Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Surgery for pulmonary embolism was historically associated with high mortality rates, and these poor outcomes led to a subsequent decrease in operative volumes. Significant advances in operative technique and patient selection, however, have resulted in improved outcomes and a recent renewed interest in surgery for PE. In the past, surgical pulmonary embolectomy (SPE) was reserved for acutely ill patients presenting with PE and hemodynamic collapse or cardiac arrest. More recent data has supported expanded eligibility criteria for SPE to include earlier intervention for patients with acute PE who demonstrate clinical, serologic, and echocardiographic signs of right ventricular dysfunction. Institutions with cardiac surgery are implementing surgical pulmonary embolectomy earlier for management of both massive and submassive PEs with documented excellent short- and long-term outcomes and with sustained evidence of improved right ventricular function. More recently, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been successfully employed to stabilize patients with massive PE, allowing for right ventricular decompression and potential recovery. Several academic institutions have developed standardized protocols for the management of PE which include utilizing VA-ECMO as first-line treatment with the possibility for further intervention including SPE. Pathways with up front VA-ECMO for very ill patients with PE have summarily shown promising short-term outcomes.