Outcomes of catheter-directed versus systemic thrombolysis for the treatment of pulmonary embolism: A real-world analysis of national administrative claims

Abstract

Catheter-directed thrombolysis (CDT) and systemic thrombolysis (ST) are used to treat intermediate/high-risk pulmonary embolism (PE) in the absence of comparative safety and effectiveness data. We utilized a large administrative database to perform a comparative safety and effectiveness analysis of catheter-directed versus systemic thrombolysis. From the Optum® Clinformatics® Data Mart private-payer insurance claims database, we identified 100,744 patients hospitalized with PE between 2004 and 2014. We extracted demographic characteristics, high-risk PE features, components of the Elixhauser Comorbidity Index, and outcomes including intracranial hemorrhage (ICH), all-cause bleeding, and mortality among all patients receiving CDT and ST. We used propensity score methods to compare outcomes between matched cohorts adjusted for observed confounders. A total of 1915 patients (1.9%) received either CDT ( n = 632) or ST ( n = 1283). Patients in the CDT group had fewer high-risk features including less shock (5.4 vs 11.1%; p < 0.001) and cardiac arrest (6.8 vs 11.0%; p = 0.004). In 1:1 propensity-matched groups, ICH rates were 1.9% in both the CDT and ST groups ( p = 1.0). All-cause bleeding was higher in the CDT group (15.9 vs 8.7%; p < 0.001), while in-hospital mortality was lower (6.5 vs 10.0%; p = 0.02). Among a nationally representative cohort of patients with PE at higher risk for mortality, CDT was associated with similar ICH rates, increased all-cause bleeding, and lower short and intermediate-term mortality when compared with ST. The competing risks and benefits of CDT in real-world practice suggest the need for large-scale randomized clinical trials with appropriate comparator arms.

Short-term effects of fibrinolytic therapy on the hemodynamic parameters of patients with intermediate- and high-risk pulmonary embolism

“…Intracranial bleeding is one of the most undesirable complications of fibrinolytic therapy. Here, only one patient (1.3%) had intracranial bleeding; the rate of intracranial bleeding was 3% in the ICOPER study [ 8 ], 5% in the study by Fiumara et al 12 2% in the study by Kanter et al [ 15 ] and 1.4% in the study by Geller et al [ 14 ].…”

“…Table 5 shows the rates of bleeding complications reported in previous studies [ 8 , 10 - 14 ]. The ICOPER study reported that major bleeding occurred in 21.7% of patients receiving fibrinolytic therapy [ 8 ].…”

Abnormal wire’s trajectory during edge-to-edge mitral valve repair—a rare case report of inferior vena cava anomaly

“… 2 New techniques and devices are continually developing to treat valvular diseases, heart defects, pulmonary embolism, and arrhythmias and require using femoral veins as preferred access. 3 , 4 …”

Advanced management of intermediate-high risk pulmonary embolism

“…Catheter-directed thrombolysis is when low-dose fibrinolytic agents are directly injected into the pulmonary artery at a slow infusion rate, often over the course of 12-24 h. The theoretical advantage of this technique is that the fibrinolytic infusion is at the site of thrombosis and a lower dose of fibrinolytics can be given despite longer exposure. There is conflicting evidence as to whether catheter-directed thrombolysis has less bleeding risk compared to systemic thrombolysis [30,31].…”