Endovascular Treatments for Pulmonary Embolism: A Narrative Historical Review

INTRODUCTION: This narrative review examines endovascular treatments for acute pulmonary embolism (PE), focusing on percutaneous mechanical thrombectomy (MT). METHODS: PubMed (Medline) and Google Scholar were searched from January 1990 up to November 2024 (updated Feb 2026). Studies were included if they discussed PE and the use of thrombectomy devices. Full-text randomised controlled trial studies, observational studies, case series, and case reports were included. Opinion articles, letters to the editor, animal studies, and non-English studies were excluded. RESULTS: A total of 116 articles were reviewed. Current guidelines recommend systemic thrombolysis as first-line reperfusion for high-risk PE, whereas intermediate-high-risk PE is managed with anticoagulation and monitoring, with reperfusion reserved for deterioration. MT is currently an alternative, mainly when thrombolysis is contraindicated or has failed. However, the last two decades have seen a surge in thrombectomy devices including the FlowTriever, Indigo, and AngioVac. Numerous studies, most notably the PEERLESS trial, have reported rapid haemodynamic improvement with MT, including reduced pulmonary artery pressure, low major bleeding rates, and fewer intensive care admissions [1]. CONCLUSION: MT has shown early promise in the management of PE. Much of the current evidence derives from single-arm trials, registries, and industry-sponsored observational studies, with randomised comparative data still limited. Nonetheless, randomised evidence suggests MT may reduce clinical deterioration, intensive care use, and hospital length of stay compared with catheter-directed thrombolysis, though without a demonstrated difference in mortality, intracranial haemorrhage, or major bleeding. Further trial evidence is required before MT is recommended as first-line in PE.