Outcomes with Catheter-Directed Thrombolysis versus Mechanical Thrombectomy for Patients with Intermediate/High Risk Pulmonary Embolism: A Meta-Analysis of 24,090 Patients

Q: What are the key findings of this study?

Catheter-directed thrombolysis showed no significant difference in all-cause mortality (RR 0.88, p=0.068) compared to mechanical thrombectomy in intermediate/high-risk PE, but increased ICU stay.

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Intermediate/high risk pulmonary embolism (n=24090). Intervention: Catheter-directed thrombolysis (CDT) vs. Mechanical thrombectomy (MT). Primary outcome: All-cause mortality (RR 0.88, 95% CI 0.76-1.01, p=0.068).

Q: What does this research mean for the field?

In patients with intermediate- to high-risk pulmonary embolism, catheter-directed thrombolysis shows no significant difference in all-cause mortality or major bleeding compared with mechanical thrombectomy, but results in a longer ICU stay. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Mohamed Saad Sayed; Doaa Mohamed Gebaly; Hasan Ilyas; Rawan Abdelhamed; Waleed Mohaned Rasheed; Hossam Hamdy; Lydia Melad; Giuseppe Andò; Toshiki Kuno; Islam Y. Elgendy

doi:10.1007/s00408-026-00950-7

November 10, 2026LungOpen Access

Outcomes with Catheter-Directed Thrombolysis versus Mechanical Thrombectomy for Patients with Intermediate/High Risk Pulmonary Embolism: A Meta-Analysis of 24,090 Patients

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Key result

Catheter-directed thrombolysis shows no mortality benefit over mechanical thrombectomy in PE, but increases ICU stay.

Why the study?

Randomized trials comparing clinical outcomes of catheter-directed thrombolysis versus mechanical thrombectomy for patients with intermediate/high risk pulmonary embolism are limited.

Does catheter-directed thrombolysis reduce all-cause mortality and improve clinical outcomes compared with mechanical thrombectomy in adult patients with intermediate- or high-risk pulmonary embolism?

Key Points

To compare clinical outcomes, including mortality, bleeding risk, and intensive care unit stay duration, between catheter-directed medical thrombolysis and mechanical thrombectomy in patients with intermediate- or high-risk pulmonary embolism.
Systematic review and meta-analysis of 18 eligible studies (1 randomized controlled trial and 17 retrospective cohort studies) comprising 24,090 intermediate- and high-risk patients retrieved from PubMed, Web of Science, Scopus, and Cochrane CENTRAL through June 2026.
Primary outcomes included all-cause mortality, major bleeding, and length of intensive care unit stay, with summary estimates pooled using random-effects models.
Risk of all-cause mortality showed no significant difference between catheter-directed thrombolysis and mechanical thrombectomy (RR 0.88, 95% CI 0.76–1.01, p = 0.068), nor did risk of major bleeding (RR 1.07, 95% CI 0.74–1.55, p = 0.705).
Catheter-directed thrombolysis was associated with a significantly longer intensive care unit stay compared to mechanical thrombectomy (mean difference: 1.01 days, 95% CI 0.87–1.15, p < 0.0001).
Incidence of secondary endpoints showed no significant differences between groups for all-cause readmission, pulmonary embolism-related readmission, blood transfusions, total hospital stay, cardiac arrest, or stroke.

Study Design

Type

Meta-Analysis (n=24,090)

Multicenter

Yes

Structured PICO

Does catheter-directed thrombolysis reduce all-cause mortality and improve clinical outcomes compared with mechanical thrombectomy in adult patients with intermediate- or high-risk pulmonary embolism?

P

Population

24,090 adult patients across 18 studies with intermediate or high-risk pulmonary embolism undergoing catheter-based therapies (catheter-directed thrombolysis vs. mechanical thrombectomy), followed for a weighted mean of 8.07 months.

I

Intervention

Catheter-directed medical thrombolysis (CDT) using conventional infusion catheters (UniFuse, Cragg-McNamara, Multi-Sideport) or ultrasound-assisted catheters (EKOS/EkoSonic Endovascular System) delivering thrombolytic agents (recombinant tissue plasminogen activator [rtPA/alteplase] typically at 0.5–1 mg/h or urokinase at 200,000–800,000 IU/day).

