Pharmacomechanical thrombectomy versus catheter-directed thrombolysis in acute limb ischemia: a systematic review and meta-analysis

INTRODUCTION: Acute limb ischemia (ALI) is one of the most common arterial emergencies and is associated with a high risk of limb loss, morbidity, and mortality. Among endovascular techniques, catheter-directed thrombolysis (CDT) is the most widely used, though it presents limitations related to slow thrombus resolution and bleeding risk. Pharmacomechanical thrombectomy (PMT) has emerged as a faster and potentially more effective alternative. However, the comparative efficacy and safety of these two modalities remain a matter of debate. EVIDENCE ACQUISITION: A systematic review and meta-analysis was conducted by searching PubMed and EMBASE databases to identify studies directly comparing PMT and CDT. Outcomes assessed included technical success, procedural complications, primary patency, limb salvage, and survival. Pooled analyses were performed using a random-effects model (OR; 95% CI). EVIDENCE SYNTHESIS: Four retrospective observational studies met the inclusion criteria, comprising a total of 607 patients (163 treated with PMT and 444 with CDT). Baseline demographics, comorbidities, and clinical limb presentation were similar, although more recent studies reported a higher prevalence of IIB Rutherford class ischemia in the PMT group. No differences were found in technical success OR 0.69 (95% CI: 0.16-3.03, P=0.62). At 30 days, there were no significant differences in limb loss rate OR 1.22 (95% CI: 0.66-2.27, P=0.52) and mortality OR 1.17 (95% CI: 0.59-2.31, P=0.65). At 12 months, no differences were observed in primary patency OR 1.84 (95% CI: 0.57-5.96, P=0.31), freedom from limb loss OR 1.20 (95% CI: 0.59-2.45, P=0.62), or freedom from all-cause death OR 1.53 (95% CI: 0.74-3.13, P=0.25). Adverse events such as distal embolization and acute kidney injury occurred more frequently in PMT group, with OR 2.09 (95% CI: 1.22-3.59, P=0.007) and OR 4.77 (95% CI: 1.85-12.30, P=0.001), respectively. Bleeding complications were slightly lower in the PMT group but did not reach statistical significance (P=0.67). Hospital stay was significantly shorter in the PMT group (MD -1.27 days; 95% CI: -1.84 to -0.70, P<0.001). CONCLUSIONS: PMT and CDT appear to provide comparable early and mid-term outcomes in the treatment of ALI. While PMT was associated with more periprocedural complications, it may offer advantages in selected cases requiring rapid revascularization. No clear superiority emerged between the two approaches. Considering the current limited evidence base, further high-quality prospective studies are warranted to define the optimal endovascular strategy and assess long-term effectiveness.