Embolectomy For Acute Pulmonary Embolism Research Articles

Chronic thromboembolic disease among patients undergoing surgical pulmonary embolectomy for acute pulmonary embolism.

This study aimed to assess the prevalence of chronic thromboembolic lesions in the pulmonary arteries among patients undergoing pulmonary embolectomy for acute pulmonary embolism and their impact on treatment outcomes. We conducted a retrospective, single-center analysis of consecutive patients undergoing emergency pulmonary embolectomy for acute pulmonary embolism between 2013 and August 2021. According to European Society of Cardiology guidelines, the diagnosis was based on clinical presentation, imaging studies and laboratory tests. Surgery was selected as the optimal treatment modality within the Pulmonary Embolism Response Team. Based on the intraoperatively identified chronic lesions patients were divided into two groups: acute only and acute/chronic. The analysis comprised history, laboratory and imaging studies, early and long-term mortality, and postoperative complications. We determined predictive factors for chronic thromboembolic lesions and risk factors for death. The analysis included 33 patients. Intraoperatively, 42% (14) of patients had chronic lesions. Predictive factors for these lesions are the duration of symptoms >1 week (OR=13.75), pulmonary artery dilatation >3.15 cm (OR=39.00) and right ventricle systolic pressure >52 mmHg (OR=29.33). No hospital deaths occurred in the acute only group and two in the acute/chronic group (0% vs. 14.3%; P=0.172). Risk factors for death are the duration of symptoms >3 weeks (HR=7.35) and postoperative use of extracorporeal membrane oxygenation (HR=7.04). Acute thromboembolic disease overlapping chronic clots is relatively common among patients undergoing pulmonary artery embolectomy. A detailed evaluation of the patient's medical history and imaging studies can identify these patients, as they require special attention when making treatment decisions. Surgical treatment in a center of expertise in pulmonary endarterectomy seems reasonable.

Outcome after surgical embolectomy for acute pulmonary embolism.

Patients with pulmonary embolism (PE) and contraindications for or failed thrombolysis are at the highest risk for PE-related fatal events. These patients may benefit from surgical embolectomy, but data concerning this approach are still limited. The method used here was retrospective data analysis of 103 patients who underwent surgical embolectomy from 2002 to 2020 at our department. Mean age was 58.4 (±15.1) years. Fifty-eight (56.3%) patients had undergone recent surgery; the surgery was tumor associated in 32 (31.1%) cases. Thirty (29.1%) patients had to be resuscitated due to PE, and 13 (12.6%) patients underwent thrombolysis prior to pulmonary embolectomy. Fifteen (14.5%) patients were placed on extra corporeal membrane oxygenation (ECMO) peri-operatively. Five patients (4.9%) died intra-operatively. Neurological symptoms occurred in four patients (3.9%). Thirty-day mortality was 23.3% ( n = 24). Re-thoracotomy due to bleeding was necessary in 12 (11.6%) patients. This parameter was also identified as an independent risk factor for mortality. Surgical pulmonary embolectomy resulted in survival of the majority of patients with PE and contraindications for or failed thrombolysis. Given the excessive mortality when left untreated, an operative approach should become a routine part of discussions concerning alternative treatment options for these patients.

Role of extracorporeal membrane oxygenation and surgical embolectomy in acute pulmonary embolism.

Purpose of reviewSurgery is an important option to consider in patients with massive and submassive pulmonary emboli. Earlier intervention, better patient selection, improved surgical techniques and the use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) have contributed to improve the safety of surgery for pulmonary emboli.Recent findingsVA ECMO is rapidly changing the initial management of patients with massive pulmonary emboli, providing an opportunity for stabilization and optimization before intervention. The early and long-term consequences of acute pulmonary emboli are better understood, in particular with regard to the risks of chronic thromboembolic pulmonary hypertension (CTEPH), an entity that should be identified in the acute setting as much as possible. The presence of chronic thromboembolic pulmonary disease can be associated with persistent haemodynamic instability despite removal of the acute thrombi, particularly if pulmonary hypertension is established. The pulmonary embolism response team (PERT) is an important component in the management of massive and submassive acute pulmonary emboli to determine the best treatment options for each patient depending on their clinical presentation.SummaryThree types of surgery can be performed for pulmonary emboli depending on the extent and degree of organization of the thrombi (pulmonary embolectomy, pulmonary thrombo-embolectomy and pulmonary thrombo-endarterectomy). Other treatment options in the context of acute pulmonary emboli include thrombolysis and catheter-directed embolectomy. Future research should determine how best to integrate VA ECMO as a bridging strategy to recovery or intervention in the treatment algorithm of patients with acute massive pulmonary emboli.

