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.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.
Short and long-term outcomes of intermediate-high risk pulmonary embolism treated with catheter-directed reperfusion therapy versus anticoagulation.
Clinical takeaway Catheter-directed intervention was associated with lower mortality and post-discharge morbidity, but this observational comparison does not establish benefit. Randomized trials with long-term patient-centred outcomes are needed.
Summary & abstract
Study summary
This retrospective US cohort compared catheter-directed intervention with anticoagulation for hospitalized intermediate-high risk pulmonary embolism, including 50,614 patients in short-term analyses. After overlap weighting, intervention was associated with lower 30-day mortality (adjusted HR 0.70; 95% CI 0.66–0.73). Among discharge survivors, intervention was associated with fewer heart-failure readmissions (aHR 0.79; 95% CI 0.75–0.83), respiratory-failure readmissions (0.85; 0.81–0.90), and less chronic oxygen use (0.69; 0.65–0.74). Post-discharge analyses included 49,122 patients; the abstract did not specify the duration of long-term follow-up.
Study limitation: Residual confounding may explain associations despite weighting; bleeding results and the duration of post-discharge follow-up were not reported.
Published abstract
BACKGROUND: Treatment of intermediate-high risk pulmonary embolism (PE) with catheter directed therapy remains a topic of controversy. It is unknown if long-term post-hospitalization outcomes of these patients are improved compared to anticoagulation. RESEARCH QUESTION: What is the comparative effectiveness of catheter-directed reperfusion therapy versus conventional anticoagulation on both short- and long-term outcomes among patients with intermediate-high risk PE? STUDY DESIGN AND METHODS: This was a retrospective cohort study of hospitalized patients in the United States with intermediate-high risk pulmonary embolism between 2010 and 2024 from a multi-institutional aggregated electronic health record database. Patients were categorized as receiving catheter-directed intervention (CDI) or conventional anticoagulation and followed for 30-day mortality, bleeding and procedural complications (short-term outcomes) and, among those who survived discharge, for readmission related to heart failure or respiratory failure, oxygen dependence, and pulmonary hypertension related diagnosis (long-term outcomes). Overlap weighting was used to balance characteristics between patients in both groups and weighted hazard ratios were calculated. RESULTS: After application of a specific phenotype definition integrating diagnosis codes, vital signs, and laboratory biomarkers to identify patients with intermediate high-risk PE in a large-scale data set, a total of 50,614 patients were included in the analysis of short-term outcomes and 49,122 were included in the analysis of post-discharge outcomes. CDI was associated with a lower hazard of death in both crude (HR 0.56; 95% CI 0.53-0.59, p < 0.001) and adjusted comparisons (aHR 0.70; 95% CI 0.66-0.73, p < 0.001). Although there was no increase in CTEPH rates (aHR 1.05; 95% CI 1.00-1.10, p = 0.057), long-term outcomes favored CDI including lower rates of readmission for heart failure (aHR 0.79; 95% CI 0.75-0.83, p < 0.001), readmission for respiratory failure (aHR 0.85; 95% CI 0.81-0.90, p < 0.001), and lower chronic oxygen usage (aHR 0.69; 95% CI 0.65-0.74, p < 0.001). INTERPRETATION: Among patients with intermediate-high risk pulmonary embolism, CDI was associated with improved short- and long-term survival compared to anticoagulation alone. These findings suggest a potential benefit of CDI in intermediate-high risk PE and support the need for randomized trials powered for long-term, patient-centered outcomes.
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Mechanical Thrombectomy Versus Anticoagulation Alone in Intermediate-High Risk PE: Improved Functional 90-Day Outcomes in STORM-PE RCT.
Clinical takeaway Thrombectomy was associated with better measured functional recovery at 90 days in this randomized trial. Incomplete testing and secondary-endpoint status temper interpretation; mortality benefit and equivalent safety were not established.
Summary & abstract
Study summary
STORM-PE randomized 100 patients with acute intermediate-high risk pulmonary embolism to computer-assisted vacuum thrombectomy plus anticoagulation or anticoagulation alone; this report evaluates 90-day secondary outcomes. Six-minute walk distance was greater with thrombectomy (478.7 ± 159.5 versus 368.0 ± 127.8 m; P = 0.003), although only approximately two-thirds completed testing. NYHA class I was more frequent with thrombectomy (97.4% versus 75.6%; P = 0.005). Dyspnea and quality-of-life scores were comparable, and no between-group differences were reported in all-cause mortality, PE-related mortality, or symptomatic PE recurrence through 90 days.
Study limitation: Functional outcomes were secondary endpoints, and only approximately two-thirds completed walk testing, creating potential follow-up bias.
