Catheter-directed interventions versus surgical embolectomy in massive pulmonary embolism

Catheter-directed intervention (CDI) use in massive pulmonary embolism (PE) is rarely studied due to guideline recommendations for systemic thrombolysis (stPA). Nevertheless, surgical embolectomy (SE) and CDI remain well-accepted alternatives in massive PE management, particularly when patients have contraindications to or do not improve after stPA. We hypothesized that CDI and SE have comparable outcomes in the treatment of massive PE.

We conducted a retrospective review of patients presenting with massive PE who underwent CDI or SE at a multihospital health care system (2010-2024). Baseline characteristics, in-hospital outcomes, and long-term mortality were recorded. Data was analyzed using Kaplan-Meier survival curves and multivariate Cox regression.

A total of 99 patients with massive PE were analyzed, with 24 (24.2%) undergoing SE and 75 (75.8%) receiving CDI (41 suction thrombectomies and 34 catheter-directed thrombolysis). SE and CDI baseline characteristics were similar with mean age of 58.5 years in SE and 64.5 years in CDI (P = .09). The majority in both groups had absolute (CDI, 17.3%; SE, 16.7%; P = .94) or relative contraindication (CDI, 58.7%; SE, 66.7%; P = .49) to stPA. The use of preoperative stPA was similar in both groups (CDI, 13.3%; SE, 25.0%; P = .21). Median time to procedure was also similar (CDI, 14.3 hours; SE, 18.5 hours; P = .42). CDI was associated with a lower total intensive care unit (ICU) length of stay (LOS) (median, 2.2 vs 3.3 days; P = .04) and lower major bleeding complications (9.3% vs 79.2%; P < .001). However, there was no statistically significant difference in fatal bleeding (CDI, 5.33%; SE, 4.17%; P = 1.00), need for bailout intervention (CDI, 8.0%; SE, 16.7%; P = .25), resolution of right heart strain (CDI, 27.8%; SE, 41.2%; P = .37), or median hospital LOS (CDI, 8 days; SE, 5 days; P = .12) between both groups. In-hospital mortality occurred equally (CDI, 21.3%; SE, 20.8%; P = 1.00). On Kaplan-Meier analysis, there was no survival difference between the two groups. On Cox regression, procedure type was not a significant predictor for mortality (adjusted hazard ratio 1.36; 95% confidence interval, 0.58-3.20; reference: SE).

CDI is a minimally invasive alternative to SE in massive PE and offers comparable outcomes and similar survival rates. Nevertheless, CDI offers advantages in terms of shorter ICU stay and fewer major bleeding complications.