Emergency Surgical Pulmonary Embolectomy

Abstract

Emergency surgical pulmonary embolectomy is a highly effective treatment for selected patients with pulmonary embolism. Rapid noninvasive diagnostic modalities allow proper patient selection based on anatomic location of the emboli, right heart function, and contraindications to thrombolysis. Operative results are a direct reflection of the preoperative hemodynamic status, the degree of underlying cardiopulmonary disease, and attention to minimizing surgical trauma and protecting the right heart. An operative mortality of 10% or less and excellent long-term outcomes can be expected if the procedure is performed prior to cardiovascular collapse as part of a multidisciplinary strategy which emphasizes careful patient selection, rapid diagnosis, triage, and transport.

Percutaneous Mechanical Thrombectomy for Massive Pulmonary Embolism Using a Conservative Treatment Strategy

“…1,5 Even contemporary series of surgical embolectomy for selected patients with massive and submassive PE report an operative mortality of 11-30%. 6,31,32 The inhospital mortality found in the present study of 15% confirms the pooled mortality rates of the other studies using the Angiojet system for this indication of 11% (9 of 83 patients). These mortality rates of <20% certainly appear favorable to the rates of thrombolytic or even open surgical therapy.…”

“…Depending on the degree of hemodynamic compromise, the mortality of massive PE (treated or untreated with thrombolytics) ranges between 25 and 65% 1,5 . Even contemporary series of surgical embolectomy for selected patients with massive and submassive PE report an operative mortality of 11–30% 6,31,32 . The in‐hospital mortality found in the present study of 15% confirms the pooled mortality rates of the other studies using the Angiojet system for this indication of 11% (9 of 83 patients).…”

“…All patients or their surrogates were consented prior to the procedure emphasizing the offlabel nature of the intervention. Bilateral femoral venous sheaths (6)(7)(8) and an arterial sheath (4-5 French) were placed, if no indwelling radial arterial line was in place. Following venography to confirm patency of the inferior vena cava and absence of thrombus in transit, hemodynamics were recorded and diagnostic pulmonary angiography was performed.…”

“…Despite multiple shortcomings including a lack of randomized controlled trial data, thrombolytic therapy and surgical embolectomy are accepted treatment strategies for the treatment of massive PE 3,4 . Limitations commonly encountered include absolute contraindications to either conventional therapy, frequent treatment‐related complications, borderline effectiveness in the case of thrombolytic therapy, as well as logistical difficulties surrounding emergent surgical embolectomy 1,5–9 . Even if thrombolytics are administered or surgical embolectomy is performed, the mortality of massive PE remains high 5 …”

“…3,4 Limitations commonly encountered include absolute contraindications to either conventional therapy, frequent treatment-related complications, borderline effectiveness in the case of thrombolytic therapy, as well as logistical difficulties surrounding emergent surgical embolectomy. 1,[5][6][7][8][9] Even if thrombolytics are administered or surgical embolectomy is performed, the mortality of massive PE remains high. 5 In an attempt to overcome those shortcomings percutaneous mechanical thrombectomy (PMT) using a variety of devices has been tested.…”