Pulmonary embolism (PE) remains a leading cause of cardiovascular mortality, particularly in its high-risk and intermediate-high risk presentations where acute right ventricular (RV) failure is the primary driver of hemodynamic collapse. This review comprehensively examines the pathophysiology of RV failure in PE, their indications based on current evidence and guidelines, practical considerations for implementation, management strategies, complications, and integration with other therapeutic modalities. We also highlight the crucial role of a multidisciplinary team and discuss future directions in this rapidly evolving field. Emphasis is placed on practical application for the interventional cardiologist.