Safety and efficacy of clot-dissolving therapies for submassive pulmonary embolism: A network meta-analysis of randomized controlled trials

Cardiovasc Revasc Med. 2024 May:62:73-81. doi: 10.1016/j.carrev.2023.12.011. Epub 2023 Dec 21.


Background: Acute pulmonary embolism (PE) is a serious condition that needs quick and effective treatment. Anticoagulation therapy is the usual care for most PE patients but may not work well for higher-risk ones. Thrombolysis breaks the clot and improves blood flow. It can be given systemically or locally. Ultrasound-assisted catheter-directed thrombolysis (USAT) is a new technique that boosts clot-busting drugs. This network meta-analysis compares death, bleeding, and benefits of four treatments in acute submassive PE.

Methods: We comprehensively searched relevant databases up to July 2023 for RCTs. The outcomes encompassed all-cause mortality, major and minor bleeding, PE recurrence, and hospital stay duration. Bayesian network meta-analysis computed odds ratios (OR) and 95 % CI estimates.

Results: In this network meta-analysis of 23 RCTs involving 2521 PE patients, we found that SCDT had the most favorable performance for mortality, as it had the lowest odds ratio (OR) among the four interventions (OR 5.41e-42; 95 % CI, 5.68e-97, 1.37e-07). USAT had the worst performance for major bleeding, as it had the highest OR among the four interventions (OR 4.73e+04; 95 % CI, 1.65, 9.16e+13). SCDT also had the best performance for minor bleeding, as it had the lowest OR among the four interventions (OR 5.68e-11; 95 % CI, 4.97e-25, 0.386).

Conclusion: Our meta-analysis suggests that SCDT is the most effective treatment intervention in improving the risks of All-cause mortality and bleeding. Thrombolytic therapy helps in improving endpoints including the risk of PE recurrence and the duration of hospital stay.

Keywords: Bleeding risk; Catheter-directed thrombolysis; Pulmonary embolism; Thrombolytic therapy.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Anticoagulants / administration & dosage
  • Anticoagulants / adverse effects
  • Female
  • Fibrinolytic Agents* / administration & dosage
  • Fibrinolytic Agents* / adverse effects
  • Hemorrhage* / chemically induced
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Network Meta-Analysis*
  • Pulmonary Embolism* / diagnosis
  • Pulmonary Embolism* / diagnostic imaging
  • Pulmonary Embolism* / drug therapy
  • Pulmonary Embolism* / mortality
  • Pulmonary Embolism* / therapy
  • Randomized Controlled Trials as Topic*
  • Recurrence*
  • Risk Assessment
  • Risk Factors
  • Thrombolytic Therapy* / adverse effects
  • Thrombolytic Therapy* / mortality
  • Time Factors
  • Treatment Outcome
  • Ultrasonic Therapy / adverse effects


  • Fibrinolytic Agents
  • Anticoagulants