SpringerLink
Log in

Catheter directed compared to systemically delivered thrombolysis for pulmonary embolism: a systematic review and meta-analysis

  • Published:
Journal of Thrombosis and Thrombolysis Aims and scope Submit manuscript

Abstract

To compare the efficacy and safety of systemic and catheter directed thrombolysis for patients with pulmonary embolism. Pubmed and Cochrane Central Register of Controlled Trials were systematically searched from inception to May 31st 2020 to identify relevant studies. Outcomes of interest were in-hospital mortality and major bleeding including intracranial hemorrhage. We included 8 observational studies comprising 11,932 patients with PE. Catheter directed thrombolysis was associated with lower in-hospital mortality [RR 0.52; 95% confidence interval (CI) 0.40–0.68]. Although there was no difference in major bleeding by treatment strategy (RR 0.80; 95% CI 0.37–1.76), intracranial hemorrhage was lower in patients receiving catheter directed therapy (RR 0.66; 95% CI, 0.47–0.94).The certainty in these estimates was low. Non-randomized studies suggest that catheter directed delivery of thrombolytic therapy may be associated with lower in-hospital mortality and intracranial hemorrhage rates. These results may help inform management strategies for health care and pulmonary embolism response teams (PERT) involved in the management of high risk patients with massive or submassive pulmonary emboli.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Germany)

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

CDT:

Catheter directed thrombolysis

ICD-9-CM:

International classification of disease, ninth revision, clinical modification

ICH:

Intracranial hemorrhage

PAI1:

Plasminogen activator inhibitor type 1

PERTs:

Pulmonary embolism response teams

ST:

Systemic thrombolysis

tPA:

Tissue plasminogen activator

References

  1. Javaudin F, Lascarrou JB, Le Bastard Q et al (2019) Thrombolysis during resuscitation for out-of-hospital cardiac arrest caused by pulmonary embolism increases 30-day survival: findings from the French National Cardiac Arrest Registry. Chest 156:1167

    Article  PubMed  Google Scholar 

  2. Kahn SR, Houweling AH, Granton J, Rudski L, Dennie C, Hirsch A (2014) Long-term outcomes after pulmonary embolism: current knowledge and future research. Blood Coagul Fibrinolysis 25:407–415

    Article  PubMed  Google Scholar 

  3. Smith SB, Geske JB, Kathuria P et al (2016) Analysis of national trends in admissions for pulmonary embolism. Chest 150:35–45

    Article  PubMed  PubMed Central  Google Scholar 

  4. Konstantinides SV, Barco S, Lankeit M, Meyer G (2016) Management of pulmonary embolism: an update. J Am Coll Cardiol 67:976–990

    Article  PubMed  Google Scholar 

  5. Marti C, John G, Konstantinides S et al (2015) Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 36:605–614

    Article  CAS  PubMed  Google Scholar 

  6. Stein PD, Matta F (2012) Thrombolytic therapy in unstable patients with acute pulmonary embolism: saves lives but underused. Am J Med 125:465–470

    Article  PubMed  Google Scholar 

  7. Pei DT, Liu J, Yaqoob M et al (2019) Meta-analysis of catheter directed ultrasound-assisted thrombolysis in pulmonary embolism. Am J Cardiol 124:1470

    Article  PubMed  Google Scholar 

  8. Engelberger RP, Kucher N (2011) Catheter-based reperfusion treatment of pulmonary embolism. Circulation 124:2139–2144

    Article  PubMed  Google Scholar 

  9. Jaff MR, McMurtry MS, Archer SL et al (2011) Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 123:1788–1830

    Article  PubMed  Google Scholar 

  10. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 151:264–269

    Article  PubMed  Google Scholar 

  11. Gusto I (1993) An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 329:673–682

    Article  Google Scholar 

  12. Stang A (2010) Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25:603–605

    Article  PubMed  Google Scholar 

  13. Viswanathan M, Patnode CD, Berkman ND et al (2018) Recommendations for assessing the risk of bias in systematic reviews of health-care interventions. J Clin Epidemiol 97:26–34

    Article  PubMed  Google Scholar 

  14. Murad MHMV, Ioannidis JPA, Prasad K, Cook DJ, Guyatt G (2014) Advanced topics in systematic reviews: fixed-effects and random-effects models. In: Guyatt GRD, Meade MO, Cook DJ (eds) User’s guide to the medical literature, 3rd edn. The JAMA Network: McGraw Hill, New York

    Google Scholar 

  15. Turner RM, Davey J, Clarke MJ, Thompson SG, Higgins JP (2012) Predicting the extent of heterogeneity in meta-analysis, using empirical data from the Cochrane Database of Systematic Reviews. Int J Epidemiol 41:818–827

    Article  PubMed  PubMed Central  Google Scholar 

  16. Murad MH (2017) Clinical practice guidelines: a primer on development and dissemination. Mayo Clin Proc 92:423–433

    Article  PubMed  Google Scholar 

  17. Liang NL, Avgerinos ED, Singh MJ, Makaroun MS, Chaer RA (2017) Systemic thrombolysis increases hemorrhagic stroke risk without survival benefit compared with catheter-directed intervention for the treatment of acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 5:171-176.e171

