OBJECTIVES:  To review the efficacy and safety of the recanalization procedures for the treatment of acute symptomatic pulmonary embolism (PE). METHODS: Searches were performed in PubMed, the Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL from inception through July 31, 2015, without language restrictions. Randomized clinical trials that compared the effect of a recanalization procedure vs. each other or anticoagulant therapy in patients diagnosed with acute symptomatic PE were included. Two reviewers independently screened by abstract and full text and extracted data. Disagreements were resolved by consensus. We used network meta-analysis and multivariate random-effects meta-regression to estimate pooled differences between each intervention. The primary outcomes were all-cause mortality and major bleeding. RESULTS: From a total of 930 unique studies identified, 22 studies were included in the analysis (2,494 patients). Of these studies, 16 compared full-dose thrombolysis to no thrombolysis, 1 compared low-dose thrombolysis to no thrombolysis, 1 compared catheter-directed thrombolysis with no thrombolysis, and 4 compared full-dose thrombolysis with low-dose thrombolysis. For all-cause mortality, there were no significant differences in events rates between any of the recanalization procedures and anticoagulant treatment (full-dose thrombolysis: OR, 0.60; 95% confidence interval, 0.36 to 1.01; low-dose thrombolysis: 0.47, 0.14 to 1.59; and catheter-associated thrombolysis: 0.31, 0.01 to 7.96). Full-dose thrombolysis increased the risk of major bleeding (2.00, 1.06 to 3.78) compared with anticoagulant treatment. The adjusted indirect comparison between full-dose thrombolysis, low-dose thrombolysis and catheter-directed thrombolysis did not show superiority of any procedure over the others for all-cause mortality or major bleeding. CONCLUSIONS: When considering the risk–benefit profile of recanalization procedures in the acute treatment of PE, these treatments do not seem to offer a clear advantage compared with standard anticoagulation. Low-dose thrombolysis is probably the best option to consider when a recanalization procedure is indicated.