Back to 2024 Abstracts
Catheter-Based Intervention in the Low-Intermediate Risk PE Patient: Increased Utilization with Only Modest Benefits
Anthony James Laico, Junji Tsukagoshi, Kamil Khanipov, Ruth L. Bush, Mitchell W. Cox
University of Texas Medical Branch at Galveston, Galveston, TX
Background: Catheter-based interventions, including percutaneous mechanical thrombectomy and catheter-directed thrombolysis, have become established treatments for massive, high-risk pulmonary embolism. We have received reports that these therapies are being increasingly used in lower-risk patients, despite unclear efficacy. We evaluated the use of catheter-based interventions for PE in a low-intermediate risk stratified population versus existing treatments.
Methods: In this multicenter retrospective cohort study, we utilized the TriNetX database to identify three low-intermediate risk PE cohorts, defined as PE with evidence of right heart strain on echocardiography, but without elevated cardiac biomarkers, between the period 2010-2024. The treatment cohorts were defined as the following: 1 - systemic anticoagulation only (AC: warfarin, low-molecular-weight heparin, or direct oral anticoagulants (DOAC)), 2 - systemic thrombolysis (ST: rtPA, alteplase, etc.), or 3 - catheter-based procedures (CDT), including catheter-directed thrombolysis and mechanical thrombectomies. Cohorts were propensity score matched based on demographics, surgical history, and comorbidities. Study outcomes included mortality, bleeding complications, and pulmonary hypertension on periprocedural (30-day) and long-term (3-year) timeframes.
Results: In this dataset, 48,809 low-intermediate risk patients were identified: AC (
n=41,980); ST (
n=3,485); and CDT (
n=3,344). Between July 2018-January 2024, the incidence of CDT increased markedly (192%).
Overall, 30-day all-cause mortality was low: 2.30% (AC), 2.67% (CDT), and 11.348% (ST).
When comparing AC vs. CDT, CDT demonstrated a small, but statistically significant decrease in mortality vs. AC at 3 years (OR 0.816, 95% CI 0.677-0.984). Gastrointestinal (GI) bleeding was significantly increased in patients treated with all-medication (warfarin, heparin, and/or DOAC) AC vs. CDT [(30-day OR 1.466, 95% CI 1.007-2.133)], but this effect was not seen with direct oral anticoagulant monotherapy. Intracranial hemorrhage (ICH) rates were low, and similar between AC and CDT (0.0-0.011%).
With regards to ST, the all-cause mortality was also significantly increased vs. AC [(30-day OR 4.113 95% CI 3.290-5.140)(3-year OR 2.341 95% CI 2.045-2.680)], and vs. CDT [(30-day OR 2.989 95% CI 2.234-4.000)(3-year OR 2.662 95% CI 2.164-3.275)]. Periprocedural (30-day) GI bleeding was greater in ST vs. AC (OR 1.647 95% CI 1.204-2.253) and vs. CDT (OR 1.953 95% CI 1.258-3.032). Notably, 30-day ICH rates were increased fivefold in ST vs. AC (OR 5.562 95% CI 3.481-8.887) and twofold vs. CDT (OR 2.249 95% CI 1.420-3.564).
Rates of chronic (3-year) pulmonary hypertension were very low in all cohorts at 0.007-0.018%, making intergroup comparisons insignificant.
Conclusions: Trend analysis reveals a marked increase in the utilization of catheter-based procedures in a low-intermediate risk population, despite the lack of established evidence to support their use. This study adds that CDT has a small mortality benefit over anticoagulation, with comparably low rates of bleeding. Additionally, CDT has the safety benefit of decreased periprocedural bleeding compared to systemic thrombolysis. Newer direct oral anticoagulants are associated with a reduced bleeding risk compared to warfarin and heparin in the treatment of PE. Further studies are needed to optimize patient selection for catheter-based intervention.
Back to 2024 Abstracts
