Assistant Professor of Clinical Thoracic Medicine at the Lewis Katz School of Medicine at Temple University

Samantha Pettigrew, MD

Recent randomized trials in intermediate-high-risk pulmonary embolism (PE) support catheter-based intervention over anticoagulation alone, particularly in patients with added markers of clinical severity, according to Samantha Pettigrew, MD, assistant professor of clinical thoracic medicine at the Lewis Katz School of Medicine at Temple University.

CHEST 2026 Annual Meeting in Phoenix, Arizona

, held October 18-21, after presenting in the Pulmonary Vascular Disease Section session "Pulmonary Embolism Care in 2026: New Randomized Clinical Trials and What's Coming Next."

, PEERLESS, and other trials reported in the past year.

New Trials Favor PE Intervention in Sicker Intermediate-Risk Patients

"So I think in choosing your patients, if you have somebody who you are a little bit more worried about than usual, if it is just not sitting right, maybe if they do not fit very clearly into the guidelines we have out right now, thinking about escalating their care, talking to them about intervention, talking to your interventionalists is really important," Pettigrew said.

HI-PEITHO randomized 544 patients with intermediate-high-risk PE plus tachycardia, low systolic blood pressure without shock, or hypoxemia to ultrasound-facilitated catheter-directed thrombolysis or anticoagulation alone.

 The composite of PE-related death, cardiorespiratory decompensation or collapse, or symptomatic recurrent PE occurred in 4.0% versus 10.3% of patients, driven by fewer decompensation events, with no significant difference in major bleeding or all-cause death.

PRAGUE-26 applied the standard intermediate-high-risk definition in 558 patients, and the 7-day composite of death, recurrent PE, or cardiorespiratory decompensation or collapse occurred in 0.7% with catheter-directed thrombolysis versus 6.8% with anticoagulation alone (relative risk, 0.10; 95% CI, 0.02–0.44).

 For patients without added severity markers, Pettigrew said bleeding risk assessment carries more weight in the decision to intervene.

In PEERLESS, the first head-to-head randomized comparison of catheter-based therapies, large-bore mechanical thrombectomy outperformed catheter-directed thrombolysis on a hierarchical win ratio (5.01; 95% CI, 3.68–6.97; 

 < .001), driven by lower ICU utilization, the lowest-ranked component.

 Excluding ICU outcomes, the win ratio was 1.34 (95% CI, 0.78–2.35; 

 = .30). Pettigrew noted no trial has yet shown a mortality benefit, though she said reduced ICU use matters for hospital flow and for limiting delirium and infection risk.

Pulmonary embolism care in 2026: new randomized clinical trials and what's coming next. Session presented at: CHEST 2026 Annual Meeting; October 18-21, 2026; Phoenix, AZ.

Konstantinides SV, et al. Ultrasound-facilitated catheter-directed thrombolysis vs anticoagulation alone for acute intermediate-high-risk pulmonary embolism: primary results of the HI-PEITHO randomized clinical trial. 

Kroupa J, Radvan M, Mrozek J, et al. Catheter-directed thrombolysis in intermediate-high-risk pulmonary embolism. 

Jaber WA, Gonsalves CF, Stortecky S, et al. Large-bore mechanical thrombectomy versus catheter-directed thrombolysis in the management of intermediate-risk pulmonary embolism: primary results of the PEERLESS randomized controlled trial. 

Videos

Samantha Pettigrew, MD, reviews HI-PEITHO, PRAGUE-26, and PEERLESS and how they shape intervention choices in intermediate-risk PE at CHEST 2026.

Samantha Pettigrew, MD

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