Pulmonary embolism (PE) is the third cause of cardiovascular death. Percutaneous treatment (PT) is an emerging treatment for patients with high and intermediate-high PE. The aim of this study is to describe the efficacy and safety of PT in patients hospitalized with an acute PE in a University Hospital.

Methods and Results: 

We performed a single center retrospective study in patients with intermediate-high- and high-risk PE undergoing PT from 2014 to 2023. Percutaneous treatment included catheter directed thrombolysis (CDT) with or without ultrasound (EKOS, Boston Scientific and Fountain, Merit Medical, USA, respectively) or embolectomy (Indigo, Penumbra, USA). Demographic, clinical, and angiographic details were recorded. Primary outcomes included efficacy defined by mean pulmonary pressure drop and safety defined by intracranial bleeding and Bleeding Academic Research Consortium (BARC) 3-5 bleeding. Data are reported as mean and standard deviation or number and percentage (%). Comparison of pulmonary pressures (continuous variables) was performed with T-test for paired data.
During the study period, 53 patients with acute PE were treated with PT. The mean age of the patients was 62 +/- 17.8 years old, 22 (42%) of the patients were male and 12 (25%) presented with high-risk PE. Common risk factors for PE included obesity 24 (44%) patients, personal history of deep vein thrombosis 7 (13%) patients or PE 5 (9%), recent surgery 16 (30%) and malignancy 11 (21%). The most frequently used PT was ultrasound facilitated CDT (EKOS) (47 [74%]) although no patient with CDT received EKOS after 2019. Nine patients (17%) received CDT without ultrasound (Fountain) and 4 (9%) patients received thrombus aspiration (Indigo, 3 with 8Fr catheter and one with 12Fr). PT was used as first treatment in 29 (55%) of the patients, upscale after failed anticoagulation in 21 (40%) and 3 (5%) patients received PT after failed systemic thrombolytics. Among high-risk PE, almost all were treated with CDT (11 [91%]) and 4 (33%) received PT as a first treatment. In the CDT group, the mean total dose of recombinant tissue plasminogen activator (rtPA) used was 29 +/- 8.5 mg over 21 +/- 5.6 hours, without differences between EKOS and Fountain.
In CDT patients, both mean pulmonary artery pressure (mPAP) and systolic pressure (sPAP) decreased after treatment: mPAP from 34.5 +/- 8.2 mmhg vs 25.2 +/- 7.7 mmhg; p=0.002; sPAP from 55.3 +/- 16.6 mm Hg to 41.1 +/- 11.3 mm, p<0.0001. There were no differences between EKOS and Fountain in mPAP after CDT (26.2 +/- 8.3 mmHg and 21.5 +/- 3.07 mmHg, p=0.113, respectively).
There were no intracranial or fatal bleeding, and no hemoptysis after treatment. Six (11%) patients had BARC 3-5 bleeding, all in the CDT group. Five (9%) patients had an access site bleeding, before ultrasound was routinely used. Seven (13%) patients died In-hospital, of which only 2 patients died due to PE.
Conclusions: 

Percutaneous treatment for PE is effective and safe in patients with high and intermediate-high risk PE. This therapy reduced pulmonary artery systolic and mean pressure with no intracranial hemorrhage. There were no differences between CDT with and without ultrasound. Ongoing randomized trials will help decide the best treatment for each patient.