Many PE Teams Embraced Mechanical Thrombectomy Early On: PERT Registry

In recent years there has been an explosion in the use of mechanical thrombectomy for acute pulmonary embolism (PE), according to an analysis of trends and practice patterns in the Pulmonary Embolism Response Team (PERT) Consortium Registry.

Between 2016 and 2024, mechanical thrombectomy use increased by 18% per year compared with declines of 13% per year for catheter-directed thrombolysis and 12% per year for systemic thrombolysis. By 2021, mechanical thrombectomy had surpassed catheter-directed thrombolysis.

Brett J. Carroll, MD (Beth Israel Deaconess Medical Center, Boston, MA), senior investigator for the new analysis, told TCTMD that this shift emerged early on.

It predates the completion of the STORM-PE trial demonstrating the benefit of mechanical thrombectomy with anticoagulation over anticoagulation alone in acute intermediate-high-risk patients. It also predates the PEERLESS trial, which compared catheter-directed thrombolysis to thrombectomy in a similar patient population, but wasn’t considered a huge win for mechanical thrombectomy. Prior to that, there had been positive signs from nonrandomized trials like FLASH and FLARE.

“So, despite lack of strong data supporting mechanical thrombectomy, experts in PE teams from around the country have felt that was the best option,” Carroll said. “That’s not to say they were right or wrong, it’s just that rarely do we see such a change in practice without groundbreaking studies to support those changes.”

The PERT registry data, which included 2,958 intermediate- and high-risk patients (mean age 61 years; 47% female) treated at 48 centers in the United States, also show that odds of receiving mechanical thrombectomy versus catheter-director thrombolysis increased with factors such as older age, vasopressor use, extracorporeal membrane oxygenation use, clot-in-transit, and saddle PE. Additionally, men were more likely to get mechanical thrombectomy, while catheter-directed thrombolysis was more often used in younger patients, women, and cases with lower clinical acuity.

“That makes sense given the feeling that though in the PEERLESS trial there was no significant difference clinically, you can get quicker resolution of clot burden with mechanical thrombectomy compared to catheter-directed thrombolysis,” Carroll said. “If a patient is sicker, you’re trying to do [things] more quickly.

“I think that that fits with the general gestalt of what we had suspected but that had not been demonstrated previously, at least to this level of granularity: that the more acutely ill patients tend to get mechanical thrombectomy,” he continued. “Also not surprising was [that in] older patients there was a trend towards not getting thrombolysis to try to avoid higher bleeding risk associated with [it].”

Drivers of Change and Patterns of Use

The study of real-world practice patterns, published last week in JACC by Carroll and colleagues led by Joseph M. Kim, MD (Beth Israel Deaconess Medical Center), highlights the maturation of PE care into its own distinct interventional discipline, the authors say.

Among the other findings in the registry was marked variation in the adoption of advanced therapies for PE. In particular, some centers have persisted in relying heavily on catheter-directed thrombolysis or systemic thrombolysis, which the authors say underscores an “absence of uniform practice patterns despite the rapid rise of [mechanical thrombectomy] overall.” The disparity in the adoption of mechanical thrombectomy was seen across intermediate- and high-risk patient groups.

The heterogeneity also extended to geographic regions. The Midwest had higher rates of mechanical thrombectomy adoption than the Northeast overall. Between 2020 and 2024, adoption was highest in Michigan, Oklahoma, Missouri, Ohio, California, New York, and Connecticut. Others like Texas, Illinois, Pennsylvania, and Massachusetts had extremely low adoption rates during those years.

To TCTMD, Carroll said familiarity with mechanical thrombectomy within institutions may account for some of these trends.

“If you have providers that start to use it and then their colleagues start to use it because they . . . were able to try it out with them, I think that can lead to a snowball effect in certain institutions,” he added. Other factors to explain the heterogeneity may include device availability, differences in operator expertise, and financial considerations.

Carroll and colleagues say the finding “underscores the urgent need for forthcoming randomized trial evidence to guide therapy selection,” because without it, center-driven practice patterns may continue to perpetuate heterogeneity in PE care. They add that standardized algorithms that incorporate factors such as anatomic, hemodynamic, and bleeding risk parameters are needed to align practice across centers and ensure that choice of therapy is “guided by patient factors rather than institutional culture or resources.”

Recently, a joint clinical practice guideline from the American Heart Association  and the American College of Cardiology gave a class 1 recommendation to PERT teams and provided guidance on how to build them.

Carroll said the composition of those teams may be another factor that can help change some of the diversity in therapy selection.

“Having various specialties involved may lead to a more balanced discussion of the most appropriate therapy, though I don’t think our paper goes far enough in terms of just what the data was available to say that one device is better than another in certain circumstances or that a certain specialty involvement would be more beneficial,” he added.

“But given some of the heterogeneity and the breadth of options,” said Carroll, “having both noninvasive and a variety of invasive specialties offers the most balanced recommendations.”