    Article  PubMed  PubMed Central  Google Scholar 

  18. Avgerinos ED, Abou Ali AN, Liang NL et al (2018) Catheter-directed interventions compared with systemic thrombolysis achieve improved ventricular function recovery at a potentially lower complication rate for acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 6:425–432

    Article  PubMed  PubMed Central  Google Scholar 

  19. Arora S, Panaich SS, Ainani N et al (2017) Comparison of in-hospital outcomes and readmission rates in acute pulmonary embolism between systemic and catheter-directed thrombolysis (from the National Readmission Database). Am J Cardiol 120:1653–1661

    Article  PubMed  Google Scholar 

  20. Klevanets J, Starodubtsev V, Ignatenko P, Voroshilina O, Ruzankin P, Karpenko A (2017) Systemic thrombolytic therapy and catheter-directed fragmentation with local thrombolytic therapy in patients with pulmonary embolism. Ann Vasc Surg 45:98–105

    Article  PubMed  Google Scholar 

  21. Yoo JW, Choi HC, Lee SJ, Cho YJ, Lee JD, Kim HC (2016) Comparison between systemic and catheter thrombolysis in patients with pulmonary embolism. Am J Emerg Med 34:985–988

    Article  PubMed  Google Scholar 

  22. Sharifi M, Awdisho A, Schroeder B, Jimenez J, Iyer P, Bay C (2019) Retrospective comparison of ultrasound facilitated catheter-directed thrombolysis and systemically administered half-dose thrombolysis in treatment of pulmonary embolism. Vasc Med 24:103–109

    Article  PubMed  Google Scholar 

  23. Patel N, Patel NJ, Agnihotri K et al (2015) Utilization of catheter-directed thrombolysis in pulmonary embolism and outcome difference between systemic thrombolysis and catheter-directed thrombolysis. Catheter Cardiovasc Interv 86:1219–1227

    Article  PubMed  Google Scholar 

  24. Geller BJ, Adusumalli S, Pugliese SC et al (2020) Outcomes of catheter-directed versus systemic thrombolysis for the treatment of pulmonary embolism: a real-world analysis of national administrative claims. Vasc Med 25:334

    Article  PubMed  Google Scholar 

  25. Piazza G, Hohlfelder B, Jaff MR et al (2015) A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II Study. JACC Cardiovasc Interv 8:1382–1392

    Article  PubMed  Google Scholar 

  26. Engelberger RP, Moschovitis A, Fahrni J et al (2015) Fixed low-dose ultrasound-assisted catheter-directed thrombolysis for intermediate and high-risk pulmonary embolism. Eur Heart J 36:597–604

    Article  PubMed  Google Scholar 

  27. Chatterjee S, Chakraborty A, Weinberg I et al (2014) Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 311:2414–2421

    Article  PubMed  CAS  Google Scholar 

  28. Chandler WL, Alessi MC, Aillaud MF, Henderson P, Vague P, Juhan-Vague I (1997) Clearance of tissue plasminogen activator (TPA) and TPA/plasminogen activator inhibitor type 1 (PAI-1) complex: relationship to elevated TPA antigen in patients with high PAI-1 activity levels. Circulation 96:761–768

    Article  CAS  PubMed  Google Scholar 

  29. Nicoloso G, Hauert J, Kruithof EK, Van Melle G, Bachmann F (1988) Fibrinolysis in normal subjects–comparison between plasminogen activator inhibitor and other components of the fibrinolytic system. Thromb Haemost 59:299–303

    Article  CAS  PubMed  Google Scholar 

  30. Siegbahn A, Ruusuvaara L (1988) Age dependence of blood fibrinolytic components and the effects of low-dose oral contraceptives on coagulation and fibrinolysis in teenagers. Thromb Haemost 60:361–364

    Article  CAS  PubMed  Google Scholar 

  31. Harpel PC (1981) Alpha2-plasmin inhibitor and alpha2-macroglobulin-plasmin complexes in plasma. Quantitation by an enzyme-linked differential antibody immunosorbent assay. J Clin Invest 68:46–55

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Kearon C, Akl EA, Comerota AJ et al (2012) Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:e419S-e496S

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Kucher N, Rossi E, De Rosa M, Goldhaber SZ (2006) Massive pulmonary embolism. Circulation 113:577–582

    Article  PubMed  Google Scholar 

  34. Konstantinides SV, Meyer G, Becattini C et al (2019) 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 41:543

    Article  Google Scholar 

  35. Yaghi S, Boehme AK, Dibu J et al (2015) Treatment and outcome of thrombolysis-related hemorrhage: a multicenter retrospective study. JAMA Neurol 72:1451–1457

    Article  PubMed  PubMed Central  Google Scholar 

  36. Chatterjee S, Weinberg I, Yeh RW et al (2017) Risk factors for intracranial haemorrhage in patients with pulmonary embolism treated with thrombolytic therapy development of the PE-CH Score. Thromb Haemost 117:246–251

