Percutaneous thrombectomy in patients with intermediate- and high-risk pulmonary embolism and contraindications to thrombolytics: a systematic review and meta-analysis

Abstract

Catheter-directed interventions have slowly been gaining ground in the treatment of pulmonary embolism (PE), especially in patients with increased risk of bleeding. The goal of this study is to summarize the evidence for the efficacy and safety of percutaneous thrombectomy (PT) in patients with contraindications to systemic and local thrombolysis. We performed a systematic review and meta-analysis using MEDLINE, Cochrane, Scopus and the Web of Science databases for studies from inception to March 2022. We included patients with intermediate- and high-risk PE with contraindications to thrombolysis; patients who received systematic or local thrombolysis were excluded. Primary endpoint was in-hospital and 30-day mortality, with secondary outcomes based on hemodynamic and radiographic changes. Major bleeding events were assessed as a safety endpoint. Seventeen studies enrolled 455 patients, with a mean age of 58.6 years and encompassing 50.4% females. In-hospital and 30-day mortality rates were 4% (95% CI 3-6%) and 5% (95% CI 3-9%) for all-comers, respectively. We found a post-procedural reduction in systolic and mean pulmonary arterial pressures by 15.4 mmHg (95% CI 7-23.7) and 10.3 mmHg (95% CI 3.1-17.5) respectively. The RV/LV ratio and Miller Index were reduced by 0.42 (95% CI 0.38-46) and 7.8 (95% CI 5.2-10.5). Major bleeding events occurred in 4% (95% CI 3-6%). This is the first meta-analysis to report pooled outcomes on PT in intermediate- and high-risk PE patients without the use of systemic or local thrombolytics. The overall mortality rate is comparable to other contemporary treatments, and is an important modality particularly in those with contraindications for adjunctive thrombolytic therapy. Further studies are needed to understand the interplay of anticoagulation with PT and catheter-directed thrombolysis.

Keywords: Bleeding; Hemodynamics; Mortality; Percutaneous thrombectomy; Pulmonary embolism.

Fig. 1

PRISMA 2020 Flowdiagram

Fig. 2

Pooled proportional incidence of in-hospital mortality in intermediate, intermediate-high and high risk PE patients

Fig. 3

Pooled proportional incidence of 30-day mortality in intermediate, intermediate-high and high risk PE patients

Fig. 4

a Absolute mean difference reduction in heart rate reduction pre and post procedure; b Absolute mean difference reduction in O₂ saturation on pulse oximetry pre and post procedure; c Absolute mean difference reduction in systolic blood pressure pre and post procedure; MD mean difference

Fig. 5

a Absolute mean difference in sPAP pre and post procedure; b Absolute mean difference in mPAP pre and post procedure; MD mean difference

Fig. 6

a Absolute mean difference reduction in RV/LV Ratio pre and post procedure; b Absolute mean difference reduction in Miller index pre and post procedure; MD mean difference

Fig. 7

Pooled proportional incidence of major bleeding post-procedurally in intermediate, intermediate-high and high risk PE patients