Mechanical Thrombectomy or Thrombolysis Treatment of Pulmonary Embolism: What Is State of the Art In 2026?

As pulmonary embolism (PE) care continues to evolve, the practical question facing many teams is no longer whether to escalate beyond anticoagulation, but how to do it – and how quickly it can be achieved. With catheter-directed thrombolysis increasingly refined and mechanical thrombectomy platforms expanding, the field is in an active phase of workflow redesign, evidence-generation and real-world adoption.

Today at LINC, Marianne Brodmann (Division of Angiology, Medical University Graz, Austria) reflects on where the balance lies in 2026, what drives modality choice at the bedside, and what data gaps still limit decision-making.

“In the past, and still to this day, mechanical thrombectomy is not as widely used in daily practice as thrombolysis,” she told LINC Today. “Treatment depends a lot on site facilities, equipment and the experience of the hospital and regional set up. For example, in remote rural hospitals, where the patient presents first, thrombolysis is still the first-line treatment.”

That pragmatism runs through her outlook. Despite the growing visibility of thrombectomy, real-world uptake still depends heavily on infrastructure, trained teams and time-to-treatment. As such, how has her perspective changed with modern catheter-directed techniques and lower-dose regimens – which patients still benefit the most, and when should lysis be avoided? “Thrombolysis has really changed a lot, especially with the use of catheter-directed thrombolysis (if feasible in a hospital), but also in general, as the dosage approach has been reduced,” she said.

“This helps a lot in reducing bleeding complications. Thrombolysis should be completely avoided in patients with a high risk of bleeding.”

She continued: “In the treatment of patients with PE – those who need to be treated with more than just anticoagulation alone – speed and completeness of clot removal are the most important aspects related to hemodynamic impact.”

When that clot removal is achieved, she expects patients to improve quickly – with an important qualifier that the result depends on how rapid and effectively the thrombus is cleared.

Bleeding risk is the classic trade-off with lysis. In 2026, Professor Brodmann looks to the balance of bleeding risk versus urgency of reperfusion in high-risk populations such as older patients, post-operative patients, cancer patients, or those following a recent stroke. “Where there is high bleeding risk there will for sure be a switch to thrombectomy if reperfusion treatment needs to be applied,” she underlined.

In massive PE with shock, she is careful not to reduce the decision to a single threshold. Instead, she points to the combination of hemodynamic status and operational realities – time, access, and the availability of experienced staff – that ultimately determines what can be delivered safely and rapidly.

“First and foremost is the hemodynamic status of the patient. Then we must consider the availability and time to get into the cath lab, the experienced staff available, and so on...”

She also described a place for combination strategies in selected cases, particularly when residual distal clot remains after a primary intervention and clinical recovery is incomplete, noting that her team combine thrombectomy with targeted dose lysis if the patient does not recover sufficiently after clot removal and there is still clot burden in the distal segments of the pulmonary arteries that are not able to be removed.”

Looking beyond the acute setting, Professor Brodmann highlighted what she sees as the most pressing evidence need: extended comparative outcomes that clarify whether one strategy better reduces chronic sequelae. “The most important data we need are longer-term outcome data comparing both treatment modalities and their impact on preventing the occurrence of chronic thromboembolic pulmonary hypertension.”

Alongside devices and data, she also stressed the organizational shift that is helping centers make faster, more consistent escalation decisions. PE response teams have become an important part of modern practice, but she argues they must be built around clear leadership and local realities: “The rise of PE response teams has significantly improved the treatment of patients with PE, but such a team needs to be set up according to the situation of the institution – that is, what kind of specialties are available.

“Furthermore, it is very important to have a clear leader who is in charge of bringing all key players together to make a quick decision and work up of the patient.”

In day-to-day practice, her bedside framework begins with risk stratification, then moves to anatomy and feasibility. “We choose anticoagulation only in low-risk or intermediate-low-risk patients, otherwise mechanical thrombectomy if central PE staff and cath labs are available. In peripheral PE, where thrombectomy might not be feasible or the patient is so hemodynamically unstable that an immediate approach is needed, we use thrombolysis.”

Finally, she points to a barrier that is less technical and more cultural: lingering skepticism around thrombectomy, including concern that it may be driven by novelty rather than evidence.

“The most important issue is still the disbelief in thrombectomy, as there is a suspicion regarding this approach; people are thinking it is overused because it is just a ‘new device possibility’ driven by the device industry,” she cautioned.

Taken together, Professor Brodmann’s view captures a state of the art defined by conditional choices. Overarching all of it is the need for longer-term comparative data and streamlined multidisciplinary pathways that make rapid, appropriate escalation possible in the real world.