Pulmonary Embolectomy for Acute Pulmonary Embolism: A Word of Caution.

Pulmonary embolectomy is an effective treatment of acute pulmonary embolism (APE) but not for chronic pulmonary thromboembolism. We described surgical experience of two patients with APE in preexistent unidentified chronic pulmonary thromboembolism. One patient who presented with severe hypoxia but stable hemodynamics underwent successful pulmonary endarterectomy for proximal organized thrombus instead of pulmonary embolectomy. The other patient who required extracorporeal membrane oxygenation for severe hypoxia developed right heart failure because of residual distal organized thrombus after pulmonary embolectomy. Clinical and radiographical presentation of APE in chronic pulmonary thromboembolism mimics APE, and thus, candidates of pulmonary embolectomy should be carefully selected.

National Outcomes of Surgical Embolectomy for Acute Pulmonary Embolism

Guidelines outlining the role of surgical embolectomy for acute pulmonary embolism remain consensus based; however, recent outcomes have improved compared with traditional experiences. This study examined contemporary outcomes of patients treated for acute pulmonary embolism on a nationwide scale. Patients undergoing systemic thrombolysis, catheter-directed therapy, and surgical embolectomy for acute pulmonary embolism from 2010 to 2014 in the National Inpatient Sample were included. The study included 58,974 patients with acute pulmonary embolism; of these, 33,553 were treated with systemic thrombolysis, 22,336 with catheter-directed therapy, and 3085 underwent surgical embolectomy. Thrombolysis was the most common, with a substantial increase after 2012, while surgical volumes remained stable. Patients in the surgical group, compared with systemic thrombolysis and catheter-directed therapy, had more saddle emboli (22% vs 10% vs 10%) and were more frequently at severe risk of death (56% vs 42% vs 26%; both P < .01). Surgical embolectomy patients had 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 < .01). Rates of major bleeding and intracranial hemorrhage were highest in the systemic thrombolysis group. Among surgical patients, age older than 60 years, atrial fibrillation and nonsaddle embolus were associated with increased odds of mortality. In this contemporary, real-world study, mortality occurred in 19.8% of patients undergoing surgical embolectomy for acute pulmonary embolism. This represents a significant improvement compared with traditional outcomes and supports the role of surgery in the multidisciplinary treatment of this high-risk condition.

Short- and long-term outcomes for the surgical treatment of acute pulmonary embolism.

ObjectivesAcute pulmonary embolism can be a life-threatening condition with a high mortality. The treatment choice is a matter of debate. The early and late outcomes of patients treated with surgical pulmonary embolectomy for acute pulmonary embolism in a single center were analyzed.MethodsAll consecutive patients operated on for pulmonary embolism between January 2002 and March 2017 were reviewed. Patient demographics and pre- and postoperative clinical data were retrieved from our patient registry, and risk factors for in-hospital and long-term mortality were identified.ResultsIn total, 175 patients (mean age 59±3 years, 50% male) were operated on for acute pulmonary embolism. In-hospital mortality was 19% (34/175). No differences were found when comparing surgery utilizing a beating heart or cardioplegic arrest. Risk factors for in-hospital mortality were age >70 years [odds ratio (OR) 4.8, confidence interval (CI) 1.7–13.1, p=0.002], body surface area <2 m2 (OR 4.7, CI 1.6–13.7, p=0.004), preoperative resuscitation (OR 14.1, CI 4.9–40.8, p<0.001), and the absence of deep vein thrombosis (OR 9.6, CI 2.5–37.6, p<0.001). Follow-up was 100% complete with a 10-year survival rate of 66.4% in 141/175 patients surviving to discharge. Once discharged from hospital, none of the risk factors identified for in-hospital mortality were relevant for long-term survival except the absence of deep vein thrombosis (OR 3.2, CI 1.2–8.2, p=0.019). The presence of malignancy was a relevant risk factor for long-term mortality (OR 4.3, CI 1.8–10.3, p=0.001).ConclusionSurgical pulmonary embolectomy as a therapy for acute pulmonary embolism demonstrates excellent short- and long-term results in patients with an otherwise life-threatening disease, especially in younger patients with a body surface area >2 m2 and pulmonary embolism caused by deep vein thrombosis. Pulmonary embolectomy should therefore not be reserved as a treatment of last resort for clinically desperate circumstances.

