By Samuel Rouleau
Spoon Feed
In a RCT of 550 patients with intermediate-risk PE, those who received large-bore mechanical thrombectomy (LBMT) were less likely to suffer clinical decompensation than those who received catheter-directed thrombolysis (CDT).
Mechanical thrombectomy is PEERLESS among catheter-based interventions
Some patients with intermediate-risk PE, defined by RV dysfunction, may develop shock and could benefit from advanced intervention. Emerging evidence shows that catheter-based interventions are safe and effective. PEERLESS is the first RCT that compared LBMT to CDT in patients with intermediate-risk PE, with over 90% meeting the definition for intermediate-high risk. 550 patients with acute PE and RV dysfunction on imaging were randomized to receive LBMT (n=274) or CDT (n=276). LBMT outperformed CDT in the primary outcome (win ratio 5.01, 95%CI 3.68–6.97), which was a composite of all-cause mortality, intracranial hemorrhage, major bleeding, clinical deterioration/bailout therapy, and ICU admission. Among individual outcomes, LBMT had lower rates of clinical deterioration/bailout therapy (1.8% v 5.4%) and ICU admission (41.6% v 98.6%). Notably, clinical deterioration for CDT occurred a couple days after the procedure and included 2 cardiac arrests, 1 unstable bradycardia, 3 cases of respiratory failure and 1 case of hypotension/shock that required ECMO. No meaningful differences were observed in mortality, intracranial hemorrhage, or major bleeding; however, one patient in the CDT arm died from hemorrhage. Patients who received LBMT recovered more quickly within 24 hours, but there were no statistical differences at 30 days.
How will this change my practice?
Some patients with intermediate-high risk PE benefit from advanced interventions rather than anticoagulation alone.
- LBMT outperforms CDT, and, if there is a suitable target, I would always prefer LBMT over CDT.
- Patient selection is tricky. Not every patient with intermediate-risk PE needs procedural intervention. I am excited for the results of PEERLESS II, PE-TRACT, and HI-PEITHO!
Source
Large-Bore Mechanical Thrombectomy Versus Catheter-Directed Thrombolysis in the Management of Intermediate-Risk Pulmonary Embolism: Primary Results of the PEERLESS Randomized Controlled Trial. Circulation. 2025 Feb 4;151(5):260-273. doi: 10.1161/CIRCULATIONAHA.124.072364. Epub 2024 Oct 29. PMID: 39470698
