Real-world outcomes of large-bore catheter-based thrombectomy in intermediate-high and high-risk pulmonary embolism

Background Catheter-based thrombectomy (CBT) is increasingly used for intermediate–high and high-risk acute pulmonary embolism (PE), but most evidence derives from industry-sponsored trials conducted in selected centres. Purpose To evaluate the clinical characteristics and short-term outcomes of patients treated with large-bore CBT in a multicentre real-world cohort. Methods The Spanish Registry of Catheter Intervention in Pulmonary Embolism prospectively enrols consecutive patients undergoing catheter-based treatment for acute PE across 22 centres (overall registry population n=1002). For this analysis, patients treated with large-bore (≥24 French) thrombectomy devices were selected. The primary outcome was a 7-day composite of recurrent PE, in-hospital resuscitation, or death. Secondary outcomes included in-hospital adverse events. Results A total of 221 patients were analysed. In-hospital PE occurred in 14%, prior PE in 9.5%, and active or recent cancer in 20%. Overall, 32.1% were classified as high risk and 67.9% as intermediate–high risk, with additional markers of clinical severity shown in Figure 1A. The mean shock index was 1.06 ± 0.41 (Figure 1B), mean PESI 123 ± 41.3, and mean lactate 3.29 ± 3.76 mmol/L. Moderate-to-severe right ventricular dysfunction was present in 63%, and bilateral main pulmonary artery involvement in 79%. A formal reperfusion indication was present in 62% of cases; 13% were treated as rescue after failed fibrinolysis and 25% electively according to local protocols or PE response team decisions. Lysis-free mechanical thrombectomy was performed in 91%. In centres reporting paired haemodynamic data (n=177), mean pulmonary artery pressure decreased significantly after the procedure (−7.4 ± 6.2 mmHg; p<0.001) (Figure 1C). Technical success was achieved in 94%. The 7-day composite outcome occurred in 9.9% of patients (Figure 1D); seven-day mortality was 7.0%, recurrent PE 0.9%, and in-hospital cardiac arrest 5.4%. Major bleeding occurred in 10%, respiratory failure in 15%, renal failure in 11%, and infection in 15%. Conclusions In this multicentre real-world cohort, large-bore CBT was associated with significant immediate haemodynamic improvement and high procedural success. The 7-day composite outcome occurred in 9.9%, driven mainly by a 7.0% mortality rate. Early adverse events were more frequent than those reported in industry-sponsored trials, likely reflecting greater clinical severity and broader real-world inclusion criteria.