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According to research, advanced recanalization may increase short-term survival in patients presenting with high-risk PE compared to VA‑ECMO monotherapy.
Advanced recanalization may increase short-term survival in patients presenting with high-risk pulmonary embolism (PE) compared to the use of veno‑arterial extracorporeal membrane oxygenation (VA‑ECMO) alone, according to a multinational observational study recently published in Intensive Care Medicine.
“To address the … uncertainties regarding emergency management of high-risk acute PE, we emulated a target trial from one of the largest retrospective datasets compiled to date,” wrote corresponding author Daniele Camboni, MD, of University Medical Center Regensburg, and study coauthors. “The purpose of this study was to estimate the treatment effect of VA-ECMO alone, SYS [systemic thrombolysis], ST [surgical thrombectomy], and percutaneous catheter-directed treatment [PCDT] on in-hospital mortality.”
Study Design & Population
The researchers conducted a target-trial emulation using retrospective data from 991 adults with high-risk acute PE treated at 34 European clinical sites. Median age was 62 years, and 53.3 % were men. Patients received one of four primary strategies: VA‑ECMO alone (n=126), intrahospital-administered SYS (n=643), ST (n=49), or PCDT (n=173). VA‑ECMO was allowed as a bridge to recanalization in the latter three cohorts.
Comparative Mortality Risk
Primary target trial intention-to-treat analysis revealed an estimated probability of in-hospital mortality of 57% with VA-ECMO alone, 48% with SYS, 34% with ST, and 43% with PCDT.
“Accordingly, the mortality risk ratios between intrahospital SYS versus VA-ECMO alone, ST versus VA-ECMO alone, and PCDT versus VA-ECMO alone were largely in favor of any advanced recanalization strategy over VA-ECMO alone,” the researchers reported. “Supported also by a mortality risk ratio of 1.34 (95% CI, 1.07; 1.67) between VA-ECMO alone versus any other treatment approach.”
Sensitivity analyses supported the robustness of the findings.
Neurologic Outcomes
The authors found that, across all modalities, most survivors to hospital discharge exhibited a favorable neurologic outcome of a cerebral performance category (CPC 1–2). At 91%, PCDT yielded the highest percentage of survivors classified as CPC 1, suggesting that less invasive reperfusion may preserve cerebral integrity.
Limitations & Implications
The team noted that key limitations of the study included potential unmeasured confounding and breaches of analytical assumptions, which may have biased the main trial and secondary findings.
“While our findings should be interpreted as hypothesis generating, the data indicate that the role of ST in managing high‑risk PE may be underestimated in current clinical practice,” the authors wrote, “and that this approach, but also the use of novel promising catheter‑directed systems, could have a positive impact on outcomes.”
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