Abstract
BACKGROUND: Catheter-based interventions for acute pulmonary embolism (PE) have transformed the therapeutic landscape over the past decade despite a lack of high-quality, randomized data demonstrating clinical benefit. In addition, multicenter data describing their real-world diffusion, patient selection, and outcomes remain limited.
OBJECTIVES: This study sought to characterize national trends, patient and imaging characteristics, and institutional variation in the use of catheter-directed thrombolysis (CDT) and mechanical thrombectomy (MT) across the Pulmonary Embolism Response Team (PERT) Consortium Registry from 2016 to 2024.
METHODS: The authors analyzed 2,958 patients with intermediate- or high-risk PE treated with advanced therapies from 48 U.S. institutions in the prospective PERT registry. Temporal trends in use of systemic thrombolysis, CDT, and MT were evaluated using mixed-effects Poisson models; factors associated with MT vs CDT were identified using mixed-effects logistic regression with site-level random intercepts. Patients were stratified by the European Society of Cardiology 2019 risk categories. The Composite Pulmonary Embolism Score (CPES) was used to further assess patient acuity.
RESULTS: Of the 2,958 patients who received advanced therapies, 75.9% had intermediate-risk PE and 24.1% high-risk PE. The use of MT increased by 18% per year (incident rate ratio [IRR]: 1.18; 95% CI: 1.14-1.23), surpassing CDT use by 2021, whereas the use of CDT and systemic thrombolysis declined by 13% and 12% per year, respectively. MT was independently associated with older age (≥70 years; OR: 1.37; 95% CI: 1.04-1.81), male sex (OR: 1.54; 95% CI: 1.19-1.99), vasopressor use, extracorporeal membrane oxygenation support, and saddle embolus or clot in transit, whereas CDT was more often used in younger female patients and in the presence of cardiorespiratory symptoms. The proportion of high-risk patients treated increased as did the mean CPES over the study period, reflecting treatment of progressively higher-acuity patients with catheter-based intervention.
CONCLUSIONS: Over the past decade, MT has rapidly replaced CDT as predominant catheter-based therapy for acute PE, reflecting both technological innovation and evolving operator confidence. The PERT registry captures this diffusion of innovation across institutions and patient profiles, revealing a shift toward treating sicker patients and greater procedural integration across specialties. These findings highlight the need for randomized evidence to define optimal patient selection and comparative outcomes across device classes.