Outcomes of Pulmonary Embolectomy for Acute Pulmonary Embolism.

Acute pulmonary embolism (PE) is a major threat to the health and lives of hospitalized patients. This study was conducted to clarify the real-world outcomes of pulmonary embolectomy.Methods and Results:Retrospective investigation of 355 patients who underwent pulmonary embolectomy for acute PE was conducted using the Japanese Cardiovascular Surgery Database. Risk factors for operative death within 30 days after pulmonary embolectomy and major adverse cardiovascular events (MACE), including operative death, postoperative stroke and postoperative coma, were analyzed. Cardiopulmonary resuscitation (CPR) was required preoperatively in 27.6%, and preoperative veno-arterial extracorporeal membrane oxygenation was performed in 26.5%. Urgent or emergency operation was performed in 93% of patients. Operative mortality rate was 73/355 (20.6%). Incidence of MACE was 97/355 (27.3%). In univariate analysis, preoperative predictors of death were obesity, renal dysfunction, chronic obstructive pulmonary disease, liver injury, recent myocardial infarction, shock, refractory shock, CPR, heart failure, inotrope use, poor left ventricular function, preoperative arrhythmia and tricuspid regurgitation. In multivariate analysis, independent risk factors for operative death were heart failure (P=0.013), poor left ventricular function (P=0.007), and respiratory failure (P=0.001). Poor left ventricular function (P=0.033), preoperative CPR (P=0.002) and respiratory failure (P=0.007) were independent risk factors for MACE. The outcomes of pulmonary embolectomy were acceptable, considering the urgency and preoperative comorbidities of patients. Early triage of patients with hemodynamically unstable PE is important.

Retrograde Pulmonary Embolectomy for Acute Pulmonary Embolism: A Simplified Technique

Surgical embolectomy in acute pulmonary embolism is usually reserved for patients with massive pulmonary embolism presenting with cardiogenic shock, or for whom thrombolysis is absolutely contraindicated or has failed. Incomplete removal of thrombotic material lodged in the distal pulmonary arterial bed is considered an important cause of persistent pulmonary hypertension. Retrograde pulmonary embolectomy is an adjunct to conventional pulmonary embolectomy, resulting in more complete embolectomy, specifically of material lodged in the distal pulmonary arterial bed. We describe our simplified technique of retrograde pulmonary embolectomy as a safe adjunct to conventional pulmonary embolectomy.

Surgical Techniques of Pulmonary Embolectomy for Acute Pulmonary Embolism

Acute pulmonary embolism (PE) is a common occurrence in hospitalized patients. The majority of patients have low-risk PE (no right ventricular dysfunction or myocardial injury) that can be treated with anticoagulation. For patients with a massive PE (circulatory instability, shock, or arrest) or a high-risk submassive PE (maintained blood pressure, right ventricular dysfunction, and myocardial injury), anticoagulation alone is insufficient. Systemic thrombolysis, catheter-based procedures (with or without local thrombolytic therapy), and surgical pulmonary embolectomy are procedures that can be used; however, the choice is largely based on institutional and physician experience. Surgical pulmonary embolectomy is used preferentially for patients with contraindications to or for those who have failed thrombolysis and in patients with free-floating thrombus in the right atrium or right ventricle. Surgical pulmonary embolectomy has been undertaken infrequently in the past, but there has been an increased interest and some institutions are now using this procedure preferentially. The technique of surgical pulmonary embolectomy is outlined.

Retrograde pulmonary perfusion as an adjunct to standard pulmonary embolectomy for acute pulmonary embolism.

