Safety and effectiveness of ultrasound assisted catheter-directed thrombolysis for acute intermediate-high and high risk pulmonary embolism: all eyes on elderly

pulmonary embolism (PE) is one of the leading causes of in-hospital mortality. In elderly diagnosis can be challenging due to nonspecific and often atypical presentation, as well as the presence of multiple comorbidities that can complicate, mimic or account for patient’s symptoms. Furthmore, these patients have an increased risk of hemorrhagic events related to age-associated physiological changes and the use of anticoagulant or antiplatelet medications.

the aim of this sub-analysis is to evaluate the clinical presentation of PE and the safety and effectiveness of catheter-directed therapy (CDT) in elderly.

we performed a retrospective study of patients treated with CDT from march 2018 to september 2025. Data were extracted from the ongoing retrospective and prospective multicenter USAT IH-PE registry. Patients with intermediate-high and high risk PE, aged above and below 65 years, were assessed and compared.

a total of 306 patients with intermediate-high risk (70%) or high risk (30%) PE were included. Elderly patients were more often female (59.9% vs 42.6%, p=0.004) and had a median age of 76 (IQR 70-82) compared with 56 years (IQR 47-61) in younger patients. Patients aged ≥65 years presented with a higher burden of comorbidities, including systemic hypertension (73% vs 48.9%, p<0.001), chronic kidney disease (14.7% vs 6.3%, p=0.037) and previous PE (10.2% vs 2.8%, p=0.024) compared with the younger cohort. Dyspnea was more frequently reported as the presenting symptom among older patients (72.4% vs 61.1%, p=0.05), whereas chest pain and syncope occurred in 21.7% and 20.4% of cases respectively. No significant differences were observed between groups in device-related complications (6% vs 2.7%, p=0.4), BARC bleeding (OR 1.7, 95% CI 0.88-3.48, p=0.1) or need for trasfusion (8.6% vs 12.1%, p=0.4). Similarly, in-hospital mortality rates were comparable between elderly (5.2%, 95% CI 2.3-10) and younger patients (4.7%, 95% CI 1.9-9.4, p=0.4). Kaplan-Meier analysis confirmed the absence of significant differences in in-hospital mortality between the two groups (log rank p=0.3).

Elderly patients often present with nonspecific or atypical symptoms. CDT is as safe and effective in this population as in younger patients with PE.

Kaplan-Meier for in-hospital mortality