Transcatheter Directed Interventions in Pulmonary Embolism: Recent Evidence, Guidelines and Challenges

Acute pulmonary embolism (PE) is a major cause of cardiovascular mortality, and managing patients at risk of deterioration despite anticoagulation is challenging. Transcatheter interventions, including catheter-directed thrombolysis (CDT) and mechanical thrombectomy (MT), aim to rapidly unload the right ventricle while limiting the bleeding risk of systemic thrombolysis. Their use long preceded robust evidence, but recent randomised trials have changed this. In normotensive patients with right ventricular dysfunction and elevated cardiac biomarkers, low-dose CDT, with or without ultrasound, reduced early clinical deterioration in two trials with differing eligibility criteria: HI-PEITHO required troponin elevation and at least two additional markers of cardiorespiratory compromise, whereas PRAGUE-26 required troponin or natriuretic peptide elevation. No statistically significant difference in major bleeding was detected, although mortality did not improve and intracranial haemorrhage occurred. MT accelerated right ventricular recovery versus anticoagulation and, in an open-label trial against CDT, improved a composite driven by deterioration and intensive care use. Guidelines predate most of these data and differ between continents: the 2019 European Society of Cardiology guideline and European consensus documents reserve transcatheter treatment mainly for high-risk PE with contraindicated or failed thrombolysis and for rescue after deterioration, whereas the 2026 American Heart Association/American College of Cardiology guideline allows its consideration in incipient cardiopulmonary failure. This review summarises techniques, evidence and recommendations, and it discusses patient selection, comparative effectiveness and long-term outcomes. Pending updates, decisions should be individualised by multidisciplinary PE response teams.