Clinical outcomes of catheter-directed thrombolysis compared with anticoagulation in acute haemodynamically stable pulmonary embolism: a systematic review and meta-analysis of randomised controlled trials

Background: The role of catheter-directed thrombolysis (CDT) in haemodynamically stable pulmonary embolism (PE) remains controversial with observational data supporting a mortality benefit for CDT. This meta-analysis aimed to assess the effect of CDT, compared with anticoagulation alone, on mortality, haemodynamic decompensation and major bleeding in haemodynamically stable PE. Methods: Randomised controlled trials comparing treatment with CDT versus anticoagulation in patients with acute haemodynamically stable pulmonary embolism were systematically searched in the PubMed/MEDLINE database. The primary outcome was all-cause mortality at 30 days. Secondary outcomes were haemodynamic decompensation (efficacy) and major bleeding, minor bleeding and intracranial haemorrhage (safety). Results: A total of 8 clinical trials comprising 1503 patients with acute haemodynamically stable pulmonary embolism were included. CDT was not associated with a significant difference in 30-day all-cause mortality compared with anticoagulation alone (OR, 0.83; 95% CI, 0.24–2.92). CDT reduced the risk of haemodynamic decompensation at 7 days (OR, 0.27; 95% CI, 0.08–0.87). Regarding safety, there was no significant difference in major bleeding between groups (OR, 1.39; 95% CI, 0.63–3.07), whereas minor bleeding occurred more frequently with CDT (OR, 2.77; 95% CI, 1.41–5.42). There were four reported cases of intracranial haemorrhage in the CDT arm. Conclusions: In patients with haemodynamically stable acute PE, CDT reduced early haemodynamic decompensation without a detectable difference in mortality. There was no significant increase in major bleeding, but minor bleeding was significantly increased. These findings might inform decisions of pulmonary embolism response teams.