Surgical and Transvenous Catheter Embolectomy for Acute Pulmonary Embolism: A Review

Abstract

Pulmonary embolectomy remains a treatment option for a small group of patients who have acute pulmonary embolism (PE). Surgical embolectomy under cardiopulmonary bypass (CPB) is indicated for hemodynamically compromised patients if thrombolytic treatment is contraindicated and for those with a deteriorating hemodynamic condition despite intensive medical treatment, including the use of thrombolytics. Recent reports document an average operative mortality from pulmonary embolectomy of 33% for patients undergoing pulmonary embolectomy under CPB. Numerous reports have identified an increased mortality (50%–60%) for patients who required cardiopulmonary resuscitation prior to embolectomy. In such severely compromised patients, preliminary circulatory assistance with partial femoral bypass has been advocated to allow time for diagnostic procedures, surgical preparation, induction of anesthesia, and institution of CPB. There is general agreement that embolectomy without a firm diagnostic confirmation is advocated only in exceptional cases. Although direct evidence of PE is best provided by pulmonary angiography, alternating imaging modalities (transesophageal echocardiography, spiral computed tomography angiography) may be used. The long-term prognosis is good for the majority of survivors of surgical pulmonary embolectomy. Recent transvenous embolectomy procedures have now been added to the list of management strategies. Although the role of these interventional procedures is quickly evolving, most remain poorly evaluated or even purely experimental. In institutions where the equipment and expertise for transvenous catheter embolectomy exist, this therapeutic option is an alternative if surgery is contraindicated or not readily available.