Anticoagulation, Catheter-Directed or Systemic Thrombolysis in PE

Oct 20, 2023
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Authors:
Zhang RS, Maqsood MH, Sharp AS, et al.
Citation:
Efficacy and Safety of Anticoagulation, Catheter-Directed Thrombolysis, or Systemic Thrombolysis in Acute Pulmonary Embolism. JACC Cardiovasc Interv 2023;Oct 18:[Epublished].
Summary By:
Debabrata Mukherjee, MD, FACC

Quick Takes

  • Catheter-directed thrombolysis (CDT) was associated with lower all-cause mortality in patients with acute PE when compared with anticoagulation alone.
  • Of note, CDT was associated with increased major bleeding and numerically higher ICH when compared with anticoagulation alone, but these rates were lower when compared with systemic thrombolytics.
  • Prospective randomized trials are needed to validate these findings, and assess the efficacy and safety of these approaches.

Study Questions:

What is the efficacy and safety of anticoagulation (AC) alone, catheter-directed thrombolysis (CDT), and systemic thrombolysis (ST) in patients with acute pulmonary embolism (PE)?

Methods:

The investigators searched PubMed and EMBASE for randomized controlled trials (RCTs) or observational studies, which compared outcomes of AC alone, CDT, and ST in acute PE. Efficacy outcome was all-cause mortality. Safety outcomes were major bleeding and intracranial hemorrhage (ICH). The authors presented a random effects model so as to have a conservative interpretation, given data are from largely nonrandomized studies.

Results:

The investigators identified 45 studies (17 RCTs, two prospective nonrandomized, and 26 retrospective observational trials), which included 81,705 patients. When compared to AC alone, CDT had lower mortality (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.39-0.80), but higher major bleeding (OR, 1.84; 95% CI, 1.10-3.08) and numerically higher ICH (OR, 1.51; 95% CI, 0.75-3.04). ST was associated with no difference in mortality but higher major bleeding (OR, 2.16; 95% CI, 1.38-3.38) and ICH (OR, 2.26; 95% CI, 1.14-4.48) when compared to AC alone. The risk of mortality (OR, 2.05; 95% CI, 1.46-2.89) and ICH (OR, 1.50; 95% CI, 1.13-1.99) was higher with ST when compared to CDT. Findings were similar when analysis was restricted to trials of intermediate-risk PE.

Conclusions:

The authors report that in patients with acute PE, when compared with AC alone, CDT was associated with a lower mortality but higher risk of bleeding.

Perspective:

This study reports that CDT was associated with lower all-cause mortality in patients with acute PE when compared with AC alone, even when restricting the analysis to the subgroup of patients with intermediate-risk PE. Furthermore, CDT was associated with increased major bleeding and numerically higher ICH when compared with AC alone, but these rates were lower when compared with systemic thrombolytics. Prospective randomized trials are needed to validate these findings, and assess the efficacy and safety of these approaches.

Clinical Topics: Anticoagulation Management, Vascular Medicine

Keywords: Anticoagulants, Pulmonary Embolism, Thrombolytic Therapy


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