Mechanism-Driven Percutaneous Therapies for Acute Pulmonary Embolism: A Contemporary Review for Vascular Surgeons

Abstract Objective Acute pulmonary embolism (PE) remains a major cause of cardiovascular morbidity and mortality. Rapid advances in percutaneous therapy have transformed PE management from lytic-heavy strategies toward mechanism-driven thrombectomy and aspiration techniques. Understanding how device mechanisms translate to clinical performance is essential for appropriate patient selection and for defining the expanding role of vascular surgeons in Pulmonary Embolism Response Teams (PERTs). This review provides vascular surgeons with a mechanistic, evidence-based framework to guide device selection, integration in PERT workflows, hemodynamic decision-making, and the adoption of thrombectomy as a core component of modern vascular practice. Methods A narrative review was conducted using PubMed, Embase, and Scopus from 1998–2024, focusing on clinical trials, registries, multicenter studies, and prospective cohorts evaluating mechanical thrombectomy, aspiration systems, catheter-directed thrombolysis (CDT), ultrasound-assisted thrombolysis (USAT), and hybrid pharmacomechanical devices. Outcomes extracted included RV/LV ratio reduction, pulmonary artery pressure, bleeding complications, major adverse events, procedure time, length of stay, and mortality. Devices were categorized by mechanism to allow cross-platform interpretation. Results Mechanically driven thrombectomy systems—particularly FlowTriever and AlphaVac—demonstrate rapid RV/LV ratio improvement (35–40%), minimal bleeding (<1%), and reduced ICU/hospital utilization, with unique advantages in patients with contraindications to thrombolysis. Aspiration systems such as Penumbra Indigo provide significant RV/LV reduction (∼27%) with the lowest bleeding rates among all percutaneous options. CDT and USAT platforms enable substantial reduction in thrombolytic dose compared with systemic therapy and achieve consistent RV/LV recovery, though bleeding risk remains higher than lytic-free strategies. Hybrid devices such as the Bashir catheter enhance intrathrombus drug dispersion and demonstrate early evidence of improved hemodynamic recovery with very low complication rates. Across mechanisms, device selection is most effective when matched to clot morphology, thrombus chronicity, hemodynamics, bleeding risk, and institutional expertise. Conclusion Endovascular therapy for PE has evolved into a mechanistically diverse, device-specialized field in which vascular surgeons play a central leadership role. Mechanical thrombectomy offers rapid, lytic-free reperfusion ideal for intermediate-high and selected high-risk patients, while CDT, USAT, and hybrid systems provide valuable alternatives when there is distal thrombus distribution or patient phenotype favors pharmacologic augmentation. Mechanism-aligned device selection, multidisciplinary PERT integration, and advances in hemodynamic support—including ECMO—are redefining contemporary PE care. Rigorous comparative trials and long-term outcome studies are needed to optimize device choice, refine patient selection, and evaluate the impact on chronic thromboembolic disease.