Pulmonary Embolectomy Research Articles

Risk factors and treatment interventions associated with incomplete thrombus resolution and pulmonary hypertension after pulmonary embolism

BackgroundResidual pulmonary vascular occlusion (RPVO) affects one half of patients after a pulmonary embolism (PE). The relationship between the risk factors and therapeutic interventions for the development of RPVO and chronic thromboembolic pulmonary hypertension is unknown. MethodsThis retrospective review included PE patients within a 26-month period who had baseline and follow-up imaging studies (ie, computed tomography [CT], ventilation/perfusion scans, transthoracic echocardiography) available. We collected the incidence of RPVO, percentage of pulmonary artery occlusion (%PAO), baseline CT %PAO, most recent CT %PAO, and difference between the baseline and most recent %PAO on CT (Δ%PAO). ResultsA total of 354 patients had imaging reports available; 197 with CT and 315 with transthoracic echocardiography. The median follow-up time was 144 days (interquartile range [IQR], 102-186 days). RPVO was present in 38.9% of the 354 patients. The median Δ%PAO was −10.0% (IQR, −32% to −1.2%). Fewer patients with a provoked PE developed RPVO (P ≤ .01), and the initial troponin level was lower in patients who developed RPVO (P = .03). The initial thrombus was larger in the patients who received advanced intervention vs anticoagulation (baseline CT %PAO: median, 61.2%; [IQR, 27.5%-75.0%] vs median, 12.5% [IQR, 2.5%-40.0%]; P ≤ .0001). Catheter-directed thrombolysis (CDT; median Δ%PAO, −47.5%; IQR, −63.7% to −8.7%) and surgical pulmonary embolectomy (SPE; median Δ%PAO, −42.5; IQR, −68.1% to −18.7%) had the largest thrombus reduction compared with anticoagulation (P = .01). Of the 354 patients, 76 developed pulmonary hypertension; however, only 14 received pulmonary hypertension medications and 12 underwent pulmonary thromboendarterectomy. Cancer (odds ratio [OR], 1.7) and planned prolonged anticoagulation (>1 year; OR, 2.20) increased the risk of RPVO. In contrast, the risk was lower for men (OR, 0.61), patients with recent surgery (OR, 0.33), and patients treated with SPE (OR, 0.42). A larger Δ%PAO was found in men (coefficient, −8.94), patients with a lower body mass index (coefficient, −0.66), patients treated with CDT (coefficient, −18.12), and patients treated with SPE (coefficient, −21.69). A lower Δ%PAO was found in African-American patients (coefficient, 7.31). ConclusionsThe use of CDT and SPE showed long-term benefit in thrombus reduction.

Percutaneous pulmonary thrombectomy as life-saving therapy in high-risk pulmonary embolism with obstructive shock in early pregnancy.

Percutaneous pulmonary thrombectomy as life-saving therapy in high-risk pulmonary embolism with obstructive shock in early pregnancy.

Extending donor criteria: successful lung transplantation post ex vivo back table donor pulmonary artery thrombolysis

Abstract Pulmonary embolization in donor lungs is a common finding and found in up to 38% of cases. To expand the pool of organs, transplant centers now utilize lungs, from increased risk donors, that may have pulmonary embolic disease. Modalities of clearing pulmonary artery embolisms are critical to reduce the prevalence of primary graft dysfunction post transplantation. There have been anecdotal cases of pulmonary embolectomy pre and post organ procurement or in vivo and ex vivo thrombolytic therapy performed in donors with massive pulmonary emboli. We report for the first time therapeutic ex vivo thrombolysis on the back table without Ex Vivo Lung Perfusion (EVLP), followed by successful transplantation.

Retrograde pulmonary embolectomy performed without aortic cross-clamping and closed left-sided heart chambers

Despite recent diagnostic and surgical management advances in massive pulmonary embolism (PE) treatment, the prognosis of patients is still unfavorable. The current surgical technique is direct antegrade embolectomy using cardiopulmonary bypass and beating heart, without cardioplegic arrest and hypothermia. A significant disadvantage of this approach is the inability to evacuate distally located thrombotic substances. Several authors offer a solution to these problems by applying retrograde pulmonary perfusion or retrograde pulmonary embolectomy. In 2017 Hussain provided a simplified method for performing retrograde perfusion without left atriotomy. In 2019, we served emergency procedures similar to Hussain’s in two patients with massive PE. As an adjunct, we did them on normothermia beating heart and without aortic clamping.

