Mechanical Thrombectomy Versus Anticoagulation Alone for Intermediate-Risk Pulmonary Embolism: A Systematic Review and Meta-Analysis

Background Controversy surrounds the optimal therapy for intermediate-risk pulmonary embolism (PE). We aimed to compare the outcomes of mechanical thrombectomy (MT) versus anticoagulation alone in patients with intermediate-risk PE. Methods We searched Medline, EMBASE, Cochrane, and Scopus (from inception to January 19th, 2026) for studies comparing outcomes of MT versus anticoagulation alone in intermediate-risk PE. Studies were identified and data were extracted by two independent reviewers. A random-effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CIs) for outcomes with three or more studies. Outcomes included in-hospital, 30-day, 1-year, and 2-year mortality, major bleeding, hospital and intensive care unit (ICU) length of stay (LOS), 30-day readmission, and chronic thromboembolic disease (CTEPH). Results A total of 12 studies (1 randomized, 11 observational) with 4,268 patients were included, of whom 1,878 (44.0%) received MT. Compared with anticoagulation alone, MT was associated with similar in-hospital mortality (RR 0.72; 95% CI 0.31-1.69) but significantly lower 30-day mortality (RR 0.24; 95% CI 0.09-0.67), 1-year mortality (RR 0.34; 95% CI 0.19-0.58), and 2-year mortality (RR 0.45; 95% CI 0.29-0.69). The risk of major bleeding, hospital and ICU LOS, and 30-day readmission were similar between the two strategies. The risk of CTEPH was significantly lower with MT versus anticoagulation alone (RR 0.40; 95% CI 0.17-0.94). Conclusions In patients with intermediate-risk PE, MT is associated with lower short- and long-term mortality and future development of CTEPH compared with anticoagulation alone. This study expands the evidence supporting MT as first-line therapy for intermediate-risk PE. Further randomized controlled trials are indicated to confirm our findings.