What is the clinical evidence from this study?

Study design: Observational. Population: High-risk pulmonary embolism (n=719). Intervention: Mechanical thrombectomy vs. Catheter-directed thrombolysis. Primary outcome: 1-year mortality (HR 1.16, 95% CI 0.84-1.59).

March 24, 2025Open Access

Mechanical Thrombectomy vs Catheter-Directed Thrombolysis for High-Risk Pulmonary Embolism

Key Result

Mechanical thrombectomy resulted in similar 1-year mortality compared to catheter-directed thrombolysis (HR 1.16) in older adults with high-risk pulmonary embolism.

Study Design

Type

Observational (n=719)

Multicenter

Yes

Structured PICO

Does mechanical thrombectomy improve 1-year mortality compared to catheter-directed thrombolysis in older adults with high-risk pulmonary embolism?

Population

719 Medicare fee-for-service beneficiaries aged 65 to 99 years (median age 73, 59.7% female) admitted with high-risk pulmonary embolism (defined by cardiac arrest, shock, and vasopressor use) in the United States.

Intervention

Mechanical thrombectomy (MT) performed within the first 3 days of index hospitalization.

Comparator

Catheter-directed thrombolysis (CDT) performed within the first 3 days of index hospitalization.

Outcome

1-year mortality.hard clinical

In older adults with high-risk pulmonary embolism, mechanical thrombectomy and catheter-directed thrombolysis resulted in similar 1-year mortality and in-hospital outcomes.

Main Result

Effect estimate: HR 1.16 (95% CI 0.84-1.59)

Absolute Event Rate: 48.4% vs 45.4%

Limitations

Subject to unmeasured confounders due to lack of vital signs, pulmonary artery pressure, or imaging data
Detailed information on the treatment regimen was not available
Potential misclassification bias due to reliance on ICD-10 codes
Analysis for health care spending was relatively underpowered
Findings may not be applicable to the younger population

Abstract

BACKGROUND: Evidence is limited regarding the comparative effectiveness and safety of mechanical thrombectomy (MT) vs catheter-directed thrombolysis (CDT) for high-risk pulmonary embolism (PE). OBJECTIVES: This observational study aimed to compare the outcomes of older adults with high-risk PE treated with MT vs CDT using a target trial emulation framework. METHODS: We included Medicare fee-for-service beneficiaries aged 65 to 99 years admitted with high-risk PE (defined by cardiac arrest, shock, and vasopressor use) who underwent MT/CDT from 2017 to 2020. We evaluated 1-year mortality using an inverse probability of treatment weighting approach, controlling for 62 baseline covariates. We also evaluated readmissions and in-hospital outcomes, including intracranial hemorrhage. Patients were followed from the date of the index procedure to the outcomes of interest, 1 year, or December 2020. RESULTS: We included 235 and 484 patients in the MT and CDT groups, respectively. The absolute risk of 1-year mortality was 48.4% (95% CI: 34.1%-63.3%) in the MT group and 45.4% (95% CI: 37.8%-55.8%) in the CDT group, with an adjusted HR of 1.16 (95% CI: 0.84-1.59). We found no evidence that all-cause readmission (MT vs CDT; subdistribution HR: 0.89; 95% CI: 0.56-1.40), intracranial hemorrhage (adjusted OR: 0.36; 95% CI: 0.07-1.77), or transfusions (adjusted OR: 0.96; 95% CI: 0.52-1.76) differed significantly between the 2 groups. CONCLUSIONS: Among older adults with high-risk PE treated with catheter-based therapies, the clinical outcomes were similar between the patients treated with MT vs CDT. Randomized trials are needed to confirm our findings.

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