Published abstract
BACKGROUND: Up to 50% of pulmonary embolism (PE) survivors experience long-term functional limitations and reduced quality of life (QoL). Reperfusion strategies can rapidly relieve right-ventricular (RV) dysfunction and prevent clinical deterioration or hemodynamic collapse; however, these approaches have never been evaluated in a randomized trial against anticoagulation alone using patient-centered outcomes. OBJECTIVES: This study sought to evaluate whether mechanical thrombectomy with anticoagulation improves functional, QoL, and safety outcomes compared with anticoagulation alone in patients with acute intermediate-high risk PE over 90 days. METHODS: STORM-PE enrolled 100 PE patients randomized 1:1 to computer-assisted vacuum thrombectomy (CAVT) with anticoagulation or anticoagulation alone across 22 international sites, with RV-to-left-ventricular (RV/LV) ratio change at 48 hours as the primary endpoint. Secondary endpoints included major adverse events within 7 days, functional and QoL outcomes, mortality, and symptomatic PE recurrence through 90 days. RESULTS: For all patients, median time from randomization to last follow-up visit was 91.0 days [Q1-Q3: 80.5-100.0]. At 90 days, 66.0% (31/47) of CAVT and 64.2% (34/53) of anticoagulation patients completed the 6-min walk test. The CAVT arm exhibited a longer 6-min walk distance compared with anticoagulation alone (478.7 ± 159.5 m vs 368.0 ± 127.8 m, P = 0.003). More CAVT than anticoagulation patients were NYHA Functional Class I (97.4% [37/38] vs 75.6% [34/45], P = 0.005) at 90 days. Dyspnea and QoL scores were comparable between groups, with no differences between arms for all-cause mortality, PE-related mortality, and symptomatic PE recurrence within 90 days. CONCLUSIONS: In STORM-PE, CAVT with anticoagulation resulted in improved functional outcomes at 90 days compared with anticoagulation alone, with equivalent safety rates. This trial supports CAVT as an effective and safe reperfusion strategy for intermediate-high risk PE. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov Unique Identifier: NCT05684796.
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Prognostic significance of the glucose-to-lymphocyte ratio in acute pulmonary embolism.
Clinical takeaway GLR showed modest prognostic discrimination in acute pulmonary embolism, but its mortality association was sensitive to adjustment for active infection. These findings do not establish a clinically actionable threshold.
Summary & abstract
Study summary
This retrospective study included 631 patients with acute pulmonary embolism; 41 (6.5%) died in hospital. Admission glucose-to-lymphocyte ratio (GLR) had modest mortality discrimination (area under the curve 0.626, 95% confidence interval 0.548–0.705). An exploratory GLR threshold of 80.06 was associated with mortality in the primary multivariable model (adjusted odds ratio 2.43, 95% confidence interval 1.15–5.15). After additional adjustment for active infection, the association weakened and was no longer statistically significant (adjusted odds ratio 1.85, 95% confidence interval 0.86–3.97), limiting confidence in its independent prognostic value.
Study limitation: Retrospective observational design and a data-derived exploratory threshold limit causal interpretation and confidence in generalizability.
Published abstract
BACKGROUND: Acute pulmonary embolism has a heterogeneous clinical course, and simple laboratory markers reflecting metabolic and inflammatory stress may provide additional prognostic information. We investigated the association between the glucose-to-lymphocyte ratio (GLR) and in-hospital mortality in acute pulmonary embolism. METHODS: This retrospective observational study included 631 consecutive patients diagnosed between January 2023 and June 2025. GLR was calculated as admission blood glucose divided by absolute lymphocyte count. Receiver operating characteristic (ROC) analysis assessed the discriminatory ability of GLR for in-hospital mortality and identified a ROC-derived exploratory threshold for subsequent analyses. Clinical characteristics and in-hospital outcomes were compared between GLR groups, and logistic regression analyses identified factors associated with mortality. RESULTS: The median age was 69 years, 52.6% were female, and in-hospital mortality occurred in 41 patients (6.5%). GLR showed modest discrimination for mortality (area under the curve 0.626, 95% confidence interval [CI] 0.548-0.705; p=0.007), with a ROC-derived exploratory threshold of 80.06. Mortality was higher in patients with GLR ≥80.06 than in those with GLR <80.06 (9.5% vs. 3.3%; p=0.001). Elevated GLR was also associated with right ventricular dysfunction, vasopressor requirement, intensive care unit admission, hemodynamic deterioration, active infection, and longer hospital stay. GLR ≥80.06 remained associated with mortality in the primary multivariable model (adjusted odds ratio [OR] 2.43, 95% CI 1.15-5.15; p=0.020), but this association was attenuated after additional adjustment for active infection (adjusted OR 1.85, 95% CI 0.86-3.97; p=0.118). CONCLUSION: Higher admission GLR was associated with in-hospital mortality in the primary multivariable analysis. Although its discriminatory performance was modest, GLR may provide complementary prognostic information; however, the attenuation of the association after adjustment for active infection warrants cautious interpretation.
AI summary and clinical bottom line, with automated source checks. Consult the original paper before applying findings.
Clinical features and outcomes of unsuccessful mechanical aspiration thrombectomy in acute pulmonary embolism.
Clinical takeaway Unsuccessful thrombectomy was associated with chronic thrombus, a less acute presentation, and higher in-hospital PE-related mortality. These observational findings do not establish that procedural failure caused the mortality difference.
