OC 01.3 - Systemic and catheter-directed thrombolysis in high and intermediate-high risk pulmonary embolism: a systematic review with meta-analysis

Saturday, June 24, 2023

13:30 – 13:45 ET

Room: 516

Session Available As: Live-Stream and On-Demand

Presenting Author(s)

Vicky Mai, MD MSc (she/her/hers)

MD, MSc
Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada.
Ottawa, Ontario, Canada

Co-Author(s)

LC

Lucia Caiano

MD
Department of Medicine and Surgery, University of Insubria, Varese, Italy
Varese, Lombardia, Italy
AP

Anuj Bharatkumar Patel

BSc
Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada.
Ottawa, Ontario, Canada
Marc Carrier, MD

MD, MSc
Ottawa Hospital Research Institute, Ottawa, ON, Canada
Ottawa, Ontario, Canada
Gregoire Le Gal, MD PhD

MD, PhD
Ottawa Hospital Research Institute, University of Ottawa, Canada
Ottawa, Ontario, Canada
Lana A. Castellucci, MD, MSc

MD, MSc
Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada.
Ottawa, Ontario, Canada

Background: Systemic and catheter-directed thrombolysis (CDT) potentially improve mortality in high risk and intermediate-high risk pulmonary embolisms (PE), but with a higher risk of major bleeding (MB). There are still uncertainties about benefits and harms of systemic thrombolysis and CDT in these patients.

Aims: To evaluate the efficacy and safety of systemic thrombolysis and CDT in patients with high risk and intermediate-high risk PE.

Methods: Systematic search of MEDLINE, EMBASE and Cochrane was performed. Randomized trials and cohort/observational studies were included. The primary efficacy and safety outcomes were all-cause mortality and MB, respectively. Relative risks (RR) and their 95% confidence intervals (CI) were calculated.

Results: Fifty-four studies (52,078 patients) were included. In randomized trials, when comparing anticoagulation alone with systemic thrombolysis, there was no difference in mortality (RR 1.43; 95%CI 0.93-2.20; I2=0%; p=0.10) and there was a reduction in MB (RR 0.49; 95%CI 0.28-0.86; I2=26%; p=0.01). In cohort/observational studies, there was no difference in mortality when comparing anticoagulation alone to systemic thrombolysis (RR 0.98; 95%CI 0.72-1.34; I2=64%; p=0.91) or CDT (RR 1.02; 95%CI 0.44-2.34; I2=58%; p=0.96), whereas there was a lower mortality with CDT than with systemic thrombolysis (RR 0.52; 95%CI 0.35-0.77; I2=80%; p=0.001). In cohort/observational studies, there was no difference in MB in patients receiving anticoagulation alone or CDT (RR 1.06; 95%CI 0.57-1.99; I2=0%; p=0.85), or in patients treated with CDT or systemic thrombolysis (RR 0.74; 95%CI 0.53-1.03; I2=44%; p=0.07), but there were less MB with anticoagulation alone than with systemic thrombolysis (RR 0.44; 95%CI 0.33-0.58; I2=0%; p< 0.001).

Conclusion(s): In patients with high risk and intermediate-high risk PE, cohort/observational studies showed a lower mortality with CDT compared to systemic thrombolysis and no difference in MB. These results should be viewed as exploratory. More studies are needed to determine which therapy would be the most optimal.

Learning Objectives:

To evaluate all-cause mortality and bleeding in patients with high risk and intermediate-high risk pulmonary embolism (PE) treated with catheter-directed thrombolysis.
To evaluate all-cause mortality and bleeding in patients with high risk and intermediate-high risk PE treated with systemic thrombolysis.
To evaluate all-cause mortality and bleeding in patients with high risk and intermediate-high risk PE treated with anticoagulation alone.