Mortality rates for pulmonary embolectomy in patients with acute massive pulmonary embolism have decreased in recent years. However, it still ranges from 30 to 45% when surgery is performed on critically ill patients, and the mortality rates reach 60% in patients who have experienced a cardiac arrest before the procedure. The causes of death in these patients are generally attributed to right heart failure due to persistent pulmonary hypertension, intractable pulmonary oedema, and massive parenchymal and intrabronchial haemorrhage. Clinical and experimental findings indicate that venous air embolism causes severe or even lethal damage to the pulmonary microvasculature and the lung parenchyma consequent to the release of endothelium-derived cytokines. These findings are similar to those observed when severely compromised patients undergo pulmonary embolectomy for air entrapped in the pulmonary artery during embolectomy, which may lead to fatal outcomes. Retrograde pulmonary perfusion (RPP), besides enabling the removal of residual thrombotic material from the peripheral branches of the pulmonary artery, fills the pulmonary artery with blood and prevents pulmonary air embolism. We believe that the use of RPP as an adjunct to conventional pulmonary embolectomy decreases the morbidity and mortality rates associated with pulmonary embolectomy in critically ill patients.

Nationwide Outcomes of Surgical Embolectomy for Acute Pulmonary Embolism

There is a nationwide inpatient mortality rate of 27.2% after pulmonary embolectomy. Death after pulmonary embolectomy is affected by factors other than arena of care.

Surgical treatment of acute pulmonary embolism—a 12-year retrospective analysis

Objectives. Surgical embolectomy for acute pulmonary embolism (PE) is considered to be a high risk procedure and therefore a last treatment option. We wanted to evaluate the procedures role in modern treatment of acute PE. Design. All data on patients treated with surgical embolectomy for acute PE were retrieved from our clinical database. The mortality was extracted from the Danish mortality register. Results. From October 1998 to July 2010, 33 patients underwent surgical embolectomy. All procedures were done through a median sternotomy and extracorporeal circulation. Twenty-six patients were diagnosed with a high risk PE and 7 with an intermediate risk PE and intracardial pathology. Six patients had been insufficiently treated with thrombolysis. Thirteen patients had contraindication for thrombolysis. Six patients were brought to the operating theatre in cardiogenic shock, 8 needed ventilator support, and 1 was in cardiac arrest. The postoperative 30-day mortality was 6% and during the 12-year follow-up the cumulative survival was 80% with 4 late deaths. Conclusion. Surgical pulmonary embolectomy can be performed with low mortality although the treated patients belong to the most compromised part of the PE population. The results support surgical embolectomy as a vital part of the treatment algorithm for acute PE.

Case Fatality Rate with Pulmonary Embolectomy for Acute Pulmonary Embolism

BackgroundThere are insufficient data to assess the potential role of pulmonary embolectomy in patients with acute pulmonary embolism. MethodsIn-hospital all-cause case fatality rate with pulmonary embolectomy was assessed from the Nationwide Inpatient Sample from 1999 through 2008. ResultsAmong unstable patients (in shock or ventilator-dependent), case fatality rate with embolectomy was 380 of 950 (40%). Among stable patients, case fatality rate was lower: 690 of 2820 (24%) (P <.0001). Case fatality rate in unstable patients was 39% in 1999-2003 and 40% in 2004-2008 (not significant), and in stable patients it was 27% in 1999-2003 and 23% in 2004-2008 (P=.01). Case fatality rates were lower in patients with a primary diagnosis of pulmonary embolism and even lower in patients with a primary diagnosis who had none of the comorbid conditions listed in the Charlson Index. Within each stratified group, patients with vena cava filters had a lower case fatality rate. ConclusionsCase fatality rate in unstable patients who underwent pulmonary embolectomy remained at 39%-40% from 1999-2003 to 2004-2008, and in stable patients it decreased only from 27% to 23%. Case fatality rates were lower in those with fewer comorbid conditions and in those who received a vena cava filter. Our data reflect average outcome in the US. It may be that experienced surgeons and an aggressive multidisciplinary team could obtain a lower case fatality rate.

