A 71-year-old female with past medical history of hypertension presented with 10 days of progressive lower extremity numbness and weakness. Magnetic resonance imaging (MRI) demonstrated likely metastatic malignant mass causing cord compression. She received intravenous fluids and dexamethasone. Initial blood pressure was 88/66 mmHg, heart rate of 92 b.p.m., respiratory rate of 26, and oxygen saturation of 91% on room air. Cardiopulmonary exam was unremarkable. Hypotension was thought to be neurogenic. Electrocardiogram was significant for anterior T wave inversions and S1Q3T3 (). Computed tomography (CT) with intravenous contrast of the chest and abdomen was done as further malignancy workup, revealing right lower lobe mass (likely primary lung malignancy), with large saddle PE from the main PA with extension into all five lobes (). Computed tomography was significant for right ventricle/left ventricle (RV/LV) ratio nearly 2:1 consistent with right heart strain (). Troponin was elevated to 1.84 ng/mL. Heparin infusion was initiated. Admission echocardiogram was not obtained due to urgency of cord compression. PE Response Team (PERT) was activated. Per multidisciplinary discussion involving the PERT team, cardiology, and neurosurgery, patient was determined to need urgent spinal cord decompression surgery to avoid paralysis. While the systolic blood pressure intermittently dropped <90 mmHg, it did not sustain <90 mmHg for >15 min. Given intermediate–high-risk PE with acute cor pulmonale, urgent need for surgery, and risk of haemodynamic collapse upon induction of general anaesthesia, decision was made to proceed with urgent percutaneous treatment of the PE. Neurosurgery deemed that administering local thrombolysis with tissue plasminogen activator was not necessarily contraindicated. It was then decided to pursue mechanical thrombectomy and IVC filter placement in a single session. The goal was to alleviate right heart strain swiftly while avoiding prolonged catheter-directed thrombolytic infusion to allow patient to undergo urgent surgery, in addition to reducing bleeding risk. The patient was brought to the cardiac catheterization lab. At case start, blood pressure 128/76 mmHg. Pulmonary artery catheterization was performed via an 8 Fr sheath in the right femoral vein demonstrating PA pressure of 34/12 mmHg (mean: 21 mmHg). An Amplatz Super Stiff wire was placed in the right interlobar artery. A 26 Fr Gore Dryseal sheath (Gore, Flagstaff, AZ, USA) was introduced to accommodate the FlowTriever system (Inari Medical Inc., Irvine, CA, USA), which consists of a 24 Fr, trackable, 95 cm long aspiration catheter used to mechanically retrieve clot. Bilateral PAs were selectively engaged with the T24 FlowTriever system. Thrombectomy was successfully performed bilaterally. Multiple aspirations were made with significant visible thrombus extracted (). Approximately 300 cc of blood loss was noted. Systemic blood pressure remained 103–118/66–77 mmHg. Repeat PA pressures improved to 26/6 mmHg (mean: 15 mmHg). Pulmonary angiogram showed near complete restoration of pulmonary blood flow to the right and left sides (). Finally, an IVC filter was placed. The patient returned to ICU on room air with stable blood pressure to 118/71 mmHg. Echocardiogram showed resolution of RV and RA dilation, with normal RV systolic function (). The patient remained haemodynamically stable. Two days after thrombectomy, the patient underwent successful C4–C7 laminectomy, C6–C7 corpectomy, and C3-–T3 posterolateral fusion. Estimated blood loss was 3.1 L, requiring transfusion. No cardiopulmonary issues occurred post-operatively. Therapeutic anticoagulation was ultimately resumed, and the patient was discharged shortly after. The patient continued to follow with Radiation Oncology for further treatment of primary lung and metastatic malignancy and was maintained on enoxaparin over DOAC ultimately under decision-making of Oncology. Sixty days later at cardiology follow-up, the decision was made to keep IVC filter permanently given incompletion of malignancy radiation therapy and high risk of further VTE.