Comparative effectiveness of suction thrombectomy versus catheter-directed thrombolysis in intermediate-risk pulmonary embolism

Objective: Catheter-directed thrombolysis (CDT) has been shown to rapidly reverse hemodynamic and echocardiographic abnormalities seen in intermediate-risk pulmonary embolism (IRPE). Suction thrombectomy (ST) devices have emerged as alternative treatment modalities demonstrating immediate results, obviating the need for thrombolytics. Comparative data between the two methods are sparse. Methods: We retrospectively reviewed interventions for IRPE (CDT or ST) at a multihospital health care system (2017-2022). IRPE was defined by evidence of right heart strain (RHS) on imaging (echocardiogram and/or computed tomography angiography) or elevated biomarkers (troponin or B-natriuretic peptide). Patients with high-risk PE (systolic blood pressure <90 mmHg) or those who received systemic thrombolytics were excluded. The primary endpoint was a composite of 7-day all-cause mortality, intracranial bleeding, major bleeding, clinical deterioration, and/or need for bailout therapy. Secondary outcomes included the primary endpoint individual components, intensive care unit length of stay, 30-day mortality, and resolution of RHS at 3 months. Inverse probability of treatment weighting (IPTW) was used to adjust for baseline imbalances between groups, generating weighted odds ratios (wORs). Results: A total of 332 patients were included, with 152 patients with CDT and 180 with ST. IPTW successfully balanced baseline differences between groups (Table I). On univariable analysis, the primary outcome did not differ between groups (CDT 6.6% vs ST 12.8%; P = .06), but ST was associated with increased 30-day mortality (CDT 1.3% vs ST 5.5%; P = .039) and the need for bailout intervention (CDT 4.6% vs ST 11.1%; P = .031). Major bleeding occurred in 3.3% CDT vs 2.2% ST (P = .551). There were no intracranial bleeds. Post-IPTW analysis showed a significantly higher rate of the primary outcome in the ST group (wOR, 4.4; 95% confidence interval [CI], 1.27-15.3; P = .02). There were no differences in 7-day mortality, 30-day mortality, major bleeding, or intracranial bleeding. The need for bailout intervention was significantly higher in the ST group (wOR, 3.7; 95% CI, 1.04-13.4; P = .044). The use of ST was significantly associated with resolution of RHS (wOR, 3.46; 95% CI, 1.32-9.11; P = .012). Conclusions: ST is associated with significantly increased odds of the primary outcome in patients with IRPE when compared with CDT after IPTW. These results were mainly driven by the bailout intervention rate. There was no statistically significant reduction in major bleeding or intensive care unit length of stay compared with CDT. RHS resolved more frequently in patients after ST, suggesting there may be benefit to rapid thrombus removal in appropriately selected patients with IPRE despite the increased need for bailout therapy. CDT should remain an integral part of the interventional armamentarium in IRPE.