Surgical embolectomy for acute massive pulmonary embolism: state of the art

Abstract

Massive pulmonary embolism (PE) is a severe condition that can potentially lead to death caused by right ventricular (RV) failure and the consequent cardiogenic shock. Despite the fact thrombolysis is often administrated to critical patients to increase pulmonary perfusion and to reduce RV afterload, surgical treatment represents another valid option in case of failure or contraindications to thrombolytic therapy. Correct risk stratification and multidisciplinary proactive teams are critical factors to dramatically decrease the mortality of this global health burden. In fact, the worldwide incidence of PE is 60-70 per 100,000, with a mortality ranging from 1% for small PE to 65% for massive PE. This review provides an overview of the diagnosis and management of this highly lethal pathology, with a focus on the surgical approaches at the state of the art.

Implementation of a regional multidisciplinary pulmonary embolism response team: PERT-POZ initial 1-year experience

“…The PERT -POZ recommendation available for PE management in the acute setting including anticoagulation, systemic thrombolytic therapy, catheter -directed therapy, embolectomy, inferior vena cava (IVC) filter placement, extracorporeal membrane oxygenation (ECMO), temporary mechanical support, or a combination of these strategies. [5][6][7][8][9][10][11][12][13][14] Current guidelines recommend a multidisciplinary approach to PE management with the creation of a pulmonary embolism response team (PERT). 4 It is a group of specialists from different disciplines including cardiology, interventional cardiology, cardiothoracic surgery, vascular medicine, anesthesiology or intensive care, radiology, pulmonology, and hematology who rapidly evaluate, coordinate diagnosis, and offer full range of most advanced therapeutic options for patients with PE to rescue and prevent further deterioration.…”

Advanced management of intermediate-high risk pulmonary embolism

“…Surgical pulmonary embolectomy has classically been reserved for patients with massive pulmonary embolism who cannot receive fibrinolysis or remain unstable after administration, or for patients with intermediate-high risk pulmonary embolism who either fail thrombolysis or have an absolute contraindication [15]. Additionally, a definitive surgical approach is recommended for patients with high-risk thrombi, such as those with appreciable clot in the right heart near or through a patent foramen ovale [36,37]. Surgical embolectomy can rapidly restore pulmonary blood flow and relieve acute obstruction.…”

“…The surgical approach is through a median sternotomy and requires the patient to be placed on cardiopulmonary bypass (CPB), typically without aortic cross-clamping or cardioplegic arrest to avoid additional ischemic injury to an already stunned right ventricle. This is followed by an incision through the pulmonary trunk and the main pulmonary arteries with subsequent extraction of the acute clot [36,38,39]. All patients should have an echocardiogram completed pre-operatively for an assessment of right and left sided heart function, and detection of a patent foramen ovale or an atrial septal defect, which helps to understand the risk of paradoxical embolism [39].…”

Future perspectives in catheter-based treatment of pulmonary embolism

“…Surgical embolectomy is the most invasive treatment available for large volume central PE, but in haemodynamically stable patients is a relatively low-risk intervention in the modern era 28 . Individual case series suggest good results with this approach and, as with the large-bore clot extraction devices, has the attraction of a conceptually immediate impact on haemodynamics.…”