For patients who require thrombolytic therapy and do not have a high risk of bleeding, the AT10 panel favored systemic thrombolytic therapy over CDT because, compared with anticoagulation alone, there is a higher quality of evidence in support of systemic thrombolytic therapy than for CDT. Catheter-Based Thrombus Removal Without Thrombolytic Therapy: Catheter-based mechanical techniques for thrombus removal involve thrombus fragmentation using various types of catheters, some of which are designed speci cally for this purpose.150-153 Fragmentation results in distal displacement of thrombus, with or without suctioning and removal of some thrombus through the catheter. Mechanical methods alone are used when thrombus removal is indicated but there is a high risk of bleeding that precludes thrombolytic therapy. No randomized trial or prospective cohort studies have evaluated catheter-based thrombus removal of PE without thrombolytic therapy. Evidence for the use of CDT compared with anticoagulation alone, CDT compared with systemic thrombolytic therapy, and catheter-based treatment without thrombolytic therapy is of low quality and our recommendations are weak. *24. In patients with acute PE who are treated with a thrombolytic agent, we suggest systemic thrombo- lytic therapy using a peripheral vein over CDT (Grade 2C). Remarks: Patients who have a higher risk of bleeding with systemic thrombolytic therapy, and who have access to the expertise and resources required to do CDT, are likely to choose CDT over systemic thrombolytic therapy. *25. In patients with acute PE associated with hy- potension and who have (i) a high bleeding risk, (ii) failed systemic thrombolysis, or (iii) shock that is likely to cause death before systemic thrombolysis can take effect (eg, within hours), if appropriate expertise and resources are available, we suggest catheter-assisted thrombus removal over no such intervention (Grade 2C). Remarks: Catheter-assisted thrombus removal refers to mechanical interventions, with or without catheter directed thrombolysis. 