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Thrombolytics for PE – Systemic vs. Catheter-Directed

January 14, 2020

Written by Clay Smith

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In high-risk PE, systemic thrombolysis was more commonly used than catheter-directed thrombolysis (CDT). Systemic vs CDT had greater in-hospital mortality and readmission, but results were confounded. CDT may have lower bleeding risk. There was no difference in plain CDT vs ultrasound-facilitated CDT.

Why does this matter?
Up to 25% of patients with high-risk PE die. Systemic thrombolysis reduces mortality and PE recurrence, but also causes major bleeding in over 20% of patients. Therapy may also be given via CDT +/- ultrasound facilitation (aka EKOS catheter). How often are thrombolytic agents used, what route, and how do these patients do?

CDT may be better and safer, but confounding is an issue.
They identified 5,436 patients in a nationwide U.S. readmissions database. The majority were given systemic lytics (62%). Patients who received systemic therapy tended to be sicker, with more high-risk features: vasopressor use, shock, cardiac arrest, and mechanical ventilation. In the cohort who received CDT, 80% were not with ultrasound facilitation. Bleeding events were less common with CDT vs. systemic: 8.7% vs. 15%, respectively. Intracranial bleeding was also lower in the CDT group, 0.5%; systemic group, 1.4%. In-hospital mortality (17.1% vs. 4.5%) and 30-day readmission (11.5% vs. 7.3%) were both higher in patients with systemic vs CDL, respectively. Keep in mind, confounding is no doubt in play here, with the systemic group sicker at baseline. There was no difference in CDL with ultrasonic facilitation vs plain CDT in any key outcomes or adverse outcomes. This calls into question the increased cost of the EKOS catheter.

Utilization and Outcomes of Thrombolytic Therapy for Acute Pulmonary Embolism: A Nationwide Cohort Study. Chest. 2019 Nov 26. pii: S0012-3692(19)34284-9. doi: 10.1016/j.chest.2019.10.049. [Epub ahead of print]

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