Large-Bore Mechanical Thrombectomy for Pulmonary Embolism in Patients With Clinically Relevant Thrombolytic Contraindications From the PEERLESS Trial

Background Reports of clinical outcomes following intervention in patients with pulmonary embolism and thrombolytic contraindications are rare. This work aimed to assess clinical outcomes in patients with intermediate-risk PE and clinically relevant contraindications to catheter-directed thrombolysis following treatment with large-bore mechanical thrombectomy (LBMT). Methods In the PEERLESS randomized controlled trial (NCT05111613), patients with clinically relevant contraindications to thrombolytics but otherwise eligible were enrolled in a prospective, nonrandomized parallel cohort. This contraindication cohort underwent LBMT with follow-up through 30 days. Key in-hospital outcomes included all-cause mortality, intracranial hemorrhage, major bleeding, clinical deterioration and/or escalation to bail out , and postprocedural intensive care unit stay. Results A total of 142 patients were enrolled. The mean age was 64.3 years, 54.9% were men, and 90.1% had elevated troponin. Notable baseline factors included recent surgery (33.8%), anemia (33.1%), active cancer (27.5%), and renal dysfunction (23.2%). At the 24-hour visit, patients had significant reductions from baseline in the mean heart rate (108.9 ± 17.2 bpm to 87.3 ± 15.0 bpm; P < .001), respiratory rate (23.1 ± 6.7 rpm to 19.3 ± 4.3 rpm; P < .001), and right ventricle/left ventricle ratio (1.32 ± 0.33 to 0.94 ± 0.18; P < .001). Major bleeding (7.0%) was similar to randomized PEERLESS trial patients (6.9%), despite higher baseline bleeding risk (proportion with VTE-BLEED score ≥2: 57.0% vs 26.4%, respectively; P < .001). The rate of clinical deterioration was 3.5%, and no patient required reintervention. The majority of patients (54.2%) did not require intensive care unit admission. No deaths or intracranial hemorrhages were observed before discharge. Adjudicated all-cause mortality at 30 days was 3.9%; total mortality following post hoc contact tracing was 4.4%. Conclusions In this prospective, nonrandomized parallel cohort of the PEERLESS trial, LBMT was associated with a favorable safety and effectiveness profile among patients with intermediate-risk pulmonary embolism with clinically relevant contraindications to thrombolytics.