Catheter-Based Interventions Have Little to No Benefit in Intermediate-Low Risk Pulmonary Embolism

Abstract

Objective: Catheter-based therapies (CBT) have become established treatments for high-risk pulmonary embolism (PE). Anecdotally, these therapies are increasingly used in lower-risk patients despite unclear efficacy. We evaluated the use of CBT for PE in an intermediate-low risk stratified population versus anticoagulation and systemic thrombolysis.

Methods: In this multicenter retrospective cohort study, three intermediate-low risk PE cohorts were identified using the TriNetX database, defined as normotensive PE patients with evidence of right heart strain on echocardiography, but without elevated cardiac biomarkers from December 2010 - December 2024. The treatment cohorts were: anticoagulation only (AC), systemic thrombolysis (ST), or catheter-based therapy (CBT), including catheter-directed thrombolysis and mechanical thrombectomy. Cohorts were 1:1 propensity-score matched based on demographics and comorbidities. Study outcomes included mortality, bleeding complications, and pulmonary hypertension on periprocedural (30-day) and long-term (3-year) timeframes, using odds ratio (OR) with 95% confidence interval (CI).

Results: AC, ST, and CBT cohorts included 52,141, 3,277, and 2,378 patients, respectively. The incidence of CBT increased markedly during the study period (387%). Of CBT procedures, 45.5% received catheter-directed thrombolysis and 52.0% received mechanical thrombectomy. When comparing CBT to AC, there was no mortality difference at any timeframe. 30-day intracranial hemorrhage (ICH) was greater in CBT (OR [95% CI] = 2.12 [1.00-4.50], p = 0.047), while the 3-year rates were comparable. Conversely, the rate of gastrointestinal (GI) bleeding was significantly lower with CBT at 3 years (OR [95% CI] = 1.45 [1.06-2.00], p = 0.02), but this difference was insignificant in a subgroup analysis among patients treated with direct oral anticoagulants. 3-year pulmonary hypertension rates were low in all cohorts (0.73-1.81%). ST carried universally high mortality in all timeframes (versus AC at 3 years (OR [95% CI] = 2.95 [2.54-3.41], p < 0.01), versus CBT at 3 years (OR [95% CI] = 3.27 [2.54-4.22], p < 0.01)). Periprocedural bleeding complication rates were higher versus AC for both ICH (OR [95% CI] = 3.34 [1.99-5.60], p < 0.01) and GI bleeding (OR [95% CI] = 1.38 [0.90-2.13], p = 0.14), but comparable versus CBT.

Conclusions: Despite a marked increase in the utilization of CBT in an intermediate-low risk PE population, CBT offers minimal benefit in mortality, gastrointestinal bleeding, or pulmonary hypertension over AC, with greater perioperative ICH risk. ST carries unacceptably high mortality and bleeding complication rates compared to AC. More granular data is needed to optimize patient selection and treatment modality for intermediate-low risk PE patients.

Keywords: catheter-based intervention; pulmonary embolism; pulmonary hypertension; systemic anticoagulation; systemic thrombolysis.