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Original Article
Efficacy and safety outcomes of recanalisation procedures in patients with acute symptomatic pulmonary embolism: systematic review and network meta-analysis
  1. David Jimenez1,2,
  2. Carlos Martin-Saborido3,
  3. Alfonso Muriel4,
  4. Javier Zamora4,
  5. Raquel Morillo1,2,
  6. Deisy Barrios1,2,
  7. Frederikus A Klok5,
  8. Menno V Huisman5,
  9. Victor Tapson6,
  10. Roger D Yusen7
  1. 1Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain
  2. 2Medicine Department, Universidad de Alcala (IRYCIS), Alcalá de Henares, Spain
  3. 3Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcon, Spain
  4. 4Biostatistics Department, Ramón y Cajal Hospital, IRYCIS, CIBERESP, Madrid, Spain
  5. 5Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
  6. 6Cedars-Sinai Medical Center, Los Angeles, California, USA
  7. 7Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St Louis, Missouri, USA
  1. Correspondence to Dr David Jimenez, Respiratory Department, Ramón y Cajal Hospital, Madrid 28034, Spain; djimenez.hrc{at}gmail.com

Abstract

Background We aimed to review the efficacy and safety of recanalisation procedures for the treatment of PE.

Methods We searched PubMed, the Cochrane Library, EMBASE, EBSCO, Web of Science and CINAHL databases from inception through 31 July 2015 and included randomised clinical trials that compared the effect of a recanalisation procedure versus each other or anticoagulant therapy in patients diagnosed with PE. We used network meta-analysis and multivariate random-effects meta-regression to estimate pooled differences between each intervention and meta-regression to assess the association between trial characteristics and the reported effects of recanalisation procedures versus anticoagulation.

Results For all-cause mortality, there were no significant differences in event rates between any of the recanalisation procedures and anticoagulant treatment (full-dose thrombolysis: OR 0.60; 95% CI0.36 to 1.01; low-dose thrombolysis: 0.47; 95% CI 0.14 to 1.59; and catheter-associated thrombolysis: 0.31; 95% CI 0.01 to 7.96). Full-dose thrombolysis increased the risk of major bleeding (2.00; 95% CI 1.06 to 3.78) compared with anticoagulation. Catheter-directed thrombolysis was associated with the lowest probability of dying (surface under the cumulative ranking curve (SUCRA), 0.67), followed by low-dose thrombolysis (SUCRA, 0.66) and full-dose thrombolysis (SUCRA, 0.55). Similarly, low-dose thrombolysis was associated with the lowest probability of major bleeding (SUCRA, 0.61), followed by catheter-directed thrombolysis (SUCRA, 0.54) and full-dose thrombolysis (SUCRA, 0.17). The results were similar in sensitivity analyses based on restricting only to studies in haemodynamically stable patients with PE.

Conclusions In the treatment of PE, recanalisation procedures do not seem to offer a clear advantage compared with standard anticoagulation. Low-dose thrombolysis was associated with the lowest probability of dying and bleeding.

Trial registration number PROSPERO CRD42015024670.

  • pulmonary embolism

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Footnotes

  • DJ and CM-S contributed equally.

  • Contributors Study concept and design: DJ, MVH, VT and RDY. Acquisition of data, analysis and interpretation of data and statistical analysis: DJ, CM-S, AM, JZ, RM, DB, FAK, MVH, VT and RDY. Drafting of the manuscript: DJ, FAK, MVH, VT and RDY. Critical revision of the manuscript for important intellectual content: DJ, CM-S, AM, JZ, RM, DB, FAK, MVH, VT and RDY. Study supervision: DJ and RDY. The corresponding author, DJ, had full access to all the data in the study and had final responsibility for the decision to submit for publication.

  • Funding This study (PII11/00246) was supported by the Instituto de Salud Carlos III (Plan Estatal de I+D+i 2013-2016) and co-financed by the European Development Regional Fund ‘A way to achieve Europe’.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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