title: Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques.
abstract: OBJECTIVE
  Systemic thrombolysis for the treatment of acute pulmonary embolism (PE) carries an estimated 20% risk of major hemorrhage, including a 3%-5% risk of hemorrhagic stroke. The authors used evidence-based methods to evaluate the safety and effectiveness of modern catheter-directed therapy (CDT) as an alternative treatment for massive PE.
  
  
  METHODS
  The systematic review was initiated by electronic literature searches (MEDLINE, EMBASE) for studies published from January 1990 through September 2008. Inclusion criteria were applied to select patients with acute massive PE treated with modern CDT. Modern techniques were defined as the use of low-profile devices (< or =10 F), mechanical fragmentation and/or aspiration of emboli including rheolytic thrombectomy, and intraclot thrombolytic injection if a local drug was infused. Relevant non-English language articles were translated into English. Paired reviewers assessed study quality and abstracted data. Meta-analysis was performed by using random effects models to calculate pooled estimates for complications and clinical success rates across studies. Clinical success was defined as stabilization of hemodynamics, resolution of hypoxia, and survival to hospital discharge.
  
  
  RESULTS
  Five hundred ninety-four patients from 35 studies (six prospective, 29 retrospective) met the criteria for inclusion. The pooled clinical success rate from CDT was 86.5% (95% confidence interval [CI]: 82.1%, 90.2%). Pooled risks of minor and major procedural complications were 7.9% (95% CI: 5.0%, 11.3%) and 2.4% (95% CI: 1.9%, 4.3%), respectively. Data on the use of systemic thrombolysis before CDT were available in 571 patients; 546 of those patients (95%) were treated with CDT as the first adjunct to heparin without previous intravenous thrombolysis.
  
  
  CONCLUSIONS
  Modern CDT is a relatively safe and effective treatment for acute massive PE. At experienced centers, CDT should be considered as a first-line treatment for patients with massive PE.
authors.affiliation: Division of Vascular and Interventional Radiology, Department of Radiology, Stanford University Medical Center, 300 Pasteur Dr, H-3630, Stanford, CA 94305-5642, USA. wkuo@stanford.edu
authors.forename: William T
authors.initials: WT
authors.lastname: Kuo
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
authors.forename: John D
authors.initials: JD
authors.lastname: Louie
authors.forename: Jarrett K
authors.initials: JK
authors.lastname: Rosenberg
authors.forename: Daniel Y
authors.initials: DY
authors.lastname: Sze
authors.forename: Lawrence V
authors.initials: LV
authors.lastname: Hofmann
mesh_terms: D002407:Catheterization, Swan-Ganz / Q000401:mortality* / Q000706:statistics & numerical data*; D004621:Embolization, Therapeutic / Q000401:mortality* / Q000706:statistics & numerical data*; D006801:Humans; D015995:Prevalence; D011655:Pulmonary Embolism / Q000401:mortality* / Q000628:therapy*; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis; D015996:Survival Rate; D015912:Thrombolytic Therapy / Q000401:mortality* / Q000706:statistics & numerical data*; D016896:Treatment Outcome