Catheter-directed thrombolysis (CDT) may lead to improved outcomes versus systemic thrombolysis in pulmonary embolism (PE), according to a new study.
Researchers in Taiwan used a national insurance database to perform a prospective open cohort study comparing patients who were first admitted for PE from 2001 to 2013 and received systemic thrombolysis or CDT. Guidelines recommend the former for PE requiring reperfusion, but bleeding risk can be high, and its role is limited in patients at high risk for bleeding or intracranial hemorrhage, the researchers noted. The study's in-hospital outcomes were death, length of ICU stay, and cardiovascular complications, with major bleeding, gastrointestinal bleeding, intracranial hemorrhage, and bleeding requiring transfusion as the safety outcomes. Follow-up outcomes were all-cause mortality, recurrent PE, heart failure, and new-onset pulmonary hypertension. The researchers used inverse probability of treatment weighting to mitigate potential selection bias. Patients were followed from the date of hospital discharge to the date of death, date of event occurrence, or Dec. 31, 2013, whichever came first. The study results were published March 31 by the Journal of the American Heart Association.
Overall, 145 CDT-treated patients and 1,158 patients who received systemic thrombolysis for PE were included in the study. Most patients in each group (61.5% and 54.5%, respectively) were women. Those in the CDT group had significantly lower in-hospital mortality rates (12.7% vs. 21.4%; odds ratio, 0.49 [95% CI, 0.36 to 0.67]), but no significant differences in bleeding outcomes were seen. Among patients who survived the first PE admission, those in the CDT group had a significantly lower all-cause mortality rate at one year (12.2% vs. 13.2%; hazard ratio [HR], 0.73 [95% CI, 0.56 to 0.94]), as well as lower risk for recurrent PE (9.3% vs. 17.5%; subdistribution HR, 0.52 [95% CI, 0.41 to 0.66]). Between-group differences persisted through follow-up, with mean follow-up periods of 3.8 years for the CDT group and 3.4 years for the systemic thrombolysis group.
The authors noted that their study was retrospective and observational and that no standard protocol was used for CDT, among other limitations. They concluded that in patients with PE who required reperfusion therapy, those who received CDT had lower rates of all-cause mortality and recurrent PE than those receiving systemic thrombolysis. Bleeding risk, however, appeared similar in both groups. “On the basis of our results, the application of CDT could be considered more often than the current guidelines suggest,” the authors wrote. They called for their findings to be “cautiously validated” in randomized controlled trials.