Surgical Pulmonary Embolectomy Versus Systemic Thrombolysis in High-Risk Pulmonary Embolism: A Retrospective Single-Center Analysis

Abstract

Background: Pulmonary embolism (PE) is a life-threatening condition with high mortality, particularly in high-risk cases where rapid clinical deterioration is common. The optimal management strategy for high-risk PE remains debated. Systemic thrombolysis (ST) is widely used but is associated with substantial bleeding risks. Surgical pulmonary embolectomy (SPE) has re-emerged as a viable alternative, particularly in patients with contraindications to thrombolysis or failed response. However, the evidence comparing SPE and ST in critically ill patients remains limited, and current guidelines provide only limited guidance. This study aims to evaluate the outcomes between SPE and ST in critically ill patients, focusing on mortality and complication rates. Methods: This retrospective study included 96 high risk patients with severe acute pulmonary embolism treated between 2015 and 2023, with 48 undergoing SPE and 48 receiving ST who were matched 1:1 based on baseline variables and hemodynamic presentation. Outcomes assessed included in-hospital mortality, PE-related death, neurological complications, bleeding events, hospitalization duration, as well as further postinterventional complications. Results: In-hospital mortality was 16.6% in the SPE group in contrast to 25.0% in the ST group (p = 0.765). Neurological complications were significantly lower in SPE (2.1%) compared to ST (12.5%) (p = 0.05). Life-threatening hemorrhage occurred at similar rates in both groups (SPE: 18.8%, ST: 14.6%); however, non-life-threatening bleeding was more common in ST (16.7% vs. 2.1%, p = 0.014). Hospitalization duration was significantly longer for SPE patients (mean 17.4 vs. 11.4 days, p < 0.001), who also presented with more severe disease, including higher ECMO utilization. Conclusions: SPE is a safe and effective alternative to ST in PE, offering comparable mortality, fewer neurologic complication and a reduced risk of bleeding. These findings highlight the importance of individualized, risk-adapted treatment pathways and support the inclusion of SPE as a frontline consideration in the management of PE in critically ill patients in experienced centers with multidisciplinary support.

Keywords: clinical outcomes; high-risk patients; pulmonary embolism; surgical pulmonary embolectomy; systemic thrombolysis.

Figure 1

Pre- and postoperative computed tomography pulmonary angiography (CTPA) images of a patient undergoing surgical pulmonary embolectomy (SPE). (A) Preoperative axial CTPA demonstrating extensive central pulmonary embolism involving the main pulmonary artery with marked luminal obstruction. (B) Postoperative CTPA after surgical embolectomy showing complete removal of thrombotic material and restoration of pulmonary artery patency. These representative images illustrate the morphological success of SPE in a high-risk patient and highlight the immediate anatomical effect of surgical reperfusion.

Figure 2

Pre- and post-treatment computed tomography pulmonary angiography (CTPA) of a patient treated with systemic thrombolysis (ST). (A) Pre-treatment CTPA demonstrating a large central pulmonary embolus with near-complete luminal obstruction. (B) Post-treatment CTPA following systemic thrombolysis showing partial reduction in thrombotic burden and improved, though incomplete, reperfusion of the pulmonary arteries. These images exemplify the radiologic effect of systemic thrombolysis in high-risk pulmonary embolism and illustrate the difference in anatomic clot clearance compared with surgical embolectomy.