Acute pulmonary embolism (PE) is associated with a broad spectrum of clinical severity. However, despite the varying presentations, therapy is primarily limited to anticoagulation. The only widely accepted exception to the use of anticoagulation alone is in those patients with massive acute PE, in whom systemic fibrinolysis is generally considered the most appropriate option. Unfortunately, there is a large group of patients without massive PE who do worse with heparin alone, and systemic fibrinolysis has not been consistently shown to be beneficial in these patients. The role of catheter directed therapies (CDT) needs to be further investigated for this all too common patient subset.