Catheter-Directed Thrombolysis for Intermediate- and High-Risk Pulmonary Embolism

Patients with high-risk pulmonary embolism (PE) — essentially those with hemodynamic instability — benefit from systemic thrombolysis. In contrast, patients with intermediate-risk PE (i.e., either signs of right ventricular dysfunction or high score on the pulmonary embolism severity index [PESI] or simplified PESI) generally receive guideline-recommended anticoagulation. A third option is catheter-directed thrombolysis (CDT), which uses less than one quarter of the dose used for systemic thrombolysis. However, whether catheter-directed thrombolysis (CDT) can benefit patients at either high or intermediate risk remains controversial. This network meta-analysis of 44 randomized and observational studies (20,000 patients) included studies of patients with intermediate- or high-risk PE (see original open-access article for definitions of intermediate and high risk).

Patients who received CDT had significantly lower mortality than did patients who received systemic thrombolysis (odds ratio, 0.43) or anticoagulation (OR, 0.36). CDT was also associated with significantly lower risk for major bleeding (OR, 0.61) — including less intracranial hemorrhage (OR, 0.44) — compared with systemic thrombolysis. Major bleeding and intracranial hemorrhage were similar in CDT and anticoagulation patients.