Surgical Embolectomy for Acute Pulmonary Embolism: Systematic Review and Comprehensive Meta-Analyses

Kalra, Rajat; Bajaj, Navkaranbir S.; Arora, Pankaj; Arora, Garima; Crosland, William A.; McGiffin, David C.; Ahmed, Mustafa I.

doi:10.1016/j.athoracsur.2016.11.016

Cited by 48 publications

(29 citation statements)

References 60 publications

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“…These outcomes are similar to those in recent publications from Edelman and colleagues, 2 Keeling and colleagues, 3 and Neely and colleagues, 4 which have detailed 30-day mortalities of 2.7%, 11.7%, and 6.6%, respectively, after surgical pulmonary embolectomy. These recent results are in stark contrast to earlier reviews by Kalra and colleagues, 5 Kilic and colleagues, 6 and Meyer and colleagues, 7 with 26.3%, 27.2%, and 37.5% 30-day mortality, respectively.…”

contrasting

confidence: 86%

Play it again…Dr Gibbon

Baciewicz

2018

The Journal of Thoracic and Cardiovascular Surgery

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If Dr John Gibbon had reviewed ''Outcomes After Surgical Pulmonary Embolectomy for Acute Submassive and Massive Pulmonary Embolism: A Single Center Experience'' by Pasrija and colleagues, 1 he would have experienced a d ej a vu moment. While caring for a woman who would eventually die from a pulmonary embolism in 1931, Dr Gibbon forged the idea for developing a machine to oxygenate the blood and save his patient's life. His later development of cardiopulmonary bypass ushered in the era of open-heart surgery and the possibility of surgical pulmonary embolectomy with circulatory support.This manuscript from the University of Maryland reports an outstanding overall 30-day mortality of 7% for surgical pulmonary embolectomy. Pasrija and colleagues achieved 100% survival (28/28) in the submassive group, 88% survival (16/18) in the massive without arrest subset, and 78% survival (7/9) in the massive with arrest group. These outcomes are similar to those in recent publications from Edelman and colleagues, 2 Keeling and colleagues, 3 and Neely and colleagues, 4 which have detailed 30-day mortalities of 2.7%, 11.7%, and 6.6%, respectively, after surgical pulmonary embolectomy. These recent results are in stark contrast to earlier reviews by Kalra and colleagues, 5 Kilic and colleagues, 6 and Meyer and colleagues, 7 with 26.3%, 27.2%, and 37.5% 30-day mortality, respectively.These markedly improved results are likely related to several factors. First, surgical techniques that isolate the pulmonary circulation, avoid aortic crossclamping, use intermittent short periods of circulatory arrest, and employ retrograde pulmonary perfusion 8 have contributed. Second, anesthetic management with drugs to manipulate the pulmonary vasculature, avoidance of positive airway pressure, and the use of transesophageal echo have assisted induction of these unstable patients and improved their postoperative care.Third, selection of patients, ie, avoiding those who have had extended periods of cardiopulmonary arrest or refusing operation on patients in cardiopulmonary arrest, may have affected reported results. Keeling and colleagues 3 reported a 30-day mortality of 32% in surgical embolectomy patients with preoperative cardiopulmonary arrest, Carvalho and colleagues 9 mentioned an 85% 30-day mortality in salvage cases, and Aymard and colleagues 10 noted 27% short-term mortality in patients having surgical pulmonary embolectomy after failure of thrombolytic therapy.Fourth, the ability to stabilize and rescue a patient at bedside with percutaneous circulatory support (veno-arterial extracorporeal membrane oxygenator) allows an operation on a patient who is well-oxygenated, nonacidotic, not requiring inotropic support, and with a clearer decision window. Takahashi and colleagues 11 reported a series of 24 patients, with 19 in cardiogenic shock and 16 on preoperative percutaneous veno-arterial extracorporeal membrane oxygenator support with a surprising 30-day mortality of only 12.5%. In the study from Pasrija and colleagues, 1 4 of 18 in the mass...