Value of retrograde pulmonary vein perfusion combined with pulmonary artery thrombectomy in acute pulmonary embolism: a protocol for a systematic review and meta-analysis

IntroductionAcute pulmonary embolism is a serious cardiovascular disease with high mortality. Surgery is an important therapeutic means. The traditional surgical method is pulmonary artery embolectomy with cardiopulmonary bypass, but there...

Role of catheter-directed therapies in the treatment of acute pulmonary embolism. Expert opinion of the Polish PERT Initiative, Working Group on Pulmonary Circulation, Association of Cardiovascular Interventions, and Association of Intensive Cardiac Care of the Polish Cardiac Society.

Thanks to advances in interventional cardiology technologies, catheter-directed treatment has become recently a viable therapeutic option in the treatment of patients with acute pulmonary embolism at high risk of early mortality. Current transcatheter techniques allow for local fibrinolysis or embolectomy with minimal risk of complications. Therefore, these procedures can be considered in high-risk patients as an alternative to surgical pulmonary embolectomy when systemic thrombolysis is contraindicated or ineffective. They are also considered in patients with intermediate-high-risk pulmonary embolism who do not improve or deteriorate clinically despite anticoagulation. The purpose of this article is to present the role of transcatheter techniques in the treatment of patients with acute pulmonary embolism. We describe current knowledge and expert opinions in this field. Interventional treatment is described in the broader context of patient care organization and therapeutic modalities. We present the organization and responsibilities of pulmonary embolism response team, role of pre-procedural imaging, periprocedural anticoagulation, patient selection, timing of intervention, and intensive care support. Currently available catheter-directed therapies are discussed in detail including standardized protocols and definitions of procedural success and failure. This expert opinion has been developed in collaboration with experts from various Polish scientific societies, which highlights the role of teamwork in caring for patients with acute pulmonary embolism.

Venoarterial extracorporeal membrane oxygenation for "protected" catheter-based embolectomy in high-risk/massive pulmonary embolism.

High-risk/massive pulmonary embolism (PE) has a high mortality rate, especially when cardiac arrest occurs. Venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) can rapidly restore and maintain circulation while a decision regarding further care or performance of other interventions takes place. Catheter-based embolectomy (CBE) is a technology that allows for percutaneous access, clot removal, and potential resolution of shock while avoiding sternotomy required for traditional pulmonary embolectomy. Rapid placement of V-A ECMO in patients with high-risk/massive PE prior to CBE may confer circulatory protection before, during, and after the procedure.

Integrated Traditional Chinese and western medicine nursing for a patient with acute pulmonary embolism undergoing percutaneous pulmonary thrombectomy

Integrated Traditional Chinese and western medicine nursing for a patient with acute pulmonary embolism undergoing percutaneous pulmonary thrombectomy

A swine model of pulmonary embolism with human-derived thrombi

Objectives: The development and evaluation of percutaneous thrombectomy devices for pulmonary embolism (PE) pose a need for standardized large in vivo models with representative anatomical and physiological conditions and clots analogs. In this study, we present a swine model of PE model employing human-derived clot analogs. Material and Methods: Baseline angiographic and physiological pressure measurements were obtained in six adult Yorkshire pigs (45–65 kg) and results were benchmarked for interspecies comparison with published human data using fluoroscopic examinations, intra-arterial pressure measurements, and histologic studies. Then, clot analogs were created ex vivo employing banked human blood and a subset incubated in iodinated contrast for fluoroscopic visualization. Clot analogs were then embolized via a femoral venous access and angiographic/physiological consequences were evaluated. Results: The main, right, and left pulmonary artery diameters were 24 ± 1.1 mm, 16.5 ± 0.8 mm, and 12.6 ± 1.2 mm, respectively. The angle between the main pulmonary artery at the bifurcation point was approximately 90–95°. The clot analogs were heterogeneous and had increased fibrin content along the clot length. The overall composition was 96.63% red blood cell (RBC)/3.37% fibrin in the initial section, 48.85% RBC/51.15% fibrin in the intermediate section, and 3.44% RBC/96.56% fibrin in the final section. Embolization of the clot analogs resulted in distal occlusion of the right and left pulmonary arteries. Conclusions: This swine model coupled with clot analog is able to accurately mimic human anatomical and physiological conditions in PE making it feasible for the evaluation of pulmonary thrombectomy devices.

Successful emergency surgical pulmonary embolectomy for massive pulmonary embolism after urgent cesarean delivery.

Successful emergency surgical pulmonary embolectomy for massive pulmonary embolism after urgent cesarean delivery.