C

Comparator

Mechanical thrombectomy (MT) using aspiration or mechanical retrieval devices (FlowTriever System, Indigo Catheter/Penumbra, LBT system, or balloon-tipped/pigtail catheters).

O

Outcome

All-cause mortality at a weighted mean follow-up of 8.07 months (range: 1 day to 60 months).hard clinical

Main Result

Relative Risk: 0.88 (95% CI 0.76–1.01)

p-value: p=0.068

Limitations

Predominantly retrospective observational studies (17 of 18 studies) with only one randomized controlled trial, leading to likely residual confounding and selection bias
Substantial clinical and methodological heterogeneity across studies regarding PE-risk categories, outcome definitions, thrombolytic dosing protocols, and device systems
Inability to stratify outcomes by specific PE risk category (intermediate-low, intermediate-high, and high-risk)
Lack of long-term outcomes such as pulmonary vascular remodeling, residual pulmonary hypertension, and right ventricular recovery
Immediate hemodynamic effects of mechanical thrombectomy (such as rapid reduction in pulmonary artery pressure and RV afterload) were not captured by the clinical endpoints
Only one included study was an RCT while the other 17 studies were retrospective observational cohort studies
Potential for coding and selection bias in retrospective administrative datasets and real-world practice where patients selected for CDT and MT are not identical
Lack of patient-level data and unextracted variables across studies (such as VA ECMO use in sicker patients) makes it difficult to separate treatment effect from patient selection
High heterogeneity (I²=73.5%) observed in the major bleeding outcome

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

In patients with intermediate- or high-risk pulmonary embolism, catheter-directed thrombolysis and mechanical thrombectomy yield comparable mortality and major bleeding rates, though catheter-directed thrombolysis is associated with a roughly 1-day longer ICU stay.

Abstract

Background Randomized trials comparing the outcomes with catheter-directed medical thrombolysis (CDT) versus mechanical thrombectomy (MT) for patients with intermediate/high risk pulmonary embolism (PE) are limited. This meta-analysis aimed to assess the clinical outcomes after CDT versus MT for patients with intermediate/high risk PE. Methods Eligible studies compared CDT and MT for patients with intermediate/high risk PE underwent catheter-based therapies were retrieved from a comprehensive literature search for PubMed, Web of Science, Scopus, and Cochrane CENTRAL through June 2026. Outcomes included all-cause mortality, major bleeding, and the length of intensive care unit (ICU) stay. Summary estimates were analyzed using a random effects model. Results A total of 18 studies (24,090 intermediate/high risk patients) were eligible for the analysis. CDT was associated with longer length of intensive care unit (ICU) stay (mean difference: 1.01 days, 95% confidence interval [CI] 0.87–1.15) compared with MT. While there was no statistical difference between the two groups regarding the risk of all-cause mortality (risk ratio [RR] 0.88, 95% CI 0.76–1.01, p = 0.068) and major bleeding (RR 1.07, 95% CI 0.74–1.55, p = 0.705). Similarly, the incidence of other clinical outcomes; all-cause readmission, PE-related readmission, blood transfusion rates, length of hospital stay, cardiac arrest, and stroke, were similar between the two groups. Conclusion Among patients with intermediate/high risk PE treated with catheter-based therapies, there was no difference regarding the clinical outcomes between CDT and MT, but CDT was associated with a longer ICU stay. Larger, well designed randomized trials are needed to confirm these findings.

Discussion

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Cite This Study

Sayed et al. (2026) conducted a meta-analysis in Intermediate/high risk pulmonary embolism (n=24,090). Catheter-directed thrombolysis (CDT) vs. Mechanical thrombectomy (MT) was evaluated on All-cause mortality (RR 0.88, 95% CI 0.76-1.01, p=0.068). Catheter-directed thrombolysis showed no significant difference in all-cause mortality (RR 0.88, p=0.068) compared to mechanical thrombectomy in intermediate/high-risk PE, but increased ICU stay.

synapsesocial.com/papers/6af46da27bb3da179b850254 https://doi.org/10.1007/s00408-026-00950-7

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Outcomes with Catheter-Directed Thrombolysis versus Mechanical Thrombectomy for Patients with Intermediate/High Risk Pulmonary Embolism: A Meta-Analysis of 24,090 Patients

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Outcomes with Catheter-Directed Thrombolysis versus Mechanical Thrombectomy for Patients with Intermediate/High Risk Pulmonary Embolism: A Meta-Analysis of 24,090 Patients

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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