Pulmonary embolism (PE) is a critical condition requiring prompt intervention. Mechanical thrombectomy (MT) and catheter-directed thrombolysis (CDT) are emerging catheter-based therapies, but their comparative effectiveness remains uncertain, particularly given the predominance of observational studies.

We conducted a systematic review and meta-analysis of studies identified through PubMed, Embase, and Web of Science from inception to February 10, 2025. Both randomized controlled trials and observational studies were included. Random-effects models were used for all analyses to account for anticipated heterogeneity. Primary outcomes were all-cause mortality, all-cause readmission, and PE-related readmission. Secondary outcomes included hospital stay, procedural time, and safety events. Heterogeneity was assessed using the I² statistic.

This meta-analysis included one randomized controlled trial (RCT) and six observational studies, comprising a total of 1369 patients (MT = 659, CDT = 710). MT was associated with a statistically significant reduction in hospital stay compared to CDT (Mean Difference = −0.47 days, 95 % CI: [−0.89, −0.05]; p = 0.03, I² = 0 %). However, there were no significant differences between MT and CDT in terms of all-cause mortality (RR = 1.24, 95 % CI: [0.47, 3.30]; p = 0.66, I² = 26 %), all-cause readmission (RR = 0.84, 95 % CI: [0.29, 2.41]; p = 0.75, I² = 54 %), or PE-related readmission (RR = 0.64, 95 % CI: [0.13, 3.23]; p = 0.59, I² = 0 %). Similarly, no significant differences were observed in procedural time (Mean Difference = 21.48 min, 95 % CI: [−5.20, 48.15]; p = 0.11, I² = 95 %), fluoroscopy time (Mean Difference = 6.63 min, 95 % CI: [−3.14, 16.41]; p = 0.18, I² = 93 %), or ICU stay (Mean Difference = −6.45 days, 95 % CI: [−20.25, 7.36]; p = 0.36, I² = 100 %).

Current evidence, primarily from observational studies, suggests that MT and CDT offer comparable clinical outcomes in PE management, with MT potentially associated with a shorter hospital stay. However, given the limitations inherent to the available data, including study design and heterogeneity, these findings should be interpreted cautiously. Further high-quality randomized trials are needed to draw definitive conclusions.