Catheter-directed interventions, systemic thrombolysis and surgical embolectomy for intermediate-high risk pulmonary embolism: a systematic review and network meta-analysis

Objectives: The optimal therapy for patients with intermediate- or high-risk pulmonary embolism (PE) is still contested. The therapeutic arsenal includes systemic thrombolysis, surgical embolectomy and catheter-based interventions. The aim of this work was to compare the efficacies of the different therapy strategies.

Methods: Electronic databases including Embase, PubMed and Cochrane Library were searched from inception to September 21st, 2024. A systematic review of the literature was conducted to include cohort studies, case-control studies and randomized-controlled trials that compared the outcomes of systemic thrombolysis (ST) with catheter-directed interventions (CDI) or surgical embolectomy (SE) in patients with intermediate- or high-risk PE. The primary outcome was early mortality (defined as 30-day mortality or operative mortality). Secondary outcomes included major bleeding, intracerebral bleeding and minor bleeding.

Results: Of 4283 studies identified, 16 studies were included in the final analysis involving 4469 patients (CDI = 2038 patients, SE = 266, ST = 2165). A network meta-analysis revealed a significant decrease in early mortality in patients treated with CDI (odds-ratio (OR) 0.42, 95%-confidence interval (CI) 0.34-0.53, p<0.0001) or surgical embolectomy (OR 0.55, 95%-CI 0.29-1.03, p=0.06) compared with ST. Ranking the different therapeutic modalities, CDI had the highest P-score (0.89), followed by surgical embolectomy (0.59), and systemic thrombolysis (0.016). Bleeding complications were less prevalent in patients subjected to CDI as opposed to ST (OR 0.44, 95%-CI 0.29-0.67, p<0.001) but were not different in patients that underwent SE (p=0.9).

Conclusions: In this network meta-analysis, CDI resulted in better outcomes than SE and ST in patients with moderate-high risk PE. SE demonstrated a trend of better survival. Patients treated with CDI also suffered significantly less from major bleeding.