Comparison of interventions for intermediate to high‐risk pulmonary embolism: A network meta‐analysis

Abstract

Background Multiple interventions, including catheter‐directed therapy (CDT), systemic thrombolysis (ST), surgical embolectomy (SE), and therapeutic anticoagulation (AC) have been used to treat intermediate to high‐risk pulmonary embolism (PE), but the most effective and safest treatment remains unclear. Our study aimed to investigate the efficacy and safety outcomes of each intervention. Methods We queried PubMed and EMBASE in January 2023 and performed a network meta‐analysis of observational studies and randomized controlled trials (RCT), including high or intermediate‐risk PE patients, and comparing AC, CDT, SE, and ST. The primary outcomes were in‐hospital mortality and major bleeding. The secondary outcomes included long‐term mortality (≥6 months), recurrent PE, minor bleeding, and intracranial hemorrhage. Results We identified 11 RCTs and 42 observational studies involving 157,454 patients. CDT was associated with lower in‐hospital mortality than ST (odds ratio [OR] [95% confidence interval (CI)]: 0.41 [0.31−0.55]), AC (OR [95% CI]: 0.33 [0.20−0.53]), and SE (OR [95% CI]: 0.61 [0.39−0.96]). Recurrent PE in CDT was lower than ST (OR [95% CI]: 0.66 [0.50−0.87]), AC (OR [95% CI]: 0.36 [0.20−0.66]), and trended lower than SE (OR [95% CI]: 0.71 [0.40−1.26]). Notably, ST had higher major bleeding risks than CDT (OR [95% CI]: 1.51 [1.19−1.91]) and AC (OR [95% CI]: 2.21 [1.53−3.19]). By rankogram analysis, CDT presented the highest p‐score in in‐hospital mortality, long‐term mortality, and recurrent PE. Conclusion In this network meta‐analysis of observational studies and RCTs involving patients with intermediate to high‐risk PE, CDT was associated with improved mortality outcomes compared to other therapies, without significant additional bleeding risk.

Intensive Care Treatment of Pulmonary Embolism: An Update Based on the Revised AWMF S2k Guideline

“…4 A recent network meta-analysis of observational studies and RCTs involving patients with intermediate-to high-risk PE showed a reduced mortality rate when utilising CDT compared with other therapeutic procedures without significant additional bleeding risk. 35 The indication for catheter-based treatment of acute PE requires-like IV thrombolysis-a manifest or impending circulatory instability. It is therefore an acute situation, so that reperfusion treatment (in analogy to acute ST elevation myocardial infarction) should begin as soon as possible after indication.…”

Current Insights for Catheter-Directed Therapies in Acute Pulmonary Embolism: Systematic Review and Our Single-Center Experience

“…In a network meta-analysis comparing the CDT, systemic TT, surgical embolectomy, and anticoagulant therapies in patients at IR to HR groups, CDT was found to be associated with significant reductions in in-hospital mortality, PE recurrence, and major bleeding rates as compared to the other 3 treatment modalities and reductions in long-term mortality equivalent to surgical embolectomy. 47 …”

Percutaneous mechanical thrombectomy in acute pulmonary embolism: Outcomes from a safety‐net hospital

“…3 While ST is recommended as first-line treatment for hemodynamically unstable PE, it has been estimated that more than half of high-risk PE patients do not received ST due to absolute or relative contraindications. 4 Though the use catheter-directed thrombolysis (CDT) allows for a reduced dose of thrombolytic therapy and has been associated with improved outcomes compared to ST, [5][6][7] it is still associated with major bleeding rates of up to 10%, including a risk of intracerebral hemorrhage (ICH) of up to 2%. 2,7 These concerns have led to growing interest in percutaneous mechanical thrombectomy (MT) as an alternative therapy for this population.…”