Aggressive Approach to Pulmonary Embolectomy for Massive Acute Pulmonary Embolism: A Historical and Contemporary Perspective

McFadden, P. Michael; Ochsner, John L.

doi:10.4065/mcp.2010.0481

Cited by 17 publications

(11 citation statements)

References 32 publications

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“…8 Surgical mortality rates in the middle-to-late 20th century exceeded 30%, resulting in the restriction of surgical pulmonary embolectomy to patients in refractory shock with no other options. 9 The observation that surgical pulmonary embolectomy was rarely associated with favorable outcomes led to the conclusion that patients who died during the operation were too ill to undergo surgery, whereas those who survived surgery were well enough that they should have been managed medically.…”

Section: Historical Use Of Surgical Pulmonary Embolectomymentioning

confidence: 99%

Surgical Pulmonary Embolectomy

et al. 2015

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A 66-year-old man with a recent prosthetic knee infection, status postprosthesis removal, was admitted with recurrent septic arthritis. On his seventh hospital day, as he was signing his discharge paperwork, he developed acute respiratory distress. On physical examination, he was tachycardic to 118 beats/min, relatively hypotensive from 144/78 mm Hg earlier in the day to 94/54 mm Hg, and hypoxemic, with an oxygen saturation of 94% on a 100% nonrebreather facemask. The ECG showed sinus tachycardia. An urgent contrast-enhanced chest computed tomogram (CT) demonstrated large saddle pulmonary embolism (PE) and severe right ventricular (RV) enlargement, with an RV diameterto-left ventricular (LV) diameter ratio of 1.8 (Figure 1). The patient was administered a bolus of intravenous unfractionated heparin followed by a continuous infusion. An urgent bedside transthoracic echocardiogram showed severe RV dilation, moderateto-severe pulmonary hypertension, and RV pressure overload as suggested by systolic deviation of the interventricular septum toward the LV (Figure 2). The Vascular Medicine and Cardiac Surgery services were consulted for consideration of advanced therapies. Because of concern for major bleeding associated with fibrinolytic therapy in the setting of recent major surgery, surgical pulmonary embolectomy was recommended. IntroductionDespite advances in diagnostics and therapeutics, acute PE remains a life-threatening condition with an in-hospital mortality rate of ≈7% for all-comers and 31% for patients with hemodynamically unstable (massive) PE.1 Current management algorithms emphasize risk stratification to identify patients who may benefit from early advanced therapies in addition to anticoagulation.2-4 Risk categories of massive, submassive, and low-risk PE are based on clinical, radiological, and laboratory criteria. Massive PE is characterized by systemic arterial hypotension, syncope, cardiogenic shock, cardiac arrest, or respiratory failure. Submassive PE is defined by evidence of RV dysfunction on imaging (RV/LV diameter >0.9 on contrastenhanced chest CT or RV dilation and hypokinesis on echocardiography), elevated cardiac biomarkers (such as cardiac troponin), or both, in a patient with preserved systemic arterial pressure. Submassive PE comprises a patient population at increased risk of adverse outcomes and early mortality. Low-risk PE patients have none of these features and typically have an uneventful clinical course when treated with therapeutic anticoagulation alone.Advanced therapies are often considered for patients with submassive or massive PE to rapidly relieve RV pressure overload and avert hemodynamic deterioration. Advanced therapies for reperfusion include systemic fibrinolysis, catheter-based pharmacomechanical intervention, and surgical pulmonary embolectomy. A recent meta-analysis showed a 1.7% absolute mortality

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Section: Historical Use Of Surgical Pulmonary Embolectomymentioning

confidence: 99%

Surgical Pulmonary Embolectomy

et al. 2015

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“…However due to high mortality it was rarely performed even with the advent of cardiopulmonary bypass 9 . Recent data suggest that there has been a gradual increase in the number of pulmonary embolectomies performed 10 . Traditional indications for embolectomy include massive embolization, hemodynamically unstable patient with pulmonary embolism and failed thrombolysis therapy 2 .…”

Section: Resultsmentioning

confidence: 99%

Surgical Management of Acute Pulmonary Thromboembolism: our Experience

Raut¹,

Mishra²,

Mohapatra³

et al. 2016

IOSR

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Acute pulmonary thromboembolism (PTE) can be a life threatening complication of deep vein thrombosis. Surgical embolectomy is a rarely performed and is only reserved for hemodynamically unstable patients, those with massive pulmonary thromboembolism and those with failed thrombolysis therapy. We reviewed the results of surgical pulmonary embolectomy performed in our institute over the last four years. Data was retrospectively studied of 28 patients who underwent pulmonary embolectomy in our institute over the last four years i.e. from 2012 to 2016. Demographic data, clinical presentation and outcomes were analyzed. Clinical presentation included dyspnea (82%), hemodynamic instability requiring continuous vasopressor support (36%), echocardiographic evidence of right ventricular dilatation (82%). There was 3% mortality rate in our study which is comparably low with previous studies. Our series implies the benefit of early consideration and performance of pulmonary embolectomy in these critically ill patients.

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“…In a small series by Digonnet et al, surgical embolectomy in hemodynamically stable patients with RV dysfunction demonstrated excellent surgical outcomes and longterm survival [120]. Although there is lack of a definitive study, there is increasing evidence to suggest favorable outcomes of an early approach to surgical embolectomy in critically ill patients with massive PE [121][122][123][124][125][126][127][128][129].…”

Section: Surgical Embolectomy and Catheter-directed Therapiesmentioning

confidence: 97%

Care of patients with acute pulmonary emboli: a clinical review with cardiovascular focus

Smith

Morgenthaler

Mankad

2012

Expert Review of Cardiovascular Therapy

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Acute pulmonary embolism (PE) is a common, multidisciplinary disease with substantial associated morbidity, mortality and healthcare expense. In this article we present a succinct review of diagnostic tools, risk stratification and medical therapies for cardiovascular care of patients with acute PE. While pulmonary angiography remains the 'gold standard' for diagnosis, a host of diagnostic modalities, interpreted in the setting of clinical probability, are available for patient assessment, including ECG, chest radiography, D-dimer, lower-extremity venous ultrasound, ventilation-perfusion scans, computed tomography and magnetic resonance angiography, and echocardiography, each with associated value. Diagnostic algorithms incorporate multiple tools in order to obtain a more comprehensive evaluation. Therapeutic anticoagulation remains the mainstay of therapy in PE. In massive PE, utilization of thrombolysis is reasonable in the absence of contraindications. Submassive PE, characterized by right ventricular dysfunction as assessed by echocardiography and ECG, is associated with higher mortality. Use of thrombolysis in submassive PE remains controversial. Catheter-directed therapies are emerging as an added approach to acute PE and have the potential to improve outcomes in PE. Use of inferior vena cava filters should be pursued in a select patient population as they serve to reduce recurrent acute PE; however, they are associated with more frequent deep venous thrombosis and provide no mortality benefit. In risk-stratified hemodynamically stable patients, an outpatient management strategy inclusive of therapeutic anticoagulation and careful clinical follow-up may be appropriate.

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Aggressive Approach to Pulmonary Embolectomy for Massive Acute Pulmonary Embolism: A Historical and Contemporary Perspective

Cited by 17 publications

References 32 publications

Surgical Pulmonary Embolectomy

Surgical Pulmonary Embolectomy

Surgical Management of Acute Pulmonary Thromboembolism: our Experience

Care of patients with acute pulmonary emboli: a clinical review with cardiovascular focus

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