vascular. ABSTRACT. Pulmonary embolism is a common cause of death. Massive pulmonary thromboembolism requires an aggressive and timely therapeutic approach. Acute pulmonary embolism associated with hemodynamic instability (shock or hypotension) has a high risk of mortality in the early hours (25-65%) and 10% risk of progressing to cardiogenic shock; an estimate of up to 50% of cases are associated with recur- rent pulmonary thromboembolism. The treatment based on evidence that has shown clinical improvement and decreased risk of mortality is anticoagulation. However, there are clinical conditions in which the use of this therapy may be contraindicated or can be detrimental to the patient's clinical status and therefore other therapeutic options should be considered. At present there is no concrete evidence based on clini- cal trials for the use of alternative options for the treatment of pulmonary embolism that are comparable with anticoagulation. We will discuss the different options available in acute pulmonary embolism.