Perioperative and intermediate outcomes of patients with pulmonary embolism undergoing catheter-directed thrombolysis vs percutaneous mechanical thrombectomy

ObjectiveThrombolytic therapy has been a mainstay of treatment for massive or sub-massive pulmonary embolism (PE), a common and highly morbid pathology. New percutaneous mechanical thrombectomy devices have recently become widely available and have been increasingly utilized for the treatment of acute PE, but evidence demonstrating its efficacy over standard catheter-directed lytic protocol remains limited.MethodsUsing TriNetX Data Network, a global federated database of over 250 million patients, we conducted a retrospective cohort study of patients from January 2017 to August 2023 with a diagnosis of PE, treated with either percutaneous mechanical thrombectomy (PMT) or catheter-directed thrombolysis (CDT). Eligible patients were 1:1 propensity score-matched for preoperative co-variates including demographics and comorbidities. We calculated and compared the 30-day outcomes of all-cause mortality, bleeding complications (blood transfusion, gastrointestinal (GI) bleed, and intracranial hemorrhage (ICH)), diagnosis of acute respiratory failure (RF), myocardial infarction (MI), and pulmonary hypertension (PH) using odds ratio (OR) with 95% confidence interval (CI). Also, the 5-year outcomes of all-cause mortality, a composite outcome of chronic PH (chronic PE, chronic cor pulmonale, chronic thromboembolic PH (CTEPH)), right heart failure (RHF), RF, and emergency department (ED) visits, were compared using hazard ratio (HR) with 95% CI.ResultsWe identified 2,978 patients treated with PMT and 1,137 patients treated with CDT. After matching, we compared 1,102 patients in each cohort. For 30-day outcomes, all-cause mortality, acute RF, and blood transfusion were similar between the two groups. However, compared to CDT, PMT was associated with a better safety profile, including lower bleeding risk for both ICH (OR 95% CI = 0.46 0.24-0.890) and GI bleed (OR 95% CI = 0.42 0.28-0.63). PMT also demonstrated better immediate functional outcomes, with less PH (OR 95% CI = 0.53 0.41-0.68) and MI (OR 95% CI = 0.54 0.41-0.76). At 5 years, the all-cause mortality and RF for both procedures were similar, but PMT was associated with lower rates of chronic PH (HR 95%CI = 0.70 0.55-0.90), RHF (HR 95% CI = 0.49 0.37-0.65), and ED visits (348 for PMT versus 426 for CDT, p<0.01).ConclusionsIn patients undergoing catheter-based therapy for PE, PMT has an improved procedural safety profile versus CDT and results in significantly fewer 30-day postoperative complications, with fewer bleeding events, and is also associated with less periprocedural MI and acute PH. Perhaps, more importantly, PMT also demonstrated improved long-term outcomes with significantly fewer chronic PH and RHF diagnoses with fewer ED visits.