Catheter-Directed Therapy Improves Survival in PE vs Anticoagulation Alone

Catheter-directed therapy (CDT) plus anticoagulation is associated with better long-term survival compared with anticoagulation alone in patients with submassive pulmonary embolism (sPE), according to study results published in Journal of Vascular Surgery: Venous and Lymphatic Disorders.

Researchers conducted a retrospective, propensity score-matched cohort study of all acute PE hospitalizations in a multihospital network from 2012 to 2019. Data were obtained from electronic health records on November 30, 2020, and were analyzed between August 2021 and December 2021. Because data collection ended on December 30, 2019—which was prior to documentation of the first case of SARS-CoV-2 infection in the United States, on January 17, 2020—none of the patients in the study cohort had been diagnosed with COVID-19.

In the current analysis, sPE was defined as the presence of right heart strain (RHS) or elevated biomarkers (ie, troponin-I or B-type natriuretic peptide). The participants were divided into 1 of 2 treatment groups: (1) those who received therapeutic anticoagulation alone and (2) those who received anticoagulation with CDT (ie, thrombolysis or suction thrombectomy).

The primary study outcome was mortality at 1 year, 3 years, and 5 years. Other study outcomes included PE-related death; short-term mortality (ie, 30-day, 3-month, and 6-month); 30-day treatment-related complications (ie, bleeding, transfusion, and stroke); chronic thromboembolic pulmonary hypertension (CTEPH), and 6-minute walk test (6MWT) at 1 year.

Among a total of 6746 hospitalizations for sPE, participants who were receiving CDT plus anticoagulation were significantly younger (58.9±15.5 years vs 61.5±17.4 years, respectively; P =.004) and were more often White (92.5% vs 85.7%, respectively; P <.001) compared with those receiving anticoagulation alone. Participants in the CDT plus anticoagulation treatment arm vs those in the anticoagulation alone arm presented with a higher mean heart rate (104.6/min vs 94.9/min, respectively; P <.001), lower mean systolic blood pressure (129 mm Hg vs 135 mm Hg, respectively; P <.001), and had higher rates of RHS (79.2% vs 20.3%, respectively; P <.001),

The study matched a total of 235 patients who were receiving CDT with 235 individuals who were receiving anticoagulation only. Results of the study showed that CDT was associated with a significantly lower risk for mortality compared with anticoagulation at 1 year (7.6% vs 9.8%, respectively; matched hazard ratio [mHR], 0.77; 95% CI, 0.65-0.92; P =.004), at 3 years (11.1% vs 16.6%, respectively; mHR, 0.64; 95% CI, 0.55-0.73; P <.001), and at 5 years (14.5% vs 19.1%, respectively; mHR, 0.71; 95% CI, 0.66-0.77; P <.001).

Treatment with anticoagulation alone was associated with higher PE-related deaths at 1 year, 3 years, and 5 years. Although mortality rates at 30 days and 3 months were similar, treatment with CDT was linked to improved survival at 6 months (mHR, 0.81; 95% CI, 0.68-0.97; P =.02). No differences between the groups were observed in bleeding complications at 30 days, the development of CTEPH, or the mean 6MWT at 1 year.

Limitations of the study include the fact that identifying participants relied on ICD coding, thus potentially leading to misclassification of patients and their outcomes. Some patients who were transferred from out-of-network hospitals might have been lost to follow-up and were not considered in the evaluation of long-term outcomes.

The study authors conclude, “CDT has a survival benefit over anticoagulation alone that emerges after 6 months and persists throughout all time points for 5 years, without any significant procedure related complications. . . .We hope that this study and ongoing randomized trials for sPE will inform a change in guidelines to support intervention for selected patients with [PE].”