Catheter-Directed thrombolysis in intermediate-high-risk pulmonary embolism: experience of a safe and potentially beneficial technique for right ventricular function recovery

Abstract Background In acute pulmonary embolism (PE), risk stratification guides treatment intensity. Guidelines recommend anticoagulation alone for intermediate–low-risk PE and systemic thrombolysis for high-risk cases. However, optimal management of intermediate–high-risk PE—particularly in patients with right ventricular (RV) dysfunction—remains unclear. Catheter-directed thrombolysis (CDT) may achieve early haemodynamic improvement and RV recovery while potentially reducing bleeding risk compared with systemic fibrinolysis, yet real-world evidence is limited. Purpose To describe our real-world experience with CDT in intermediate–high-risk PE and compare clinical, analytical, and echocardiographic outcomes with standard anticoagulation. Methods We conducted a retrospective observational study including consecutive patients with intermediate–high-risk PE at our centre from May 2024 to September 2025. Patients received either standard anticoagulation alone or CDT on top of standard of care (SOC). Baseline demographic, clinical, analytical, and echocardiographic parameters were collected. Primary endpoints were all-cause mortality, major bleeding, and persistent RV dysfunction or dilation at 3 months. Comparisons were performed using Chi-square or Fisher’s exact tests for categorical variables and Student’s t-test or Mann–Whitney U test for continuous variables, as appropriate. Results Forty-nine patients were included (12 CDT). Baseline characteristics were generally comparable, although the CDT group showed a trend toward more severe disease, with higher rates of hypotension (33% vs. 0%; p = 0.002), tachycardia (67% vs. 35%; p = 0.055), elevated lactate (median 3.0 vs. 2.0 mmol/L; p = 0.004), higher troponin (median 141.5 vs. 67 ng/L; p = 0.15) and proBNP (median 2,115 vs. 1,340 pg/mL; p = 0.16), and more frequent RV dilatation (92% vs. 65%; p = 0.07) and dysfunction (92% vs. 70%; p = 0.13). At 3 months, all-cause mortality was 16.7% in CDT versus 5.4% in the SOC group (p = 0.24). Major bleeding occurred in 25.0% of CDT patients versus 5.4% in SOC (p = 0.08). Persistent RV dysfunction or dilation occurred in 0% of CDT patients versus 27.6% in SOC (p = 0.30). While differences did not reach statistical significance, there was a clear trend toward improved RV recovery in CDT-treated patients, particularly among those with baseline RV dilation or dysfunction. Conclusions In this real-world cohort of intermediate–high-risk PE patients, catheter-directed thrombolysis was feasible and, although mortality and major bleeding rates were higher in the CDT group, these differences did not reach statistical significance and likely reflect the more severe baseline profile of these patients. Importantly, CDT was associated with a trend toward improved right ventricular recovery compared with anticoagulation alone. These findings support further prospective studies with larger cohorts to clarify the safety and efficacy of CDT in this population.Baseline characteristics and outcomes Bilateral Pulmonary Embolism