Response to Letter to the Editor regarding the article “Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary Embolism”

Comment: Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary EmbolismJournal of the Society for Cardiovascular Angiography & Interventions100613PreviewFeroze et al1 retrospectively investigated important problem in contemporary pulmonary embolism (PE) practice by demonstrating that there was no difference in mortality and rehospitalization rates in patients with intermediate-to-high-risk (IHR) PE treated with large-bore thrombectomy compared with patients treated with catheter-directed thrombolysis (CDT). Furthermore, both treatment approaches for PE were similar concerning safety. Full-Text PDF Open Access We appreciate the additional information from Giunio et al1Giunio L. Lozo M. Borovac J.A. Bradaric A. Zanchi J. Miric D. Feasibility and safety of catheter-directed thrombolysis via superficial cubital vein for the treatment of acute massive and submassive pulmonary embolism.Postepy Kardiol Interwencyjnej. 2021; 17: 389-397PubMed Google Scholar regarding the feasibility of antecubital access pigtail catheter for mechanical thrombus fragmentation and adjunctive catheter-directed thrombolysis (CDT) based on their previously published retrospective review of 27 consecutive patients. Indeed, ultrasound-assisted CDT has been studied against pigtail catheter CDT in a small cohort previously, which demonstrated similar mortality outcomes and similar reductions in pulmonary artery pressure and Miller score, but with decreased infusion times and lower total tissue plasminogen activator (tPA) infusion rates in the ultrasound-assisted CDT cohort.2Graif A. Grilli C.J. Kimbiris G. et al.Comparison of ultrasound-accelerated versus pigtail catheter-directed thrombolysis for the treatment of acute massive and submassive pulmonary embolism.J Vasc Interv Radiol. 2017; 28: 1339-1347Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar In a recent meta-analysis assessing ultrasound-assisted versus standard catheter CDT, no difference was noted in major outcomes between the 2 modalities, including mortality and major bleeding.3Sun B. Yang J.X. Wang Z.K. et al.Clinical efficacy and safety of ultrasound-assisted thrombolysis vs. standard catheter-directed thrombolysis in patients with acute pulmonary embolism: a study level meta-analysis of clinical trials.Front Cardiovasc Med. 2022; 9967786Crossref Scopus (0) Google Scholar Moreover, the dose of tPA and duration of infusion were noted to be lower in this larger analysis but was not statistically significant. We recognize the potential economic advantages of using either a standard catheter or pigtail catheter for CDT, although propose that potential decreased infusion times and tPA doses may reduce overall hospital costs in minimizing intensive care unit stay, decreasing bleeding risks, and improving patient satisfaction. Cost-analysis factoring these other components into consideration may be of interest. Our initial analysis4Feroze R. Arora S. Tashtish N. et al.Comparison of large-bore thrombectomy with catheter-directed thrombolysis for the treatment of pulmonary embolism.J Soc Cardiovasc Angiogr Interv. 2023; 2100453Google Scholar evaluated the outcomes of CDT in comparison with large-bore thrombectomy (LBT) in our institution’s experience, given the lack of randomized data comparing the 2 different modalities to date. Because there is no difference in major outcomes between ultrasound-assisted CDT and standard catheter CDT, we believe our findings may still be translated to facilities using standard catheter CDT as the primary modality of endovascular therapy. Given the nonrandomized nature of our patient cohort and the increasing ability to treat more hemodynamically unstable patients with venoarterial-extracorporeal membrane oxygenation followed by adjunctive LBT, we recognize there are intrinsic differences in between our patient population. Nonetheless, regardless of the differences between our cohorts, mortality outcomes were not statistically different based on univariate, multivariate, and inverse propensity weighting. We look forward to ongoing trials evaluating outcomes of CDT and LBT to help further our understanding of matching optimal modality to patient selection. Jun Li is a member of the Advisory board for Boston Scientific, Inari Medical, and Medtronic and consultant for Abbott Vascular, Endovascular Engineering, and Philips. Mehdi Shishehbor is a member of the Global Advisory Board for Abbott Vascular, Medtronic, Terumo, Phillips, Boston Scientific, ANT, and Inquis Medical. This letter did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.