Catheter-directed therapies improved RV:LV ratio (aspiration thrombectomy MD -0.53; 95% CI -0.70 to -0.36) but did not significantly reduce mortality compared to anticoagulation (p>0.10).
Meta-Analysis (n=5,815)
Do catheter-directed therapies reduce mortality or major bleeding compared to conventional anticoagulation in patients with acute pulmonary embolism?
In acute pulmonary embolism, catheter-directed therapies provide superior hemodynamic recovery (RV:LV ratio improvement) compared to anticoagulation alone, but do not significantly improve mortality or major bleeding.
Effect estimate: RR 1.14 (95% CI 0.15-8.70)
p-value: p=>0.10
Abstract Introduction Pulmonary embolism remains a major cause of preventable hospital mortality. Conventional anticoagulation is often inadequate for intermediate- and high-risk patients, prompting investigation of catheter-directed therapies (CDTs) and mechanical interventions. Comparative efficacy and safety data among these modalities remain limited. Methods A systematic review and network meta-analysis were conducted on 24 studies comprising 5,815 patients, including randomized controlled trials and observational studies published through October 2025. Twelve treatment strategies were evaluated for mortality (19 studies), eleven for bleeding (18 studies), and eight for hemodynamic outcomes (7 studies). Primary outcomes were all-cause mortality and major bleeding events, reported as relative risks (RR) with 95% confidence intervals (CI). Secondary outcomes included changes in right ventricular-to-left ventricular (RV:LV) ratio, expressed as mean differences (MD). Analyses employed a frequentist graph-theoretical approach using R software with DerSimonian-Laird estimator. P-scores were computed to rank treatments. Results No intervention demonstrated statistically significant mortality reduction compared with anticoagulation (all p-values 0.10; mortality heterogeneity I²=11.5%). Aspiration thrombectomy showed a mortality RR of 1.14 (95% CI: 0.15-8.70). Major bleeding analysis revealed high heterogeneity (I²=65.5%) and no significant risk reduction; suction thrombectomy (RR 8.68, 95% CI: 0.20-382.88) and catheter-directed thrombolysis (RR 7.71, 95% CI: 0.47-125.64) demonstrated nonsignificant numerically higher bleeding risk. RV:LV ratio analysis revealed significant hemodynamic improvement for aspiration thrombectomy (MD − 0.53, 95% CI − 0.70 to − 0.36, p 0.0001, P-score 0.929), standard CDT (MD − 0.48, 95% CI − 0.69 to − 0.27, p 0.0001, P-score 0.843), surgical intervention (MD − 0.45, 95% CI − 0.64 to − 0.26, p 0.0001, P-score 0.794), systemic thrombolysis (MD − 0.29, 95% CI − 0.42 to − 0.16, p 0.0001, P-score 0.570), and ultrasound-assisted thrombolysis (MD − 0.26, 95% CI − 0.39 to − 0.13, p 0.0001, P-score 0.421). Conclusions Catheter-directed therapies offer superior hemodynamic recovery over anticoagulation but do not improve mortality or major bleeding in acute PE. Aspiration thrombectomy and standard CDT provide the greatest RV dysfunction improvements, supporting individualized treatment decisions based on hemodynamic markers. The considerable bleeding heterogeneity emphasizes the importance of patient-specific risk assessment. Further large-scale randomized trials are essential to clarify optimal treatment strategies for intermediate- and high-risk PE. This abstract is funded by: None
Suresh et al. (2026) conducted a meta-analysis in Acute Pulmonary Embolism (n=5,815). Catheter-directed therapies and mechanical interventions vs. Conventional anticoagulation was evaluated on All-cause mortality and major bleeding events (RR 1.14, 95% CI 0.15-8.70, p=>0.10). Catheter-directed therapies improved RV:LV ratio (aspiration thrombectomy MD -0.53; 95% CI -0.70 to -0.36) but did not significantly reduce mortality compared to anticoagulation (p>0.10).