectomy reduce in-hospital mortality and major bleeding compared to primary systemic thrombolysis in patients with high-risk pulmonary embolism eligible for both treatments?
In high-risk pulmonary embolism patients eligible for both therapies, primary large-bore mechanical thrombectomy was associated with numerically lower rates of in-hospital mortality (2.2% vs. 27.3%) and major bleeding (6.7% vs. 24.2%) compared to primary systemic thrombolysis.
May favor large-bore mechanical thrombectomy first in eligible high-risk PE; leaves open confirmation of mortality benefit in randomized trials.
Background High-risk pulmonary embolism (PE) is characterized by hemodynamic instability, and early mortality remains high under current guidelines that recommend first-line systemic thrombolysis (ST). Large-bore mechanical thrombectomy (LBMT) might improve outcomes of high-risk PE, but comparative data are scarce. Purpose In this combined analysis of two studies that enrolled patients with high-risk PE, the results of LBMT and ST are evaluated in a population that was medically and anatomically eligible to receive either thrombectomy or a lytic-based treatment. Methods The analysis included subjects with high-risk PE from the FLAME study (NCT04795167) and the FLASH study (NCT03761173), including both the US and European cohorts. These prospective, observational studies defined high-risk PE according to European Society of Cardiology guidelines. In this analysis, subjects eligible for LBMT are defined as those with central and/or lobar PE, and subjects eligible for ST are defined as those with no absolute or relative contraindication to lytic agents. In extremis indicates cardiopulmonary resuscitation on arrival for FLASH subjects and SCAI SHOCK Stage E for FLAME subjects. Results In a cohort of 257 high-risk PE subjects, 181 were eligible for both ST and LBMT. Of these, 136 (75.1%) subjects received primary LBMT, and 33 (18.2%) received primary ST. The primary treatment groups demonstrated similar baseline characteristics: The LBMT group was a mean age of 61.0±13.6 years and 50.7% female, and the ST group was a mean age of 59.1±14.4 years and 60.6% female. Body mass index was 33.7±8.2 kg/m2 and 34.6±9.0 kg/m2 in the LBMT and ST groups, respectively. Also, baseline vitals and imaging evidence were clinically similar: heart rates at presentation were 104.9±21.1 bpm (LBMT) and 108.5±28.8 bpm (ST), lowest systolic blood pressures, including subjects on vasopressors, were 100.3±25.7 mmHg (LBMT) and 93.8±32.1 mmHg (ST), and right ventricle/left ventricle ratios were 1.7±0.5 (LBMT) and 1.6±0.5 (ST). After reperfusion therapy, the in-hospital mortality rate was 2.2% (n=3) in the LBMT group and 27.3% (n=9) in the ST group. Comparing LBMT with ST, LBMT was associated with numerically lower rates of major bleeding (6.7% [n=9] vs. 24.2% [n=8]), clinical deterioration (5.9% [n=8] vs. 12.1% [n=4]), and bailout or adjunctive therapy use (3.7% [n=5] vs. 27.3% [n=9]). When excluding the 15 FLASH subjects and 14 FLAME subjects in extremis at baseline, the outcomes remained similar (Figure). Conclusions In this pooled high-risk PE cohort, favorable clinical trends were observed among patients who received LBMT as an alternative to ST. The observed data point toward the potential utility of LBMT as a primary intervention in patients with high-risk PE who can be safely transitioned to the interventional setting.
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Hobohm et al. (2026) conducted an observational in High-risk pulmonary embolism (PE) (n=181). Large-bore mechanical thrombectomy (LBMT) vs. Systemic thrombolysis (ST) was evaluated on In-hospital mortality. Large-bore mechanical thrombectomy was associated with lower in-hospital mortality (2.2% vs 27.3%) and major bleeding (6.7% vs 24.2%) compared to systemic thrombolysis in high-risk PE.
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