Mechanical Thrombectomy vs Catheter-Directed Thrombolysis for High-Risk Pulmonary Embolism: A Target Trial Emulation

Watanabe, A; Kuno, T; Miyamoto, Y; Ueyama, HA; Gotanda, H; Bangalore, S; Tsugawa, Y

doi:10.1016/j.jacadv.2025.101706

Pulmonary vascular disease & thromboembolism

Mechanical Thrombectomy vs Catheter-Directed Thrombolysis for High-Risk Pulmonary Embolism: A Target Trial Emulation

JACC AdvPublished 24 Mar 2025observational study

Main finding · 1-year mortalityResultAdjusted hazard ratio 1.16 95% CI 0.84–1.59

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Authors' conclusion

Among older adults with high-risk PE treated with catheter-based therapies, the clinical outcomes were similar between the patients treated with MT vs CDT. Randomized trials are needed to confirm our findings.

Study context

Population: Medicare fee-for-service beneficiaries aged 65 to 99 years admitted with high-risk pulmonary embolism (PE) (defined by cardiac arrest, shock, and vasopressor use) who underwent mechanical thrombectomy (MT)/catheter-directed thrombolysis (CDT) from 2017 to 2020
Participants: 235 vs 484

Exposure: MT vs CDT
MTn = 235
CDTn = 484reference
Outcome: 1-year mortality
Follow-up: 1 year

Methodological detailstarget trial emulation framework, inverse probability of treatment weighting approach, controlling for 62 baseline covariates

Target trial emulation framework
Inverse probability of treatment weighting approach, controlling for 62 baseline covariates

Main finding

As reported in the abstract

Adjusted hazard ratio

1.16

95% CI 0.84–1.59

By group

MT48.4%absolute risk · 95% CI 34.1%–63.3%

CDT45.4%absolute risk · 95% CI 37.8%–55.8%

MTvs CDT

adjusted HR 1.16 (95% CI 0.84–1.59)

Observational data: associations, not effects.

Further findings

Outcome	← Lower risk with MT ←→ Higher risk with MT →	Subdistribution HR (95% CI)
All-cause readmissionNo evidence of significant difference	0.512	0.89 (0.56–1.40)
	0.512Subdistribution hazard ratio (log scale)

Safety

Outcome	← Lower odds with MT ←→ Higher odds with MT →	Adjusted OR (95% CI)
Intracranial hemorrhage · in-hospitalNo evidence of significant difference	0.050.21520	0.36 (0.07–1.77)
Transfusions · in-hospitalNo evidence of significant difference	0.050.21520	0.96 (0.52–1.76)
	0.050.21520Adjusted odds ratio (log scale)

Original publication

Mechanical Thrombectomy vs Catheter-Directed Thrombolysis for High-Risk Pulmonary Embolism: A Target Trial Emulation. JACC Adv. Published 24 March 2025. doi:10.1016/j.jacadv.2025.101706

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