Nationwide Analysis of Catheter-Directed Thrombolysis Versus Anticoagulation in Sub-Massive Pulmonary Embolism

Background: Data on the real-world effectiveness and safety of catheter-directed thrombolysis (CDT) versus anticoagulation in sub-massive pulmonary embolism (PE) remain limited. Objective: The aim of this study was to assess the differences in in-hospital mortality, length of stay (LOS), complications and healthcare resource utilization between catheter directed thrombolysis and anticoagulation in sub-massive pulmonary embolism using the National Inpatient Sample (NIS) dataset from 2016–2022. Methods: The National Inpatient Sample (2016–2022) was queried to identify hospitalizations for sub-massive pulmonary embolism (PE) with cor pulmonale. Patients receiving CDT were compared to those treated with anticoagulation alone. We excluded patients with shock, ventilator support, vasopressors, surgical or catheter-directed embolectomy, systemic thrombolysis, or hospice care. Outcomes included in-hospital mortality, length of stay (LOS), hospital costs, and bleeding complications. A survey-weighted analysis was performed, adjusting for demographics, comorbidities, and hospital characteristics. Multivariable regression models assessed associations between treatment groups and outcomes, with statistical significance set at p <0.05. Results: Among 31,751 patients with sub-massive PE, 3,559 received CDT and 22,910 received anticoagulation alone. CDT was associated with lower in-hospital mortality (OR = 0.33, 95% CI: 0.26–0.43, p < 0.001) and shorter length of stay (LOS) (β= –1.21 days, 95% CI: –1.41 to –1.00, p < 0.001). CDT patients had higher total hospital costs (β= $10,666, 95% CI: $10,093–$11,240, p < 0.001). In-hospital bleeding risk was similar between groups after adjustment. Predictors of higher mortality included Hispanic race, lower income, Medicaid coverage, larger hospital size, and increasing Charlson Comorbidity Index (p < 0.05 for all). Conclusion: Contemporary data from a large national database suggest CDT is associated with lower in-hospital mortality and shorter length of stay compared to anticoagulation alone in sub-massive pulmonary embolism, without increased bleeding risk. However, CDT is linked to higher hospitalization costs, highlighting the need for further cost-effectiveness analyses to optimize patient selection and resource utilization.