Ismayl Mahmoud, Ismayl Ahmad, Hamadi Dana, Aboeata Ahmed, Goldsweig Andrew M
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
Department of Medicine, Northern General Hospital, Sheffield, UK.
Cardiovasc Revasc Med. 2024 Mar;60:43-52. doi: 10.1016/j.carrev.2023.10.002. Epub 2023 Oct 12.
Controversy surrounds the optimal therapy for submassive and massive pulmonary embolism (PE). We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus surgical and catheter-based thrombectomy in patients with submassive and massive PE.
We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of CDT versus thrombectomy in submassive and massive PE. Studies were identified and data were extracted by two independent reviewers. A random effects model was used to calculate risk ratios (RRs) with 95 % confidence intervals (CIs). Outcomes included in-hospital mortality, procedural complications, hospital and intensive care unit (ICU) length of stay (LOS), 30-day readmissions, and right ventricle/left ventricle (RV/LV) ratio improvement.
Eight observational studies with 1403 patients were included, of whom 50.0 % received CDT. Compared to thrombectomy, CDT was associated with significantly lower in-hospital mortality (RR 0.62; 95 % CI 0.43-0.89; p = 0.01) and similar rates of major bleeding (p = 0.61), blood transfusion (p = 0.41), stroke (p = 0.41), and atrial fibrillation (p = 0.71). The hospital and ICU LOS, 30-day readmissions, and degree of RV/LV ratio improvement were similar between the two strategies (all p > 0.1). In subgroup analyses, in-hospital mortality was similar between CDT and catheter-based thrombectomy (p = 0.48) but lower with CDT compared with surgical thrombectomy (p = 0.01).
In patients with submassive and massive PE, CDT was associated with similar in-hospital mortality compared to catheter-based thrombectomy, but lower in-hospital mortality compared to surgical thrombectomy. Procedural complications, LOS, 30-day readmissions, and RV/LV ratio improvement were similar between CDT and any thrombectomy. Randomized controlled trials are indicated to confirm our findings.
对于亚大面积和大面积肺栓塞（PE）的最佳治疗方法存在争议。我们进行了一项系统评价和荟萃分析，以比较导管直接溶栓（CDT）与亚大面积和大面积PE患者的手术及基于导管的血栓切除术的疗效。
我们检索了PubMed、EMBASE、Cochrane和谷歌学术，以查找比较CDT与亚大面积和大面积PE患者血栓切除术疗效的研究。由两名独立的评审员识别研究并提取数据。采用随机效应模型计算风险比（RRs）及95%置信区间（CIs）。纳入的结局指标包括院内死亡率、手术并发症、住院时间和重症监护病房（ICU）住院时间（LOS）、30天再入院率以及右心室/左心室（RV/LV）比值改善情况。
纳入了8项观察性研究，共1403例患者，其中50.0%接受了CDT。与血栓切除术相比，CDT的院内死亡率显著更低（RR 0.62；95% CI 0.43 - 0.89；p = 0.01），且大出血（p = 0.61）、输血（p = 0.41）、中风（p = 0.41）和心房颤动（p = 0.71）的发生率相似。两种治疗策略的住院时间和ICU住院时间、30天再入院率以及RV/LV比值改善程度相似（所有p > 0.1）。在亚组分析中，CDT与基于导管的血栓切除术的院内死亡率相似（p = 0.48），但与手术血栓切除术相比，CDT的院内死亡率更低（p = 0.01）。
在亚大面积和大面积PE患者中，与基于导管的血栓切除术相比，CDT的院内死亡率相似，但与手术血栓切除术相比，CDT的院内死亡率更低。CDT与任何血栓切除术的手术并发症、住院时间、30天再入院率以及RV/LV比值改善情况相似。需要进行随机对照试验来证实我们的研究结果。
