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

<b>Background:</b> 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. <b>Methods:</b> 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. <b>Results:</b> In-hospital mortality was 16.6% in the SPE group in contrast to 25.0% in the ST group (<i>p</i> = 0.765). Neurological complications were significantly lower in SPE (2.1%) compared to ST (12.5%) (<i>p</i> = 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%, <i>p</i> = 0.014). Hospitalization duration was significantly longer for SPE patients (mean 17.4 vs. 11.4 days, <i>p</i> < 0.001), who also presented with more severe disease, including higher ECMO utilization. <b>Conclusions:</b> 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.