Abstract-Information is lacking on the mechanisms involved in the organization, resolution, and repair of the vascular lumen after acute pulmonary thromboembolism. Because recent data suggest that the balance between plasminogen activators (PAs) and type 1 plasminogen activator inhibitor (PAI-1) plays a role in regulating cell migration within the extracellular matrix, we investigated the expression of these molecules by immunohistochemical and in situ hybridization analysis of pulmonary artery specimens from patients suffering fatal pulmonary embolism. The data were compared with the expression of these molecules in both patients' noninvolved pulmonary arteries and organ donor pulmonary arteries. Regions of initial organization and vascular remodeling were identified by a modified trichrome stain and by the presence of proliferating cell nuclear antigen (PCNA), a cell marker of proliferation. Staining for tissue-type PA antigen was low to undetectable in endothelial cells directly in contact with the fibrin-platelet thromboembolus and in areas in which the endothelial cell lining was replaced by cell growth into the thrombus. Urokinase-like PA (u-PA) expression was detected in mononuclear cells within the thrombus in the initial phase of thromboembolism and within cells migrating into the thrombus during the later stages of organization. PAI-1 expression was elevated in the monolayer of endothelial cells underlying the fresh platelet-fibrin thromboembolus and in a PCNA-positive cell population present between the pulmonary arterial intima and the thromboembolus that represents early organization. Increased expression of PAI-1 may play a role in inhibiting proteolysis and fostering the localization of the acute fibrin-platelet thrombus to the vascular wall, which is followed by the upregulation of u-PA in migrating cells during the reorganization process. (Arterioscler Thromb Vasc Biol. 1998;18:808-815.)Key Words: thrombus organization Ⅲ plasminogen activators Ⅲ plasminogen activator inhibitor type 1 Ⅲ pulmonary thromboembolism R ecognized venous thromboembolism, comprising both pulmonary embolism and deep venous thrombosis, leads to sudden death in about 10% of patients, accounting for about 300 000 clinical episodes and 50 000 deaths per year in the United States.1,2 The origin of thrombi embolizing to the lungs is in the great majority of cases the deep veins of the legs, particularly iliac, femoral, and popliteal veins.3 The morphological features of a fresh thromboembolus are similar to those of a nondetached thrombus, with alternating layers of platelets, fibrin, and erythrocytes.3 In addition to obstruction of the pulmonary trunk and/or both main pulmonary arteries, pulmonary embolism may progress slowly until the vascular bed has been reduced by multiple small pulmonary thromboemboli. In the latter situation, a single fresh thromboembolus suffices to cause acute right ventricular failure.Resolution of pulmonary thromboemboli is usually derived by mechanical fragmentation, endogenous thrombolysis, or repa...