Modified surgical concept for fulminant pulmonary embolism

Abstract

Surgical intervention in fulminant pulmonary embolism (PE) is still associated with an overall 30% fatal outcome which increases to about 60% when cardiopulmonary resuscitation (CPR) is necessary. Despite unfavorable conditions like hemodynamic instability, failed lysis or CPR, the surgical strategy might have a certain impact on the patient's outcome since 30-40% of the surgical mortality is related to persistent right heart failure and early thromboembolic recurrence. From 1/88 to 8/94 a total of 25 patients (15 females, 10 men, mean age 57 [25-78]) years underwent emergency pulmonary embolectomy with the use of the heart-lung machine. Seventeen patients were operated upon between 1988 and 1992. A standard approach by central pulmonary artery incision with extraction of adjacent pulmonary emboli using forceps, suction of Fogarty catheters was used. Six of these patients (35%) died, with four out of six operated upon under CPR. Since 1993 we have used a modified surgical strategy in eight patients. Five patients (63%) were operated on after or under CPR. In these cases, left and right pulmonary arteries were incised peripherally and all segmental arteries were desobliterated selectively using small suction devices. Thereafter the right atrium was opened and inspected. After removal of the inferior caval vein cannula all inferior body blood was taken with cardiotomy suction while both legs and the abdomen were massaged centripetally to mobilize additional fresh thrombotic material. In three cases up to 50 cm long thrombi could be delivered. All patients have survived to date with two patients receiving a LGM caval filter placed percutaneously after bilateral postoperative phlebography had revealed ongoing thrombotic disease. We conclude that selective desobliteration of every segmental pulmonary artery in combination with simultaneous clearance of major body veins from additional thrombotic material will probably lower surgical mortality in these critically ill patients.

A More Aggressive Approach to Emergency Embolectomy for Acute Pulmonary Embolism

“…Furthermore, 3 of the 4 early deaths were due to cerebral ischemia, which likely occurred during the PEA before APE. In addition, greater attention has been paid recently to performing a complete embolectomy of both sides, 6,16 which we also think is important for a successful, long-term outcome.…”

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

“…The surgical technique used for acute pulmonary embolectomy is a variation of the modified Trendelenburg procedure used by many surgeons. [2][3][4] Specifically, the operation was conducted through a median sternotomy with aortic and bicaval cannulation and normothermic cardiopulmonary bypass. Incisions into the main pulmonary artery to remove the clot were extended into the distal pulmonary arteries when necessary.…”

“…Sareyyupoglu et al and others have emphasized a near prohibitive mortality rate (57%-85%) in patients undergoing pulmonary embolectomy during or after cardiopulmonary arrest for salvage. 4,32,34 We think there should be renewed enthusiasm for acute pulmonary embolectomy on the basis of the improved survival rates observed in patients with severe right ventricular dysfunction. Both identification and selection of appropriate candidates for acute pulmonary embolectomy have become easier because transesophageal echocardiography and computed chest tomography can detect early right ven-For personal use.…”

Chirurgische Therapie der fulminanten Lungenembolie

“…Ein kardioplegisch induzierter Herzstillstand, der den rechten Ventrikel noch weiter schädigen würde, ist nicht erforderlich. In Essen kommt eine modifizierte Technik der Pulmonalisembolektomie zum Einsatz, die erstmalig von Jakob et al 1995 beschrieben wurde [8].…”