Summary & abstract
Study summary
A retrospective tertiary-centre case-series analysis compared successful versus unsuccessful mechanical aspiration thrombectomy for presumed acute pulmonary embolism. Chronic thrombus accounted for 79% of unsuccessful cases. Unsuccessful cases had longer symptom duration (p = 0.04) and a lower presenting Shock Index (0.78 versus 1.10; p = 0.0005). Preprocedure pulmonary artery systolic pressure was numerically higher with unsuccessful thrombectomy (57 versus 48 mmHg; p = 0.06). In-hospital PE-related mortality was higher in the unsuccessful group (36% versus 0%; p = 0.01).
Study limitation: The retrospective, single-centre comparison is vulnerable to confounding; sample size and confidence intervals are not reported in the abstract.
Published abstract
BACKGROUND: Large-bore mechanical aspiration thrombectomy (MAT) for acute pulmonary embolism (PE) is thought to be less effective in patients with a component of subacute or chronic thrombus, though no studies directly compare successful and unsuccessful MAT patients. We hypothesized that unsuccessful MAT would be associated with a more subacute or chronic clinical presentation due to the presence of chronic thrombus, and that a subset of unsuccessful MAT patients would suffer unfavorable outcomes. METHODS: Retrospective case-series analysis of patients treated at a tertiary care center who underwent MAT for presumed acute PE. Clinical features including duration of symptoms, presenting vitals, laboratory results, imaging, and procedural findings were compared between the successful and unsuccessful MAT patients. Adverse outcomes including in-hospital PE-related mortality were also compared. RESULTS: The majority of unsuccessful MAT cases (79%) were attributed to chronic thrombus. Unsuccessful MAT patients presented with a longer duration of symptoms (Fisher's exact test p = 0.04), less severe vital sign abnormalities (Shock Index 0.78 vs 1.10, p = 0.0005), and higher preprocedure pulmonary artery systolic pressure (57 vs 48 mmHg, p = 0.06). In-hospital PE-related mortality was higher in the unsuccessful MAT group (36% vs 0%, p = 0.01). CONCLUSION: Unsuccessful MAT was mostly attributed to chronic thrombus and was associated with a less acute clinical presentation. A subset of patients that undergo unsuccessful MAT may be high risk for in-hospital mortality. A high index of suspicion for chronic thrombus is crucial when considering patients for MAT. Further study is needed to identify the patients most likely to benefit from this procedure, and those with a thrombus not amenable to MAT.
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Venous Thromboembolism in Severe Renal Insufficiency: 20 Years of Contemporary Management and Clinical Outcomes.
Clinical takeaway This registry highlights high short-term mortality and differing timing of fatal pulmonary embolism and bleeding in severe renal insufficiency. It does not establish which anticoagulant strategy offers better outcomes.
Summary & abstract
Study summary
This registry analysis examined 5,763 patients with acute venous thromboembolism and creatinine clearance below 30 mL/min enrolled during 2005–2024. Mean age was 81 years, 69% were women, and 56% presented with pulmonary embolism. At 90 days, recurrent venous thromboembolism occurred in 1.3%, major bleeding in 5.1%, and death in 20%. Fatal pulmonary embolism exceeded fatal bleeding during days 0–10 (2.0% versus 0.3%), while fatal bleeding exceeded fatal pulmonary embolism during days 11–90 (0.7% versus 0.3%), describing a changing pattern of fatal events over follow-up.
Study limitation: The observational cohort combines pulmonary embolism and other venous thromboembolism; reported outcomes are not restricted to critically ill patients.
Published abstract
BACKGROUND: Patients with severe renal insufficiency have been systematically excluded from randomized trials of anticoagulation for venous thromboembolism (VTE), leaving uncertainty regarding their management in clinical practice. OBJECTIVES: The purpose of this study was to describe the clinical profile, temporal trends in management, and phase-specific outcomes of patients with acute VTE and severe renal insufficiency. METHODS: We analyzed 5,763 patients with acute VTE and creatinine clearance < 30 mL/min enrolled in Registro Informatizado de Enfermedad TromboEmbólica (2005-2024). Baseline characteristics, anticoagulant strategies, and 90-day outcomes were evaluated across 4 calendar periods and during the early (days 0-10) and late (days 11-90) treatment phases. RESULTS: Mean age was 81 years; 69% were women, 56% presented with pulmonary embolism (PE), 16% had creatinine clearance <15 mL/min, and 3.6% were receiving hemodialysis. Over time, severe renal dysfunction and hemodialysis became more frequent. Initial treatment remained predominantly low-molecular-weight heparin, whereas vitamin K antagonist use declined and direct oral anticoagulant use increased. At 90 days, recurrent VTE occurred in 1.3% of patients, major bleeding in 5.1%, and 20% died. During the first 10 days, fatal PE exceeded fatal bleeding (2.0% vs 0.3%), whereas during days 11 to 90 fatal bleeding exceeded fatal PE (0.7% vs 0.3%). CONCLUSIONS: Patients with VTE and severe renal insufficiency are elderly, medically complex, and experience high short-term mortality. The relative balance between fatal PE and fatal bleeding changes over time, with fatal PE predominating early and fatal bleeding thereafter, while real-world management frequently differs from product labels and guideline recommendations.
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