Has systemic thrombolysis run its course? A systematic review and network meta-analysis of patients with...

Traditionally, first-line reperfusion strategy recommendation for patients with hemodynamically significant pulmonary embolism (PE) is systemic thrombolysis (ST). ST is associated with serious adverse events. Surgical embolectomy (SE) and catheter-directed interventions (CDI) are reported to be safe, improve right ventricular (RV) function and survival.

To compare the outcomes of patients with hemodynamically significant PE treated with CDI or SE to ST.

We systematically reviewed studies of patients with intermediate- or high-risk PE that received reperfusion therapy. The primary outcome was in-hospital mortality. Secondary outcomes included major bleeding and right ventricular function. We conducted a network meta-analysis and generated pooled survival curves using approximated individual-level time-to-event data.

Of 4283 studies identified, 15 studies were included in the final analysis involving 1598 patients (CDI = 683 patients, SE = 224, ST = 691), encompassing 3595.5 patient years. A network meta-analysis revealed a significant decrease in early mortality in patients treated with CDI or SE compared to ST (odds-ratio (OR) 0.34, 95 %-confidence interval (CI) 0.17-0.0.68, and OR = 0.37, 95 % CI (0.16-9.85), respectively). Ranking the different therapeutic modalities, CDI had the highest P-score (0.87), followed by SE (0.63), and ST (0.0008). Compared to ST, CDI resulted in less RV dysfunction (OR = 0.28, 95 % CI (0.1-0.76) and a trend for less bleeding complications.

In this study, CDI and SE were associated with superior survival compared to ST in patients with moderate- and high-risk PE. CDI resulted in improved RV function. Well-designed randomized controlled trials are needed to confirm these findings and inform future guideline recommendations.