Improved Short- and Long-term Survival with Catheter Directed Therapies over Medical Management in Patients with Submassive Pulmonary Embolism - A Retrospective Matched Cohort Study

Abstract

The benefit of catheter-directed therapies (CDT) for submassive pulmonary embolism (sPE) is subject of debate. We sought to determine short and long-term mortality and outcomes of CDT compared with anticoagulation (AC) in patients with sPE. This is a single health care network, multi-hospital, retrospective cohort study of all hospitalizations for sPE (2012-2019). sPE was defined as presence of at least one of the following: right heart strain, elevated biomarkers (Troponin-I or B-type natriuretic peptide), or vital sign abnormalities (heart rate ≥110 bpm). Patients with massive PE (systolic blood pressure <90 mmHg or vasopressor support) and those who received systemic thrombolysis were excluded. sPE groups included therapeutic AC alone or AC with CDT (thrombolysis and suction thrombectomy). Measured outcomes included mortality, treatment-related complications (bleeding, transfusion, stroke), chronic thromboembolic pulmonary hypertension, and 6-minute walk test. After 1:1 nearest-neighbor propensity-score matching, Kaplan-Meier survival plots were generated for the treatment groups and compared using log-rank testing (Figure). Multivariate Cox regression was used to determine effect of treatment on 1-year, 3-year, and 5-year survival after adjusting for confounding variables and clustering on hospitals. Of 6746 sPE hospitalizations, 235 patients receiving CDT were matched with 235 patients who received AC. Patients receiving CDT were younger (58.9 ± 15.5 vs 61.5 ± 17.4 years; P = .004) and more likely to be white (92.5% vs 85.7%; P < .001). Those who received CDT presented with higher heart rate, lower systolic blood pressure, and were more likely to have right heart strain (Table). In the matched cohort, no difference was seen in the development of chronic thromboembolic pulmonary hypertension (4.3% vs 4.3%; P = 1.0) at a mean follow-up of 2 years. The 6-minute walk test at 1 year was similar between the 2 groups (332.7 meters vs 318.8 meters; P = .62). However, AC alone was associated with higher PE-related death within 30 days (1.7% vs 0.4%; P = .047). CDT was also associated with lower rate of complications at 30 days (1.49% vs 4.25%; P = .176) and at 3 years (1.49% vs 16.6%; P = .009). CDT was associated with a lower risk of mortality compared with AC at 1 year (7.6% vs 9.8%; hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.65-0.92; P = .004), 3 years (11.1% vs 16.6%; HR, 0.64; 95% CI, 0.55-0.73; P < .001), and 5 years (14.5% vs 19.1%; HR, 0.71; 95% CI, 0.66-0.77; P < .001). CDT for sPE is associated with improved short- and long-term survival compared with AC alone, with a low complication rate. CDT should be considered in select patients with sPE given its survival benefit.TableClinical characteristics for both unadjusted and matched cohorts of patients with sPEUnadjusted cohort, No. (%)Matched cohort, No. (%)AnticoagulationCDTStandardized differenceAnticoagulationCDTStandardized differenceTotal6404 (94.9)343 (5.1)235235Mean age (SD), years61.5 (17.4)58.8 (15.5)0.16859.4 (18.2)59.46 (5.6)0.003Gender Male3087 (48.2)180 (52.5)0.085119 (50.6)125 (53.2)0.051 Female3317 (51.8)163 (47.5)116 (49.4)110 (46.8)Race White5343 (83.4)297 (86.6)0.281205 (87.2)209 (88.9)0.057 Black890 (13.9)24 (7.0)25 (10.6)21 (8.9) Unknown171 (2.7)22 (6.4)5 (2.1)5 (2.1)Ethnicity Hispanic28 (0.4)1 (0.3)0.0631 (0.4)1 (0.4)0.028 Non-Hispanic5333 (83.3)284 (85.5)210 (89.4)208 (88.5) Unknown1041 (16.3)47 (14.2)24 (10.2)26 (11.1)Diabetes1124 (17.6)57 (16.6)0.02556 (23.8)49 (20.9)0.071Hypertension3092 (48.3)155 (45.2)0.062115 (48.9)108 (46.0)0.059History of cancer1757 (27.4)40 (11.7)0.40637 (15.7)33 (14.0)0.048Recent surgery (90 days)1812 (28.3)54 (15.7)0.30649 (20.9)43 (18.3)0.064Anticoagulation655 (10.2)25 (7.3)0.10420 (8.5)18 (7.7)0.031Mean heart rate (SD), bpm94.87 (20.3)104.6 (20.2)0.482104 (19.1)104.2 (19.8)0.013Mean SBP (SD), mmHg136.9 (23.9)132.5 (21.7)0.194129.2 (22.2)132 (22.2)0.126Mean DBP (SD), mmHg79.4 (14.8)82.6 (14.3)0.22381.6 (16.3)81.8 (13.7)0.011RHS on CTA or echo1265 (20.3)271 (79.2)1.458178 (75.7)186 (79.1)0.081CDT, Catheter-directed therapies; CTA, computed tomography angiography; DBP, diastolic blood pressure; RHS, right heart strain; SBP, systolic blood pressure; sPE, submassive pulmonary embolism. Open table in a new tab