Systemic Thrombolysis Compared to Catheter Directed Thrombolysis in Acute Pulmonary Embolism

Abstract

PURPOSE: The objective of this study is to compare Catheter Directed Thrombolysis (CDT) to systemic thrombolysis (ST) in acute pulmonary embolism (APE). METHODS: We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2010 to 2012 using the ICD 9 CM, diagnosis code 415.11, 415.13, and 415.19 for APE. We compared patients treated with thrombolysis (ICD 9 CM, procedure code-99.10) to patients treated with CDT (ICD 9 CM, procedure code 88.43, 88.62). Patients with deep vein thrombosis, myocardial infarction, and stroke were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were combined in-hospital mortality and intracranial hemorrhage (ICH), and extra-cranial hemorrhage requiring transfusion. The length-of-stay (LOS), the cost of hospitalization, and disposition to a skilled nursing facility (SNF) were also evaluated. RESULTS: We identified 1521 patients with APE who received thrombolysis. 1169 patients received ST (76.85%) compared to 352 patients who received CDT (23.15%). Using propensity-matched comparison, the in-hospital mortality and the combined in-hospital mortality and intracranial hemorrhage were significantly lower in the CDT group compared to the ST group. 17.14% compared to 9.29% (p=0.02) and 17.38 % compared to 10% (p=0.04) respectively. The rate of bleeding requiring blood transfusion was similar in both groups. 1.67% in the CDT group compared to 3.57% in the ST group (p=0.19). The median length of stay was 7 days (5-9 days) in the CDT group and 7 days (5-10 days) in the ST group (p=0.17). The CDT group had higher hospital charges compared to the ST group. $23,799 ($17,892-$35,338) vs. $17,218 ($12,272-$23,906) p<0.001. More patients were discharged to SNF after ST compared to CDT. 22.45% vs. 17.09%, p=0.04. CONCLUSIONS: Patients who received CDT had lower in-hospital mortality, and combined in-hospital mortality and ICH compared to the patients who received ST. There was no difference in bleeding requiring transfusion or in LOS. More patients who received ST were discharged to SNF compared to patients who received CDT, but the hospital charges were higher in the CDT group. CLINICAL IMPLICATIONS: This is the largest study that showed survival benefit in patients with APE treated with CDT compared to ST. More randomized controlled trials are needed however to further evaluate this therapeutic modality and compare its effectiveness and potential risks to systemic thrombolysis in APE.