Objective To investigate the impact of minimally invasive intervention combined with rt-PA on survival rates in patients with massive pulmonary embolism （MPE）. Methods Retrospectively， patients who received minimally invasive interventional combined rt-PA treatment in our hospital from October 2021 to October 2024 were included in the study group （103 cases）， and propensity score matching （PSM） scoring method was used to match patients who received Nadroparin calcium and rt-PA treatment in our hospital during the same period into the control group （97 cases）. Comparisons were made between the two groups regarding overall clinical efficacy， 30-day and 90-day post-treatment survival rates， vital signs ［heart rate （HR）， respiratory rate］， blood gas parameters ［arterial oxygen partial pressure （PaO₂）， carbon dioxide partial pressure （PaCO?）， pulmonary artery pressure （PAP）， and peripheral oxygen saturation （SpO?）］， coagulation and fibrinolysis system markers ［D-dimer （D-D）， plasminogen activator inhibitor-1 （PAI-1）， tissue plasminogen activator （t - PA）， thrombomodulin （TM）， and antithrombin Ⅲ （AT-Ⅲ）］， Blood flow dynamics index and total adverse reaction rates. Results After treatment， the overall efficacy rate in the study group was 95.15%， significantly higher than the control group′s 81.44% （P < 0.05）. At 30 days post-treatment， there was no significant difference in survival rates between the two groups （P > 0.05）. At 90 days post-treatment， the survival rate in the study group was 94.13%， significantly higher than that in the control group （85.57%， P < 0.05）. Pretreatment HR and respiratory rate showed no significant differences between the two groups （P > 0.05）； post - treatment， both groups exhibited significant reductions in these parameters， with the study group demonstrating lower values than the control group （P < 0.05）. Pretreatment PaO?， PaCO?， PAP， and SpO? showed no significant differences （P > 0.05）； post-treatment， PaO?， PaCO?， and SpO? significantly increased in both groups， with the study group outperforming the control group （P < 0.05）， while PAP significantly decreased， with the study group showing lower values than the control group （P < 0.05）. Before treatment， there was no significant difference between the two groups in D - D， PAI-1， t-PA， TM and AT-Ⅲ （P > 0.05）. After treatment， D-D， PAI-1， t-PA and TM showed a significant downward trend in both groups， and the study group was significantly lower than the control group； AT-Ⅲ showed an upward trend， and the study group was higher than the control group （P < 0.05）. Before treatment， there was no significant difference in RV/LV ratio， sPAP and TAPSE between the two groups （P > 0.05）； after treatment， RV/LV ratio and sPAP decreased significantly， while TAPSE increased significantly （P < 0.001）， and the decrease of RV/LV ratio and sPAP and increase of TAPSE in the study group were better than those in the control group （P < 0.05）. There was no statistical difference in the incidence of overall bleeding events between the two groups （25.77% vs. 16.67%， P > 0.05）， However， according to the BARC classification criteria， the incidence of hemorrhagic events of type 3 or higher was higher in the control group than in the study group. Conclusion Minimally invasive intervention combined with rt-PA effectively improves oxygenation， regulates coagulation-fibrinolysis balance， and enhances clinical efficacy in patients with massive pulmonary embolism.