Sex-specific disparities in clinical characteristics and outcomes of catheter-directed treatments for acute pulmonary embolism

Background: Acute pulmonary embolism (PE) represents a cardiovascular emergency with increasing incidence. Catheter-directed treatments (CDTs) are increasingly used for high-risk or intermediate-high-risk PE patients when surgical embolectomy or systemic thrombolysis (ST) is contraindicated or ineffective. Although prior research suggests poorer outcomes in women with PE, sex-specific differences in CDTs outcomes remain unclear. Aims: To investigate the influence of sex on clinical characteristics, procedural complications, and clinical outcomes among patients undergoing CDTs for acute PE. Methods: This retrospective multicenter study included consecutive high-risk and intermediate-high-risk PE patients treated with CDTs across five Italian Centers. Clinical data, procedural complications and outcomes were collected and analyzed. Bleeding events were classified according to Bleeding Academic Research Consortium (BARC) criteria. Results: We included 191 patients (101 women, 53 %; 90 men, 47 %) treated primarily with ultrasound-assisted thrombolysis (USAT, 69 %), with no sex-based differences in device allocation. Compared with men, women more frequently experienced cardiac arrest (11 % vs. 3 %, p = 0.04), had fewer absolute contraindications to ST (23 % vs. 42 %, p = 0.004), and lower rates of recent major surgery (9 % vs. 22 %, p = 0.01). Women experienced significantly higher in-hospital mortality (20 % vs. 9 %, OR 2.53, 95 % CI 1.09–6.41, p = 0.037), higher bleeding rates (22 % vs. 10 %, OR 2.53, 95 % CI 1.13–6.13, p = 0.029), and higher 1-year all-cause mortality (29.1 % vs. 12.7 %, aHR 2.37, 95 % CI 1.12–5.04, p = 0.024). Conclusions: Women undergoing CDTs for PE present with greater clinical severity, experienced more procedural complications, and had worse early and mid-term outcomes, underscoring the need for sex-specific management strategies in patients undergoing CDTs for PE. Condensed abstract: Catheter-Directed Treatments (CDTs) are emerging therapeutic options for acute pulmonary embolism (PE) patients with contraindications or inadequate response to standard therapies. In this multicenter study, we analyzed sex-specific differences in clinical presentation and outcomes of patients with high and intermediate-high risk PE treated with CDTs. Among 191 patients enrolled, 53 % were women. Most patients presented with intermediate-high risk PE and were treated with ultrasound-assisted thrombolysis (USAT). Women presented with more severe clinical profiles, had higher procedural complication rates, and experienced significantly greater bleeding and in-hospital mortality compared with men. Female sex was an independent predictor of 1-year all-cause mortality. These findings highlight the importance of sex-specific management strategies for patients undergoing CTDs for acute PE.