CANCARE RESEARCH
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Catheter-Directed Thrombolysis Plus Anticoagulation versus Anticoagulation Alone for Acute Intermediate-Risk Pulmonary Embolism: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Clinical takeaway The pooled trials suggest less early deterioration with catheter-directed thrombolysis, but no mortality difference was demonstrated. Increased bleeding and access-site complications temper the early efficacy findings.
Summary & abstract
Study summary
This meta-analysis included six randomized trials involving 886 patients with acute intermediate-risk pulmonary embolism. Compared with anticoagulation alone, adding catheter-directed thrombolysis reduced the RV/LV ratio (mean difference −0.11, 95% CI −0.21 to −0.00) and early cardiorespiratory deterioration (risk ratio 0.36, 95% CI 0.19–0.68). Mortality did not differ between groups. Major bleeding was not significantly different, but its estimate remained imprecise (risk ratio 1.52, 95% CI 0.71–3.24). Any bleeding and vascular access-site complications or hematomas were significantly more frequent with catheter-directed thrombolysis, highlighting a trade-off between early improvement and procedural harms.
Study limitation: The major-bleeding confidence interval permits substantial harm; larger trials with longer follow-up are needed to clarify sustained clinical outcomes.
Published abstract
Systemic anticoagulation is the standard initial therapy for intermediate-risk pulmonary embolism (PE) but fails to reverse right ventricular (RV) overload rapidly. While full-dose systemic thrombolysis accelerates RV recovery, it carries an unacceptable risk of major hemorrhage. Catheter-directed thrombolysis (CDT) offers a targeted, low-dose alternative to improve hemodynamics safely. A comprehensive search of PubMed, Web of Science, CENTRAL, Scopus, and Embase was conducted up to May 2026. Mean differences (MD) and risk ratios (RR) were pooled using a random-effects model. PROSPERO ID: CRD420261402147. Six RCTs involving 886 patients were included. CDT was associated with a significantly greater reduction in the RV/LV ratio than anticoagulation alone (MD: -0.11, 95% CI: [-0.21, -0.00]; P < 0.05). Also, CDT significantly reduced the risk of early cardiorespiratory deterioration (RR: 0.36, 95% CI [0.19, 0.68]; P < 0.001). There was no significant increase in major bleeding (RR: 1.52, 95% CI [0.71, 3.24]; P = 0.28) or intracranial hemorrhage. However, CDT significantly increased the risk of any bleeding ( P = 0.02) and vascular access-site complications/hematomas ( P = 0.02). Mortality did not differ between the two groups. Adding CDT to standard systemic anticoagulation led to a statistically significant reduction in the RV/LV ratio compared with anticoagulation alone, with a significantly lower risk of early hemodynamic and cardiorespiratory deterioration, without increasing the risk of major bleeding or intracranial hemorrhage in patients with acute intermediate-risk PE. However, larger RCTs with longer follow-up are required to provide a clearer picture of its sustained effects on hard clinical outcomes.
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