Respiratory Trials·org

Topic

Pulmonary embolism

Anticoagulation, thrombolysis, and catheter-directed therapy.

Thrombolysis for intermediate-risk PE prevents decompensation and causes bleeding. Tenecteplase halved death or haemodynamic decompensation, from 5.6% to 2.6%, while raising major extracranial bleeding from 1.2% to 6.3% and causing excess haemorrhagic stroke (PEITHO). The earlier enthusiasm came from a trial whose composite endpoint was dominated by escalation of treatment rather than death (MAPPET-3).

Catheter-based treatment is where the question moved next. Large-bore mechanical thrombectomy beat catheter-directed thrombolysis on a hierarchical composite (PEERLESS) — but the win ratio is driven by intensive care use and bailout, with no difference in mortality or bleeding.

Extended anticoagulation can probably be given at a reduced dose. Formal non-inferiority was not met, but five-year recurrence was 2.2% versus 1.8% while clinically relevant bleeding fell substantially (RENOVE) — a case where the statistical verdict and the clinical one part company.

Vena caval filters added to anticoagulation prevent nothing (PREPIC2). The trial does not address the one indication that survives it, the patient who genuinely cannot be anticoagulated, because everyone in it was.

Thrombolysis in intermediate-risk PE

Trial Year Therapy Effect Finding
PEITHO 2014 Tenecteplase Thrombolysis prevented decompensation in intermediate-risk PE but caused major bleeding and stroke
MAPPET-3 2002 Alteplase Alteplase reduced treatment escalation in submassive PE, but the benefit was almost entirely in that soft endpoint

Catheter-based treatment of PE

Trial Year Therapy Effect Finding
PEERLESS 2025 Large-bore mechanical thrombectomy Mechanical thrombectomy beat catheter-directed lysis on a composite driven by less ICU use, with no mortality difference

Extended anticoagulation

Trial Year Therapy Effect Finding
RENOVE 2025 Reduced-dose direct oral anticoagulant Reduced-dose anticoagulation failed formal non-inferiority for recurrence but bled much less

Vena caval filters

Trial Year Therapy Effect Finding
PREPIC2 2015 Retrievable IVC filter Adding a retrievable IVC filter to anticoagulation prevented nothing

Key references

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