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confidence: 86%

Play it again…Dr Gibbon

Baciewicz

2018

The Journal of Thoracic and Cardiovascular Surgery

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“…Among this population, 36.0% had preoperative contraindications to systemic thrombolysis, 33.9% suffered preoperative cardiac arrest, and 27% required the use of ECMO. 27) Not surprisingly, long-term mortality was greatest among those who suffered preoperative cardiac arrest and those who required preoperative ECMO. The investigators suggested SPE as an appropriate management option in patients who show signs of RV dysfunction without hemodynamic instability as SPE can rapidly reduce RV strain and interrupt the progression to cardiogenic shock.…”

Section: Discussionmentioning

confidence: 99%

Current Management of Acute Pulmonary Embolism

Licha

McCurdy

Maldonado

et al. 2020

ATCS

103

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Purpose: Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. While non-surgical approaches have supplanted surgery as primary treatment, surgical pulmonary embolectomy (SPE) remains a vital option for select patients. We review the current management of acute PE, with a focus on surgical therapy. Methods: A PubMed search was performed to identify literature regarding PE and treatment. Results were filtered to include the most comprehensive publications over the past decade. Results: PE is stratified based on presenting hemodynamic status or degree of mechanical pulmonary arterial occlusion. Although systemic or catheter-guided fibrinolysis is the preferred first-line treatment for the majority of cases, patients who are not candidates should be considered for SPE. Studies demonstrate no mortality benefit of thrombolysis over surgery. Systemic anticoagulation is a mainstay of treatment regardless of intervention approach. Following surgical embolectomy, direct oral anticoagulants (DOACs) have been shown to reduce recurrence of thromboembolism. Conclusions: Acute PE presents with varying degrees of clinical stability. Patients should be evaluated in the context of various available treatment options including medical, catheter-based, and surgical interventions. SPE is a safe and appropriate treatment option for appropriate patients.

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“…In comparison, 1-year survival following OLT has recently been quoted to be above 80% 16. The current American College of Chest Physicians guidelines recommendation is to proceed with surgical embolectomy only in patients who are likely to die of shock prior to administration of thrombolytics 17. In addition, surgical embolectomy requires a cardiothoracic surgeon who is willing to operate on an extremely high-risk patient.…”

Section: Discussionmentioning

confidence: 99%

Use of low-dose thrombolytics for treatment of intracardiac thrombus and massive pulmonary embolus after aborted liver transplant leads to recovery of right ventricular function and redo liver transplantation

Kafi¹,

Friedman

Kim

2017

BMJ Case Reports

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This is a 61-year-old man with end-stage liver disease who experienced cardiac arrest secondary to a massive pulmonary embolus and intracardiac thrombus during cannulation for veno-venous extracorporeal membrane oxygenation (ECMO) in preparation for orthotopic liver transplantation (OLT). Surgery was aborted and the patient was taken back to the intensive care unit in cardiogenic shock on multiple vasopressors. The patient was unresponsive to heparin bolus and too high risk for systemic thrombolytics or embolectomy. He was ultimately treated with 12 mg total of alteplase through his pulmonary artery catheter over 3 hours. He had subsequent resolution of his cardiogenic shock and proceeded with successful liver transplantation 5 days after his initial event without any bleeding complications. Low-dose thrombolytic therapy in the setting of absolute contraindications to thrombolysis allowed for recovery of cardiac function and, ultimately redo OLT in a patient with otherwise little hope of survival.

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Surgical Embolectomy for Acute Pulmonary Embolism: Systematic Review and Comprehensive Meta-Analyses

Cited by 48 publications

References 60 publications

Play it again…Dr Gibbon

Play it again…Dr Gibbon

Current Management of Acute Pulmonary Embolism

Use of low-dose thrombolytics for treatment of intracardiac thrombus and massive pulmonary embolus after aborted liver transplant leads to recovery of right ventricular function and redo liver transplantation

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