Surgical thrombus removal in acute pulmonary embolism. Where do we stand today?

Acute pulmonary embolism (PE) remains a major cause of cardiovascular morbidity and mortality, with clinical presentations ranging from asymptomatic disease to obstructive shock and sudden death. Although anticoagulation is effective in most hemodynamically stable patients, a substantial proportion present with or progress to right ventricular (RV) failure and require reperfusion therapy. Surgical embolectomy (SE), first introduced in the early 20th century, was historically associated with prohibitive mortality, and largely abandoned following the advent of systemic thrombolysis. However, advances in diagnostic imaging, cardiopulmonary bypass, perioperative management, and multidisciplinary care have led to renewed interest in this approach. Contemporary series demonstrate that, when performed at experienced centers, SE is associated with acceptable operative mortality, favorable long-term survival, preserved RV function, and low rates of recurrent PE or chronic thromboembolic pulmonary hypertension. Outcomes appear to be driven primarily by preoperative clinical status - particularly cardiogenic shock and cardiac arrest - rather than by surgical technique alone, underscoring the importance of careful patient selection and timely referral. Although systemic thrombolysis and catheter-directed therapies remain central to acute PE management, available evidence suggests that SE achieves outcomes comparable to those of non-surgical reperfusion strategies, with a potentially lower risk of intracranial hemorrhage in selected high-risk patients. This narrative review summarizes the historical evolution, contemporary surgical techniques, clinical outcomes, and comparative effectiveness of surgical embolectomy in the treatment of acute pulmonary embolism, with the aim of clarifying its current role within modern multidisciplinary management strategies.