SURGICAL EMBOLECTOMY FOR ACUTE PULMONARY EMBOLISM: A MULTICENTER ANALYSIS OF OVER 58,000 CASES

Abstract

Acute pulmonary embolism (PE) is a highly morbid condition. With the emergence of multidisciplinary team-based approaches, there has been an increasing focus on individualized care of these patients. Systemic or catheter-directed thrombolysis is considered first-line therapy in the majority of cases. However, traditional surgical embolectomy has also shown excellent results in retrospective studies of highly selected patients. The purpose of this study was to examine trends, outcomes and predictors of mortality among patients treated for high-risk acute PE using National Inpatient Samples. The National Inpatient Sample is the largest publicly-available, all-payer inpatient database in the United States, representing close to 20% of all hospitalizations. Between 2010 and 2014, all adults who underwent systemic thrombolysis, catheter-directed thrombolysis or surgical embolectomy for a primary diagnosis of acute pulmonary embolism were included. A total of 58,974 patients met inclusion criteria. Of these, 33,553 (57%) were treated with systemic thrombolysis (ST), 22,336 (38%) underwent catheter-directed thrombolysis (CDT), and 3,085 (5%) underwent surgical embolectomy (SE). ST was the most common modality, with a substantial increase in procedure volume after 2012 (Figure A). The use of CDT increased slightly throughout the study period, while SE volumes remained stable. SE patients, compared to ST and CDT, were more likely to have a saddle embolus (22% vs. 10% vs. 10%) and were more frequently classified as having severe risk of mortality (56% vs. 41% vs. 26%, all P < 0.01). SE patients also had significantly higher in-hospital mortality (20% vs. 16% vs. 7%), stroke (7% vs. 6% vs. 3%) and blood transfusion (32% vs. 16% vs. 10%; All P < 0.01) compared to ST and CDT patients, although the rate of major bleeding was highest in the ST group (16% vs. 18% vs. 12%; P < 0.01). Average in-hospital costs were also substantially higher in the SE group (US $69,194 vs. $27,033 vs. $25,929; P < 0.01) compared to ST and CDT groups, respectively. Among the SE patients, age > 60 years, presence of atrial fibrillation and non-saddle PE were associated with increased odds of in-hospital mortality, while factors such as private insurance, hypertension and obesity were protective (Figure B). Acute PE requiring intervention was associated with significant morbidity across all treatment modalities, with the highest risk of mortality observed among the SE patients. Patients with acute PE should be approached in a multidisciplinary fashion and surgeons should take caution when considering SE in older patients with evidence of heart failure and non-saddle PE.