Patient description: A 62-year-old African-American man presented with left upper and lower extremity weakness, associated with dark visual spot in right eye, right facial numbness, facial drop and slurred speech. He denied dyspnea, headache, palpitations, chest pain, fever, dizziness, bowel or urinary incontinence, loss of consciousness. His medical history was significant for hypertension, hyperlipidemia and hypothyroidism. He smokes cigarette 1 pack per day for 40 years and alcohol consumption of 5 to 6 beers per week. He is not aware about his family history. He is using Levothyroxine, Atorvastatin and HTCZ. His vital signs were stable in the primary evaluation. Left-sided facial droop, dysarthria, and left-sided hemiplegia were seen in the physical exam. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. Intravenous recombinant tissue plasminogen activator (t-PA) was administered as well as high-dose statin therapy. The patient was admitted to the intensive care unit to be monitored for 24 hours. MRI of the head revealed an acute 1.7-cm infarct of the right periventricular white matter and posterior right basal ganglia.

Clinical trial eligibility criteria: eligible ages (years): 18.0-80.0,  Acute Pulmonary Embolism (PE) Acute symptomatic PE with thrombus located in the pulmonary main trunk or the left and/or right main pulmonary artery 2. High-risk PE defined as PE with sustained systemic arterial hypotension (systolic pressure <90mmHg), cardiogenic shock, or the ongoing need for catecholamine therapy OR Intermediate-high risk PE: Imaging evidence of RV-Dilatation (right-to-left ventricular diameter ratio >1.0 on echocardiography or chest computed tomography) and biomarker evidence of RV dysfunction (positive Troponin T or I Test). 3. The for both procedures must be established by the PERT team 4. Signed Informed consent (by subject or legal representative) -  Age less than 18 years or greater than 80 years. 2. Symptom duration > 14 days suggesting acute-on-chronic pulmonary embolism. 3. Known chronic thromboembolic pulmonary hypertension (CTEPH) 4. Suspected chronic thromboembolic pulmonary hypertension (CTEPH) including RV hypertrophy (RV free wall >5 mm on echocardiography), severe pulmonary hypertension (systolic pulmonary artery pressure > 80 mmHg on echocardiography), or CT findings suggestive of CTEPH including intraluminal webs, bands, strictures, or eccentric filling defects adjacent to the wall of the pulmonary arteries 5. Decompensated cardiogenic shock defined as recent (<48 hours) cardiopulmonary resuscitation therapy or worsening hemodynamic status despite extended fluid and catecholamine support 6. Inability to tolerate catheter procedure or surgical embolectomy due to severe comorbidities. 7. Allergy, hypersensitivity, or thrombocytopenia from heparin, r-tPA, or iodinated contrast, except for mild-moderate contrast allergies for which steroid pre-medication can be used. 8. Known significant bleeding risk, or known coagulation disorder (including vitamin K antagonists with INR > 2.0 and platelet count < 100 000/mm3) 9. Severe renal impairment (estimated GFR < 30 ml/min). 10. Active bleeding: recent (< 3 months) GI bleeding, severe liver dysfunction, bleeding diathesis. 11. Recent (< 3 months) internal eye surgery or hemorrhagic retinopathy; recent (< 10 days) major surgery, cataract surgery, trauma, CPR, obstetrical delivery, or other invasive procedure. 12. History of stroke or intracranial/intraspinal bleed, tumor, vascular malformation, aneurysm. 13. Severe hypertension on repeated readings (systolic > 180 mmHg or diastolic > 105 mmHg). 14. Pregnant, lactation or parturition within the previous 30 days (positive pregnancy test in women of childbearing age) 15. Recent (< 1 month) systemic thrombolysis. 16. Life expectancy < 6 months or chronic non-ambulatory status. 17. Participating in any other investigational drug or device study or previous enrollment in this study 18. Inability to comply with study assessments (e.g. due to cognitive impairment or geographic distance). 19. Any other condition that the investigator feels would place the patient at increased risk if the investigational therapy is initiated