Nationwide outcomes of surgical embolectomy for acute pulmonary embolism

The aim of the present study was to review nationwide outcomes of surgical embolectomy for acute pulmonary embolism. Adult patients undergoing surgical embolectomy for acute pulmonary embolism from 1999 to 2008 were identified in the weighted Nationwide Inpatient Sample. The primary endpoint was inpatient mortality. Multivariate logistic regression analysis incorporating significant univariate predictors (P < .2) was conducted to identify independent predictors of inpatient mortality. There were 2709 eligible patients identified as undergoing surgical embolectomy for acute pulmonary embolism during the study period. The mean age was 57.0 ± 16.0 years. Of the patients, 1242 (45.8%) were women. A total of 280 patients (10.3%) had undergone thrombolysis before surgical embolectomy. The overall inpatient mortality rate was 27.2%. On multivariate analysis, an increasing Charlson comorbidity index (odds ratio, 1.37; 95% confidence interval, 1.12-1.69; P = .003) significantly increased the odds of inpatient mortality. In addition, blacks were more than twofold more likely to die during hospitalization than whites (odds ratio, 2.29; 95% confidence interval, 1.18-4.46; P = .02). Although age, payment type, hospital location (urban versus rural), hospital embolectomy volume, and surgeon embolectomy volume were associated with inpatient mortality on univariate analysis (each P < .2), none of these factors correlated with mortality in the multivariate model. This large-cohort analysis of more than 2700 patients demonstrates a nationwide inpatient mortality rate of 27.2% after pulmonary embolectomy. Although patient factors affect mortality, the arena of care appears to have no significant effect on operative outcomes. This suggests that it might be more prudent for centers with qualified surgeons to avoid delays in treatment, rather than transfer care because of a perception of improved outcomes.

A More Aggressive Approach to Emergency Embolectomy for Acute Pulmonary Embolism

To examine operative outcomes after acute pulmonary embolectomy (APE), a recently adopted, more aggressive surgical approach. We retrospectively identified patients who underwent surgical APE from April 1, 2001, through March 31, 2009, and reviewed their clinical records for perioperative outcome. Operations were performed with normothermic cardiopulmonary bypass and a beating heart, absent a patent foramen ovale. For completeness, embolectomy was performed via separate incisions in the left and right pulmonary arteries (PAs) in 15 patients. Of the 18 patients identified, the mean age was 60 years, and 13 patients (72%) were men. Thirteen patients (72%) had been hospitalized recently or had systemic disease. The preoperative diagnosis was established by echocardiography or computed tomography (or both). The median (range) follow-up time for all surviving patients was 16 months (2-74 months). Indications for APE included cardiogenic shock (n=12; 67%) and severe right ventricular dysfunction as shown by echocardiography (n=5; 28%). Seven patients (39%) had an embolus in transit. Seven patients (39%) experienced cardiopulmonary arrest before APE. Four early deaths (22%) occurred; all 4 of these patients had preoperative cardiopulmonary arrest, and 2 had APE via the main PA only, without branch PA incisions. Two late deaths (11%) occurred. Right ventricular function improved in all survivors. The results of emergent APE are encouraging, particularly among patients without cardiopulmonary arrest. It should not be reserved for patients in extremis; rather, it should be considered for patients with right ventricular dysfunction that is an early sign of impending hemodynamic collapse.

Expedient pulmonary embolectomy for acute pulmonary embolism: improved outcomes

Indications regarding surgical pulmonary embolectomy for treatment of submassive/massive acute pulmonary embolism remain controversial. An institutional experience with pulmonary embolectomy for acute pulmonary embolism (APE) was reviewed. A retrospective analysis of all patients undergoing pulmonary embolectomy for APE from September 2004 to January 2007 was conducted. Demographic data, clinical presentation and outcomes were analyzed. Fifteen patients underwent surgery for APE over a period of 27 months [average age 59.6 (range 35-89) years, (seven male, eight female)]. Six (40%) patients were admitted with known APE and nine patients exhibited post admission APE (seven - after surgical procedures, two - after cerebrovascular accident). Clinical presentation included dyspnea (86.67%), hemodynamic instability requiring continuous vasopressor support (40%), echocardiographic evidence of right ventricular dilatation (80%). Ten patients undergoing early/expedient embolectomy all survived while delayed surgery in the other five patients (>24 h) was associated with 60% mortality. Expanding indications for early surgical pulmonary embolectomy has stemmed from reliable echocardiographic identification of right ventricular compromise and recognition of these findings as harbingers of subsequent hemodynamic embarrassment. Our series underscores the benefit of early consideration and performance of pulmonary embolectomy in these critically ill patients.

