Comparison of interventions for intermediate to high‐risk pulmonary embolism: A network meta‐analysis

• Published in: Catheterization and cardiovascular interventions 2023-08, Vol.102 (2), p.249-265
• Main Authors: Ishisaka, Yoshiko, Watanabe, Atsuyuki, Fujisaki, Tomohiro, Iwagami, Masao, So, Matsuo, Steiger, David, Aoi, Shunsuke, Secemsky, Eric A., Wiley, Jose, Kuno, Toshiki
• Format: Article
• Language: English
• Subjects: Bleeding; catheter‐directed therapy; catheter‐directed thrombectomy; catheter‐directed thrombolysis; Clinical trials; Embolism; Fibrinolytic Agents - adverse effects; Hemorrhage; Hemorrhage - chemically induced; Humans; Meta-analysis; Mortality; Network Meta-Analysis; Observational studies; Patients; pulmonary embolism; Pulmonary Embolism - drug therapy; Pulmonary embolisms; surgical embolectomy; systemic anticoagulation; systemic thrombolysis; Thrombolysis; Thrombolytic Therapy - adverse effects; Treatment Outcome
• ISSN: 1522-1946; 1522-726X; 1522-726X
• DOI: 10.1002/ccd.30745

Background Multiple interventions, including catheter‐directed therapy (CDT), systemic thrombolysis (ST), surgical embolectomy (SE), and therapeutic anticoagulation (AC) have been used to treat intermediate to high‐risk pulmonary embolism (PE), but the most effective and safest treatment remains unclear. Our study aimed to investigate the efficacy and safety outcomes of each intervention. Methods We queried PubMed and EMBASE in January 2023 and performed a network meta‐analysis of observational studies and randomized controlled trials (RCT), including high or intermediate‐risk PE patients, and comparing AC, CDT, SE, and ST. The primary outcomes were in‐hospital mortality and major bleeding. The secondary outcomes included long‐term mortality (≥6 months), recurrent PE, minor bleeding, and intracranial hemorrhage. Results We identified 11 RCTs and 42 observational studies involving 157,454 patients. CDT was associated with lower in‐hospital mortality than ST (odds ratio [OR] [95% confidence interval (CI)]: 0.41 [0.31−0.55]), AC (OR [95% CI]: 0.33 [0.20−0.53]), and SE (OR [95% CI]: 0.61 [0.39−0.96]). Recurrent PE in CDT was lower than ST (OR [95% CI]: 0.66 [0.50−0.87]), AC (OR [95% CI]: 0.36 [0.20−0.66]), and trended lower than SE (OR [95% CI]: 0.71 [0.40−1.26]). Notably, ST had higher major bleeding risks than CDT (OR [95% CI]: 1.51 [1.19−1.91]) and AC (OR [95% CI]: 2.21 [1.53−3.19]). By rankogram analysis, CDT presented the highest p‐score in in‐hospital mortality, long‐term mortality, and recurrent PE. Conclusion In this network meta‐analysis of observational studies and RCTs involving patients with intermediate to high‐risk PE, CDT was associated with improved mortality outcomes compared to other therapies, without significant additional bleeding risk.