Periprocedural efficacy and safety comparison between ultrasound-assisted catheter-directed thrombolysis and catheter-directed mechanical thrombectomy for acute pulmonary embolism

Background Catheter-directed reperfusion therapies are increasingly used in patients with intermediate- to high-risk acute pulmonary embolism (PE). However, comparative data between ultrasound-assisted catheter-directed thrombolysis (CDT) and catheter-directed mechanical thrombectomy (MT) remain limited. Methods This retrospective cohort study compared periprocedural efficacy and safety outcomes between CDT and MT in patients with acute PE. The primary efficacy endpoint was change in right ventricular to left ventricular (RV/LV) ratio from baseline to post-procedure. Secondary endpoints included 90-day all-cause mortality, hemoglobin decline, major bleeding (BARC severe bleeding) and intracranial hemorrhage (ICH). Results Eighty-three patients were included (CDT: n=41; MT: n=42). Baseline characteristics were broadly comparable between groups. Both strategies achieved significant within-group reductions in RV/LV ratio from baseline to post-procedure. In the CDT group, RV/LV ratio decreased from 1.47 ± 0.34 to 0.94 ± 0.27, while in the MT group it decreased from 1.46 ± 0.44 to 0.91 ± 0.27. There were no significant between-group differences in baseline RV/LV, post-procedure RV/LV, absolute RV/LV reduction, relative RV/LV reduction, or the proportion of patients achieving a normalized post-procedural RV/LV ratio (≤0.9). 90-day all-cause mortality was similar between CDT and MT (17.0% vs. 9.5%, P=0.50). Hemoglobin decline was numerically greater with CDT than with MT (2.56 ± 2.18 vs. 1.77 ± 1.62 g/dL), and major bleeding occurred more frequently in the CDT group (20.0% vs. 7.1%), although neither difference reached statistical significance (P=0.07 and P=0.20, respectively). No ICH occurred in the MT group, whereas two ICH events (4.9%) were observed in the CDT group. Conclusions In patients with acute PE, CDT demonstrated efficacy in improving RV/LV ratio comparable to MT but was associated with a non-significant trend toward higher rates of severe bleeding. These findings suggest that both modalities are viable catheter-directed options, and choice of strategy may be guided by institutional expertise and individual patient characteristics.