VESS10 - Outcome and Treatment Trends of High-Risk Pulmonary Embolism in the United States

Objectives: High-risk pulmonary embolism (HRPE) is a major cause of hospital morbidities and mortalities. The treatment of HRPE has evolved from anticoagulation only to systemic thrombolysis (ST) or endovascular treatment (ENDO), which includes catheter-directed thrombolysis (CDT), catheter-directed embolectomy (CDE), or a combination of the interventions. In this study, we evaluate the trends and results of treatment for HRPE using the Nationwide Inpatient Sample (NIS).

Methods: We analyzed HRPE cases from (NIS) between 2016 and 2022. We compared the outcomes and complications of two propensity score-matched cohorts using ST and ENDO interventions, which is further subdivided into CDT and CDE. Then, a post hoc comparison was made between two groups of CDT and CDE for the outcome. Treatment trends, mortality, and outcome were analyzed. We used R Studio for analysis with different statistical tests as appropriate.

Results: We identified 19,286 (6.4%) had HRPE, and 19,253 were older than 18 years of age in the period from 2016 to 2022 in the NIS. Out of those, 15,089 (78.3%) patients were treated with anticoagulation only. Patients with interventions were divided into ST (2026) and ENDO (1981) cohorts, after excluding 160 patients with both ST and ENDO. Furthermore, ENDO were subdivided into CDL (820) and CDE (1025) groups after excluding 78 patients with both CDL and CDE. ENDO intervention, mostly due to CDE, increased over the years while ST remained stable. Overall, mortality in HRPE is 25.5% and decreased over the years (p=0.01), but mortality remained stable after ST (p=0.38). Only ENDO interventions improved mortality over the years (p=0.03)(Figure 1). Comparing matched groups of ST and ENDO, the ST group had higher mortality, vasopressors, and hemorrhagic stroke, while the ENDO group had higher postoperative hematoma, hemorrhage, higher ECMO requirements and hemoptysis (Table 1). In the ENDO group, CDL patients had lower vasopressor and ECMO requirements; otherwise, CDL and CDE were similar in other complications. Compared to anticoagulation only, mortality was higher after ST and lower after ENDO. Using multivariate analysis, mortality was lower after CDL (OR=0.56) and CDE (OR=0.51). Obese patients and those on ventilators had lower mortality, while patients with DIC, on vasopressors, and with arrhythmias had higher mortality.

Conclusions: ST remained stable with unchanged mortality. The treatment of HRPE was associated with improved mortality, mostly due to increased adoption of ENDO interventions. ST was associated with higher hemorrhagic stroke and mortality, while ENDO had higher hemoptysis and ECMO use.