Open Heart. 2026 Aug 11;13(2):e004250. doi: 10.1136/openhrt-2026-004250.
ABSTRACT
BACKGROUND: Catheter-directed thrombolysis (CDT) has emerged as a reperfusion strategy for intermediate-risk and high-risk pulmonary embolism (PE), potentially improving thrombus resolution while reducing bleeding risk compared with systemic thrombolysis. However, evidence comparing CDT with anticoagulation alone remains inconsistent.
OBJECTIVE: To evaluate the efficacy and safety of CDT compared with anticoagulation alone in intermediate-risk and high-risk PE.
METHODS: A systematic review and meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Scopus, Cochrane Library, Epistemonikos and ProQuest were searched through 8 May 2026. Randomised and observational studies comparing CDT with anticoagulation alone were included. Primary outcomes were all-cause mortality and major bleeding. Random-effects models were used to calculate pooled risk ratios (RRs) and mean differences with 95% CIs.
RESULTS: 18 studies involving 16 126 patients were included. CDT was associated with a lower risk of all-cause mortality compared with anticoagulation alone (RR 0.41, 95% CI 0.32 to 0.54; p<0.0001; I²=0%). No statistically significant difference was observed in major bleeding (RR 1.78, 95% CI 0.85 to 3.71; p=0.1259; I²=51.3%), and trim-and-fill analysis yielded a similarly non-significant result (adjusted RR 0.84, 95% CI 0.39 to 1.79). CDT and anticoagulation alone showed comparable outcomes for PE-related mortality, intracranial haemorrhage, delta right ventricle (RV)/left ventricle (LV) ratio, delta Thrombus Burden Score or systolic pulmonary artery pressure. Meta-regression identified that a greater baseline RV/LV ratio was associated with attenuation of the observed mortality benefit.
CONCLUSIONS: CDT was associated with lower all-cause mortality compared with anticoagulant alone in intermediate-risk and high-risk PE without a statistically significant increase in intracranial haemorrhage. Larger adequately powered randomised trials are needed to define the role of CDT in acute PE.
PROSPERO REGISTRATION NUMBER: CRD420261373193.
PMID:42580844 | DOI:10.1136/openhrt-2026-004250