Catheter Embolectomy for Acute Pulmonary Embolism

Massive pulmonary embolism (PE) is a life-threatening condition with a high early mortality rate due to acute right ventricular failure and cardiogenic shock. As soon as the diagnosis is suspected, an IV bolus of unfractionated heparin should be administered. In addition to anticoagulation, rapid initiation of systemic thrombolysis is potentially life-saving and therefore is standard therapy. Many patients with massive PE cannot receive thrombolysis because of an increased bleeding risk, such as prior surgery, trauma, or cancer. In these patients, catheter or surgical embolectomy are helpful for rapidly reversing right ventricular failure. Catheter thrombectomy appears to be particularly useful if surgical embolectomy is not available or the patient has contraindications to surgery. Although no controlled clinical trials are available, data from cohort studies indicate that the clinical outcomes after surgical and catheter embolectomy may be comparable.

Chest CT assessment following thrombolysis or surgical embolectomy for acute pulmonary embolism

Right ventricular (RV) enlargement, assessed by two-dimensional reconstructed 4-chamber views on contrast-enhanced multirow detector computed tomography (MDCT), is emerging as an important marker for predicting adverse clinical events in patients with acute pulmonary embolism (PE). It is unclear whether dynamic changes occur on chest computed tomography (CT) in response to thrombolysis or embolectomy to treat acute PE. We retrospectively investigated 23 consecutive patients who met the criteria of (1) a positive MDCT PE protocol; (2) RV dysfunction on echocardiography; (3) reperfusion therapy by systemic thrombolysis (n=17) or surgical embolectomy (n=6); and (4) follow-up MDCT study after completion of therapy. Two blinded observers reconstructed 4-chamber views on a Leonardo (Siemens, Munich, Germany) workstation using multiplanar reformats of axial CT data and then measured right and left ventricular dimensions (RV(D), LV(D)). RV enlargement was defined as RV(D)/LV(D) > 0.9. Mean age was 52 years, and there were 10 (43%) women. The median time to MDCT follow-up was 21 (range 2-231) days. Seventeen (74%) patients had their chest MDCT follow-up within 30 days. All 23 patients had RV enlargement (mean RV(D)/LV(D) 1.28, range 0.94 to 1.74) prior to initiation of reperfusion therapy. Although right ventricular enlargement was found in 43% of patients at follow-up, the mean RV(D)/LV(D) decreased from 1.28 +/- 0.21 cm to 0.94 +/- 0.16 cm (p < 0.001). The mean change in RV(D)/LV(D) was 0.31 +/- 0.42 in thrombolysis patients and 0.42 +/- 0.09 in embolectomy patients (p = 0.33). Reconstructed 4-chamber views on chest CT provide noninvasive imaging of right ventricular enlargement and permit dynamic assessment of the right ventricular response to thrombolysis and embolectomy in patients with acute PE.

術前のショックを伴わなかった急性肺塞栓症の１治験例

症例は, 73歳女性. 呼吸困難を訴え, 右房粘液腫の疑いで緊急入院となった. 来院時の心エコーでは右房内の腫瘤は消失しており, 肺動脈造影で両肺動脈内に巨大な血栓が確認された. ショックは伴わず, t-PAの投与により呼吸困難は改善し, 肺動脈圧も66から43mmHgに低下した. しかし, その後の肺動脈造影で血栓の形態が不変であったことから, 緊急に肺塞栓除去術を施行した. 手術により肺動脈内の巨大な血栓は除去されたが, 人工心肺の装着中に容易に心室細動に陥ったり, 体外循環からの離脱時には著明な低酸素血症を認めたが, これらの際には, 部分体外循環が有効であった. 術後の肺動脈造影では明らかな陰影欠損は認められず, 肺動脈圧も正常に復した. 急性肺塞栓症の治療に関しては, 線溶療法や抗凝固療法の報告が多いが, 塞栓除去術により良好な結果を得たので文献的考察を加えて報告する.