Abstract
Acute pulmonary embolism (PE) remains a life-threatening condition. A critical therapeutic dilemma exists for a significant proportion of patients at high bleeding risk（approximately 30%-50%）. For these patients, anticoagulation is the mainstay, but the use of conventional agents (warfarin, DOACs, heparins) is severely limited by the risk of major bleeding, creating a substantial unmet medical need. Abelacimab addresses this unmet need through a novel mechanism: dual inhibition of factor XI (FXI) and activated FXI (FXIa). This paradigm shift uncouples potent antithrombotic efficacy from hemostasis, selectively suppressing contact pathway-driven thrombosis while preserving tissue factor-mediated hemostasis. We synthesize its unique mechanism of action, pharmacokinetic profile, and existing clinical evidence to evaluate its role in addressing this clinical gap. Abelacimab's mechanism selectively inhibits the contact activation pathway-crucially overactive in the RBC-rich thrombi characteristic of PE-while preserving tissue factor-mediated physiological hemostasis. Clinically, abelacimab demonstrated significantly lower rates of major bleeding or clinically relevant non-major bleeding compared to rivaroxaban in atrial fibrillation prophylaxis (AZALEA-TIMI 71 trial) and to enoxaparin in post-arthroplasty venous thromboembolism prevention (ANT-005 trial), establishing a favorable clinical safety profile. Its favorable pharmacokinetics (long half-life supporting monthly subcutaneous administration, with minimal renal/hepatic clearance) further simplify management and enhance its suitability for patients with PE. However, current evidence is extrapolated from AF/VTE prophylaxis studies, lacking direct human data for acute PE management. Urgent phase III trials (eg, PE-FOCUS) are therefore essential to validate efficacy and safety in acute PE, potentially redefining the anticoagulation paradigm.