    Article  PubMed  Google Scholar 

  37. Kanter DS, Mikkola KM, Patel SR, Parker JA, Goldhaber SZ (1997) Thrombolytic therapy for pulmonary embolism. Frequency of intracranial hemorrhage and associated risk factors. Chest 111:1241–1245

    Article  CAS  PubMed  Google Scholar 

  38. Meyer G, Vicaut E, Danays T et al (2014) Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 370:1402–1411

    Article  CAS  PubMed  Google Scholar 

  39. Bloomer TL, El-Hayek GE, McDaniel MC et al (2017) Safety of catheter-directed thrombolysis for massive and submassive pulmonary embolism: results of a multicenter registry and meta-analysis. Catheter Cardiovasc Interv 89:754–760

    Article  PubMed  Google Scholar 

  40. Kaymaz C, Ozturk S, Akbal O et al (2017) Ultrasound-assisted catheter-directed thrombolysis in high-risk and intermediate-high-risk pulmonary embolism: results from a single-center cohort. Angiology 68:433–440

    Article  PubMed  Google Scholar 

  41. Kucher N, Boekstegers P, Muller OJ et al (2014) Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation 129:479–486

    Article  PubMed  Google Scholar 

  42. Thabut G, Thabut D, Myers RP et al (2002) Thrombolytic therapy of pulmonary embolism: a meta-analysis. J Am Coll Cardiol 40:1660–1667

    Article  CAS  PubMed  Google Scholar 

  43. Fiumara K, Kucher N, Fanikos J, Goldhaber SZ (2006) Predictors of major hemorrhage following fibrinolysis for acute pulmonary embolism. Am J Cardiol 97:127–129

    Article  PubMed  Google Scholar 

  44. Kuo WT, Banerjee A, Kim PS et al (2015) Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT): initial results from a prospective multicenter registry. Chest 148:667–673

    Article  PubMed  Google Scholar 

  45. Gaba RC, Gundavaram MS, Parvinian A et al (2014) Efficacy and safety of flow-directed pulmonary artery catheter thrombolysis for treatment of submassive pulmonary embolism. AJR Am J Roentgenol 202:1355–1360

    Article  PubMed  Google Scholar 

  46. Lee KA, Cha A, Kumar MH, Rezayat C, Sales CM (2017) Catheter-directed, ultrasound-assisted thrombolysis is a safe and effective treatment for pulmonary embolism, even in high-risk patients. J Vasc Surg Venous Lymphat Disord 5:165–170

    Article  PubMed  Google Scholar 

  47. Wiske CP, Shen C, Amoroso N et al (2020) Evaluating time to treatment and in-hospital outcomes of pulmonary embolism response teams. J Vasc Surg Venous Lymphat Disord 8:717

    Article  PubMed  Google Scholar 

  48. Beydilli I, Yilmaz F, Sonmez BM et al (2016) Thrombolytic therapy delay is independent predictor of mortality in acute pulmonary embolism at emergency service. Kaohsiung J Med Sci 32:572–578

    Article  PubMed  Google Scholar 

Download references

Funding

Authors did not receive any funding or grants for this work.

Author information

Authors and Affiliations

  1. Vascular Division, Department of Cardiology, Mayo Clinic, Rochester, MN, 55905, USA

    Ahmed K. Pasha, Waldemar E. Wysokinski & Robert D. McBane II

  2. Gonda Vascular Center, Mayo Clinic, Rochester, MN, 55905, USA

    Ahmed K. Pasha, Haraldur Bjarnason, Waldemar E. Wysokinski & Robert D. McBane II

  3. Division of Hospital Medicine, Capital Health Medical Center, Trenton, NJ, 08534, USA

    Muhammad Umer Siddiqui

  4. Department of Medicine, University of South Dakota, Vermillion, SD, 57069, USA

    Muhammad Danial Siddiqui & Ammar Abdullah

  5. Amita St. Joseph Hospital, Chicago, IL, 60657, USA

    Adnan Ahmed

  6. Division of Hematology and Oncology, Mayo Clinic, Rochester, MN, 55905, USA

    Irbaz Riaz

  7. Mayo Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA

    M. Hassan Murad

  8. Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN, 55905, USA

    M. Hassan Murad

  9. Interventional Radiology Division, Department of Radiology, Mayo Clinic, Rochester, MN, 55905, USA

    Haraldur Bjarnason

Authors
  1. Ahmed K. Pasha
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Muhammad Umer Siddiqui
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Muhammad Danial Siddiqui
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Adnan Ahmed
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ammar Abdullah
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Irbaz Riaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. M. Hassan Murad
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Haraldur Bjarnason
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Waldemar E. Wysokinski
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Robert D. McBane II
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Robert D. McBane II.

Ethics declarations

Conflict of interest

Authors also do not have any conflicts of interest to report.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Pasha, A.K., Siddiqui, M.U., Siddiqui, M.D. et al. Catheter directed compared to systemically delivered thrombolysis for pulmonary embolism: a systematic review and meta-analysis. J Thromb Thrombolysis 53, 454–466 (2022). https://doi.org/10.1007/s11239-021-02556-7

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11239-021-02556-7

Keywords

Search

Navigation