(1240) Evaluation of Systemic Thrombolytics Versus Catheter-Directed Thrombolysis for Pulmonary Embolism

Introduction: Pulmonary embolism (PE) is a subtype of venous thromboembolism (VTE) with variably severities. Guidelines stratify patients into risk categories to determine treatment strategies. Hemodynamic stability and high-risk features, including right ventricular dysfunction, elevated biomarkers or residual deep vein thrombosis, determine treatment with anticoagulation with or without systemic thrombolysis. Currently, comparison only exists between these agents in myocardial infarction and ischemic stroke. If systemic thrombolysis is contraindicated, alternatives, such as catheter-directed thrombolysis (CDT) have been suggested. The purpose of this study is to compare the safety and efficacy in the treatment of PE with alteplase, tenecteplase or CDT.

Methods: This IRB-approved, multi-center retrospective cohort study included patients who received systemic alteplase, tenecteplase or CDT for the treatment of moderate to high-risk pulmonary embolism. Data was obtained by reviewing medical records from March 2013 to December 2023. Patients were excluded for cardiac arrest, died within 24 hours of therapy, received therapy without PE confirmation or were pregnant. The primary outcome was rates of major bleeding complications defined by ISTH criteria, within 72 hours of treatment.

Results: The primary outcome was significantly higher with tenecteplase and US-CDT vs alteplase (alteplase 10.9% vs tenecteplase 31.1%, p = 0.004; US-CDT 21.4%, p = 0.03). After propensity matching, tenecteplase was associated with a higher rate of major bleeding (p = 0.13) while rates were significantly higher for US-CDT compared to alteplase (p = 0.04). This was supported by multi-variate logistic regression, showing a 93% lower risk of major bleeding with alteplase vs US-CDT (OR 0.07; 95% CI 0.01, 0.3). Tenecteplase was not associated with different rates of hemodynamic decompensation or mortality compared to alteplase while US-CDT had significantly lower rates, likely secondary to acuity of illness.

Conclusions: Alteplase was associated with the lowest risk of major bleeding compared to tenecteplase and US-CDT for the treatment of PE, but with variable disease severities. Selection of agent for the treatment of PE continues to require analysis of patient-specific hemodynamics and severity.