Comparative Efficacy and Safety of Mechanical Thrombectomy and Anticoagulation in Intermediate- to High-Risk Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis

The comparative effectiveness of catheter-based mechanical thrombectomy in intermediate to high-risk acute PE remains uncertain. We reviewed comparative evidence to determine how thrombectomy performs against anticoagulation alone. We searched PubMed, Scopus, Web of Science, and the Cochrane Library through September 13, 2026. We selected adult studies that compared mechanical thrombectomy plus anticoagulation with anticoagulation alone in intermediate to high-risk PE. Random-effects pooling was supplemented by sequential study removal, influence assessment, and Baujat plots. Seven studies including 9371 participants were eligible: 2 randomized trials and 5 cohort studies. Thrombectomy was associated with fewer 30-day deaths (odds ratio [OR], 0.28; 95% CI, 0.17–0.47) and a greater improvement in RV/LV ratio (mean difference, −0.25; 95% CI, −0.36 to −0.13). The groups did not differ significantly in bleeding (OR, 0.82; 95% CI, 0.57–1.18) or PE-related mortality (OR, 1.25; 95% CI, 0.22–7.28). ICU and hospital stays were not significantly reduced, and these endpoints varied substantially between studies. Mortality and bleeding were less sensitive to individual reports than length-of-stay outcomes. Thrombectomy was linked to lower early all-cause mortality and more favorable right ventricular recovery without a significant bleeding excess. Its effects on PE-specific death and resource use remain uncertain. More adequately powered randomized trials are needed to define which intermediate to high-risk patients should receive the procedure.