Acute massive or submassive pulmonary embolism (PE) requires prompt diagnosis, risk-stratification and aggressive treatment. Mortality rates can rise up to 70% within the first hour of presentation and are strongly correlated with the degree of right ventricular (RV) dysfunction, cardiac arrest, and consequential congestive heart failure. While anticoagulation is universally employed, there are inadequate data to establish definitive guidelines for the management of massive PE despite the availability of multiple treatment modalities. Medical thrombolytic therapy has not been shown to significantly reduce mortality in patients with massive PE but is still widely employed, whereas surgical and catheter embolectomy are only reserved as last resort treatments for critically ill patients with hemodynamic instability, or for those who are either not candidates for or have failed thrombolysis. Following an extensive review of medical literature, we outline the treatment options for this clinical scenario while focusing on the role of surgical embolectomy. Although traditionally reserved as rescue therapy for cases of failed thrombolysis, surgical embolectomy is a safe procedure with low mortality when performed early and in a selected group of patients. Sufficient evidence exists to extend the criteria for surgical embolectomy from strictly rescue therapy to include hemodynamically stable patients with RV dysfunction. Multidisciplinary approach to this condition coupled with a meticulous surgical technique has significantly lowered the mortality associated with this surgical procedure over the last 10 years.