PURPOSE: To evaluate the safety, effectiveness, and prognostic factors of large-bore mechanical thrombectomy (LBMT) for acute pulmonary embolism (PE) in an all-comer population of high- and intermediate-risk patients at a tertiary center.

MATERIALS AND METHODS: This retrospective study analyzed 52 consecutive patients (male, 63.5% [33/52]; mean age, 62.6 years [SD ± 17.3]) undergoing LBMT for acute PE from 2019 to 2024: 57.7% (30/52) high-risk and 42.3% (22/52) intermediate-risk per European Society of Cardiology (ESC) criteria with a Pulmonary Embolism Severity Index (PESI) score of 160.7 (SD ± 51.7). Patients excluded from clinical trials-with malignancy (57.7% [30/52]), metastatic disease (13.5% [7/52]), and nonimprovement despite systemic thrombolytics (19.2% [10/52])-were included. Procedural outcomes, adverse events (AEs), and mortality predictors were examined.

RESULTS: Median follow-up was 13.7 months (interquartile range, 5.4-22.3 months). Mean pulmonary artery pressure decreased by 6.9 mm Hg (SD ± 6.4). Refined modified Miller index reduced by 13.7 (SD ± 5.9). Survival was 66.7% (20/30) for high-risk patients and 95.5% (21/22) for intermediate-risk patients at 6 months (P = .01). Society of Interventional Radiology (SIR) severe AEs occurred in 5.8% (3/52) of patients. Independent 6-month mortality predictors were metastatic disease (odds ratio [OR], 42.5; 95% CI, 3.28-258.81; P < .001), PESI score (OR, 1.03 per point; 95% CI, 1.00-1.06; P = .04), and ESC stratification (OR, 0.08; 95% CI, 0.003-0.48; P = .03).

CONCLUSIONS: In an unselected tertiary setting, LBMT demonstrates safety and effectiveness for acute PE with excellent survival of intermediate-risk patients and clinically meaningful outcomes for high-risk populations generally excluded from trials.