Catheter-based interventions have little to no benefit in intermediate-low-risk pulmonary embolism

Objective: Catheter-based therapies (CBTs) have become established treatments for high-risk pulmonary embolism (PE). Anecdotally, these therapies are increasingly used in lower-risk patients despite unclear efficacy. We evaluated the use of CBT for PE in an intermediate-low risk stratified population vs anticoagulation (AC) only and systemic thrombolysis (ST). Methods: In this multicenter retrospective cohort study, three intermediate-low-risk PE cohorts were identified using the TriNetX database, defined as normotensive PE patients with evidence of right heart strain on echocardiography, but without elevated cardiac biomarkers from December 2010 to December 2024. The treatment cohorts were AC, ST, or catheter-based therapy (CBT), including catheter-directed thrombolysis and mechanical thrombectomy. Cohorts were 1:1 propensity score matched based on demographics and comorbidities. Study outcomes included mortality, bleeding complications, and pulmonary hypertension on periprocedural (30-day) and long-term (3-year) timeframes, using odds ratio (OR) with 95% confidence interval (CI). Results: AC, ST, and CBT cohorts included 52,141, 3277, and 2378 patients, respectively. The incidence of CBT increased markedly during the study period (387%). Of patients undergoing CBT procedures, 45.5% received catheter-directed thrombolysis and 52.0% received mechanical thrombectomy. When comparing CBT with AC, there was no mortality difference at any timeframe. The 30-day intracranial hemorrhage (ICH) rates were greater in CBT (OR, 2.12; 95% CI, 1.00-4.50; P = .047), although the 3-year rates were comparable. Conversely, the rate of gastrointestinal (GI) bleeding was significantly lower with CBT at 3 years (OR, 1.45; 95% CI, 1.06-2.00; P = .02), but this difference was insignificant in a subgroup analysis of patients treated with direct oral anticoagulants. The 3-year pulmonary hypertension rates were low in all cohorts (0.73%-1.81%). ST carried universally high mortality in all timeframes (vs AC at 3 years: OR, 2.95; 95% CI, 2.54-3.41; P < .01; vs CBT at 3 years: OR, 3.27; 95% CI, 2.54-4.22; P < .01). Periprocedural bleeding complication rates were higher vs AC for both ICH (OR, 3.34; 95% CI, 1.99-5.60; P < .01) and GI bleeding (OR, 1.38; 95% CI, 0.90-2.13; P = .14), but comparable vs CBT. Conclusions: Despite a marked increase in the use of CBT in an intermediate-low-risk PE population, CBT offers minimal benefit in mortality, GI bleeding, or pulmonary hypertension over AC, with a greater perioperative ICH risk. ST carries unacceptably high mortality and bleeding complication rates compared with AC. More granular data are needed to optimize patient selection and treatment modality for intermediate-low-risk PE patients.