Catheter-directed thrombolysis versus anticoagulation for intermediate-risk and high-risk pulmonary embolism: a systematic review and meta-analysis

Abstract

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.