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

Yoshiko Ishisaka, Atsuyuki Watanabe, Tomohiro Fujisaki, Masao Iwagami, Matsuo So, David Steiger, Shunsuke Aoi, Eric A. Secemsky, Jose Wiley, Toshiki Kuno

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1 Scopus citations


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.

Original languageEnglish
JournalCatheterization and Cardiovascular Interventions
StateAccepted/In press - 2023


  • catheter-directed therapy
  • catheter-directed thrombectomy
  • catheter-directed thrombolysis
  • pulmonary embolism
  • surgical embolectomy
  • systemic anticoagulation
  • systemic thrombolysis


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