video1.0<iframe src="https://www.loom.com/embed/c6106815982e45f1a14f7fa38517c179" frameborder="0" width="1950" height="1462" webkitallowfullscreen mozallowfullscreen allowfullscreen></iframe>14621950Loomhttps://www.loom.com14621950https://cdn.loom.com/sessions/thumbnails/c6106815982e45f1a14f7fa38517c179-ee137da2a48799cf.gif1748.185Catheter-directed thrombolysis reduced the 7-day composite of death, recurrent pulmonary embolism, or cardiorespiratory decompensation or collapse from 6.8% to 0.7% (RR 0.10, 95% CI 0.02–0.44). The absolute risk reduction was 6.1 percentage points, which translates to a number needed to treat of roughly 17. The result was driven mainly by fewer episodes of cardiorespiratory decompensation, not a proven reduction in mortality. The trial was open-label, the adjudicators knew treatment assignment, and part of the decompensation definition relied on a National Early Warning Score threshold. Bleeding rates were similar overall, but two patients in the thrombolysis group had an intracranial hemorrhage. That is the tension at the center of this trial: catheter-directed alteplase appears to prevent early deterioration, but the benefit has to be weighed against a rare and potentially devastating harm. For carefully selected patients with intermediate-high–risk PE at experienced centers, PRAGUE-26 lowers the threshold for an early PERT discussion. It does not justify routine catheter-directed thrombolysis for everyone with RV strain and a positive troponin.