Endovascular reperfusion strategies for pregnancy-related pulmonary embolism: a systematic review

Management of acute pulmonary embolism (PE) during pregnancy or post-partum is challenging especially in women at intermediate or high-risk of adverse outcomes. Catheter-directed therapies (CDTs) are increasingly used given their potential efficacy and relatively low complication rates. We systematically reviewed the evidence on CDTs use in pregnancy and post-partum PE. Literature search was conducted in bibliographic databases, reference lists, and review articles until 2 July 2025, without restrictions. Main efficacy and safety outcomes were maternal all-cause and PE-related mortality, fetal mortality, improved right ventricle dysfunction (RVD) and/or pulmonary artery (PA) pressures, improved lung perfusion/clot burden reduction, and maternal major bleeding (MB). We identified 65 case reports, 4 case series and 1 cohort study for a total of 76 patients. Maternal all-cause mortality within 7 days from CDT was 2.8% (2/72; 95% confidence interval [CI], 0.3-9.7%) with no PE-related deaths. In-hospital fetal mortality was 12.5% (5/40; 95% CI, 4.2-26.8%). Within 72 h from CDT were observed: an improvement of RVD and/or PA pressures in 96.2% (25/26; 95% CI, 80.4-99.9%), and in lung perfusion/reduction in clot burden in 94.4% of cases (34/36; 95% CI, 81.3-99.3%); maternal MB in 17.2% of cases (11/64; 95% CI, 8.9-28.7%), with 10 out of 11 events (90.9%) reported in the post-partum period. Current evidence is limited and of low quality. CDTs should be considered only after a multidisciplinary evaluation of selected cases, balancing potential benefits and bleeding risks, the latter being mainly observed in the post-partum.