Abstract Body (Do not enter title and authors here): Background:
Anticoagulation therapy (ACT) remains the cornerstone of acute pulmonary embolism (PE) management and reduces the mortality risk to <1% in low-risk PE. However, AC is inadequate in intermediate and high-risk acute PE, thus requiring additional therapies. So, there has been a search for better advancement in therapeutic approaches, including catheter-directed thrombolysis (CDT) or thrombectomy, surgical embolectomy (SE), or mechanical thrombectomy (MT). We performed this network meta-analysis to analyze the outcome of different therapeutic approaches for acute intermediate and high-risk PE.

Method:
We conducted a Bayesian network meta-analysis to synthesize direct and indirect evidence from pertinent studies published until May 2024 using PubMed, Embase, and Scopus databases comparing different therapies for intermediate and high-risk PE patients. This study is registered with PROSPERO, and data analysis was performed using the “BUGSnet” package in R.

Result:
This analysis included 1,639,413 patients with intermediate or high-risk PE from 72 studies. The probability of CDT being ranked highest was for short-term mortality (catheter-directed intervention: 93), long-term mortality (Ultrasound-assisted Thrombolysis (USAT): 86.17), major bleeding (USAT: 85.58), and intracranial hemorrhage (USAT: 86.06) whereas surgical embolectomy for any and gastro-intestinal bleedings (93.76 and 78.7) respectively. The risk of short-term mortality and intracranial hemorrhage were lower among the patients treated with USAT [(OR: 0.38, CrI: 0.17 to 0.81) and (OR: 0.27, CrI: 0.10 to 0.69)] than those treated with AC only and MT in a random effects model.

Conclusion:
Based on the findings of this network meta-analysis, compared to other advanced PE management modalities, catheter-based interventions, especially ultrasound-assisted thrombolysis, could potentially reduce short and long-term mortality risk without increasing bleeding risk.