Management of high-risk acute pulmonary embolism: an emulated target trial analysis.

Summary

Across 991 patients in an emulated target trial, any pulmonary recanalization strategy (systemic thrombolysis, surgical thrombectomy, or catheter-directed therapy) was associated with lower in-hospital mortality estimates than VA-ECMO alone. Results were robust across g-formula, TMLE, and IPTW sensitivity analyses.

Key Findings

• In-hospital mortality estimates: VA-ECMO alone 57% (95% CI 47–67%), systemic thrombolysis 48% (44–53%), surgical thrombectomy 34% (18–50%), catheter-directed therapy 43% (35–51%).
• Mortality risk favored recanalization over VA-ECMO alone across all analytic approaches (g-formula, TMLE, IPTW).
• Survivors across strategies had high likelihood of favorable neurologic outcomes at discharge.

Clinical Implications

For decompensated PE, centers should prioritize timely reperfusion (systemic thrombolysis, surgical thrombectomy, or catheter-directed therapy), using VA-ECMO as a bridge when needed rather than definitive therapy alone.

Limitations

• Observational design cannot eliminate residual confounding or selection bias.
• Heterogeneity of operator expertise and device choice across centers may influence outcomes.

Future Directions

Prospective randomized or registry-based adaptive trials comparing specific catheter systems and surgical thrombectomy versus thrombolysis, with standardized ECMO-bridging protocols.