Acute Management and Bleeding Outcomes in Pediatric Pulmonary Embolism: A Large Single-Center Retrospective Cohort Study

Pediatric pulmonary embolism (PE) is a relatively rare but high-risk disease. There is minimal evidence to guide clinical management, particularly with respect to reperfusion therapies. Few studies capture bleeding outcomes to inform risk-benefit management decisions. In this single-center, retrospective cohort study, we aimed to describe pediatric patients <21 years of age who received acute PE care at our institution, excluding those with comorbid cardiac disease. We described the PE risk factors, in-hospital management, and acute outcomes, including bleeding and mortality. Between 2003 and 2022, 175 patients met eligibility: 120 low-risk (69%), 44 intermediate-risk (25%), and 11 high-risk (6%) PE. Most (N=142) received anticoagulation alone; 29 patients received reperfusion therapy for PE, the most common reperfusion therapy was systemic thrombolysis. There were 34 clinically relevant bleeding events in 27 patients, including major bleeding in 9 (5%) and clinically relevant non-major bleeding events in 18 (10%) patients. Sixty-two percent (21/34) of bleeding events occurred in patients receiving anticoagulation alone, while 10/34 (29%) occurred in patients receiving systemic thrombolysis. In the high-risk PE cohort, clinically relevant bleeding occurred in 73% and 45% died. Most patients with major bleeding had other bleeding risk factors independent of their PE-directed therapy. All-cause mortality was 4%, with 2% PE-related mortality. This cohort study highlights that reperfusion therapy is well-tolerated in select pediatric patients and rates of bleeding and death are high in high-risk PE. Future research should validate these findings with prospective, standardized bleeding outcome collection to inform management decisions in pediatric PE.