Transit Thrombus in a Patent Foramen Ovale — Time Is Running Out: a Case Report

We report a case of a large thrombus entrapped in a patent foramen ovale after bariatric surgery and pulmonary embolism. The 60-year-old female patient was admitted to hospital as an emergency after syncope. She suffered from metabolic syndrome with obesity (height: 180 cm, weight: 170 kg, BMI: 49.4 kg/m2) and an insulin-dependent diabetes mellitus type 2. She had had bariatric surgery (implantation of a gastric balloon) 4 weeks prior to hospitalization. A transthoracic echocardiography was performed which indicated a large entrapped thrombus in the patent foramen ovale with extensions of approximately 10 cm in both the right and the left heart. Surgical embolectomy was performed to remove the circa 20-cm-long thrombus.At the time of surgery, only 2 cm of the transit thrombus remained in the right atrium. Thus, during the time between diagnosis and emergency surgery, the thrombus had gradually migrated 8 cm. Pulmonary embolectomy and closure of the patent foramen ovale were performed during the same procedure. The patient recovered completely without any complications and was discharged 11 postoperatively. This case demonstrates the importance of urgent medical decision-making with transit thrombi — time is running out.

Clinical case of surgical treatment of pulmonary embolism

Pulmonary embolism is a disease associated with significant prevalence. Incidence of venous thromboembolism in countries of Europe is 100–200 cases per 100 thousand per year. Annual morbidity for venous thromboembolism in the United States is 71–117 cases per 100 000. Surgical pulmonary thrombectomy is an effective method of treatment, however, remains ambiguous due to the small number of multicenter studies. In this case report the result of surgical treatment of patient with acute massive pulmonary embolism is presented.

Outcomes of Catheter-Based Pulmonary Artery Embolectomy in Patients With Sub-Massive to Massive Pulmonary Embolism.

Background Pulmonary embolism (PE) is the third leading cause of cardiovascular death after myocardial infarction and stroke. The ideal therapeutic approach for these patients remains undetermined. We report our single-center outcome data for using a catheter-based pulmonary artery thrombectomy using the FlowTriever (Inari Medical, Irvine, CA) device asmanagement for patients with submassive PE. Methods We retrospectively collected data from a single center of patients who underwent thrombectomy using INARI FlowTriever device. The data on baseline characteristics, procedural and clinical outcomes was collected and analysed Results A total of 38 patients with PE treated endovascularly with the FlowTriever device were identified: 33 with submassive PE and five with massive PE. The mean age was 65.9 years (95% CI 61.9 - 69.8), and most patients were male (73.7%). All patients had right heart strain as the main indication for thrombectomy. Four patients (10.53%) required pressor support before the procedure. In 31 patients, pre- and post-thrombectomy average mean pulmonary artery pressure (mPAP) was improved significantly by 22% (p < 0.01). Two patients had significant adverse events at 48 hours (5.26%). One patient experienced procedure-related access site hematoma and life-threatening bleeding, while another developed intraprocedural-related massive hemoptysis and cardiopulmonary arrest. Overall post-procedural length of stay was 7.7 ± 5.6 days; 52.63% of patients (n = 20) required intensive care. Three patients (7.89%) required pressor support before the procedure, and 78.9% of patients (n = 30 of 38) survived hospital discharge. Thirty patients who survived were discharged with oral anticoagulation. There were no device-related complications. Conclusion Randomized trials of interventional devices for submassive PE are warranted to either support or alert the medical community of the safety and efficacy of their use for patients with submassive and massive PE. In time, pulmonary embolismresponse team (PERT)may generate outcome data that better inform treatment decisions.

Surgical Management of Massive Pulmonary Embolism Presenting with Cardiopulmonary Arrest: How Far Is Too Far?

The incidence of diagnosed massive pulmonary embolism presenting to the Emergency Department is between 3% and 4.5% and it is associated with high mortality if not intervened timely. Cardiopulmonary arrest in this subset of patients carries a very poor prognosis, and various treating pathways have been applied with modest rate of success. Systemic thrombolysis is an established first line of treatment, but surgeons are often involved in the decision-making because of the improving surgical pulmonary embolectomy outcomes.

Surgical pulmonary embolectomy: state of the art.

Acute pulmonary embolism is a significant cause of morbidity and mortality. Patients in life-threatening conditions require timely and effective interventions to improve pulmonary perfusion. The indications for surgical embolectomy in the thrombolysis era have been limited. This article discusses surgical techniques and outlines the position of surgical embolectomy concerning other treatment modalities.

Percutaneous mechanical pulmonary thrombectomy: An emerging opportunity for vascular surgeons

ObjectivePercutaneous pulmonary artery (PA) mechanical thrombectomy is a minimally invasive treatment for patients with submassive pulmonary emboli (PE). Recent registry data suggest that only approximately 12% of these procedures are being performed by vascular surgeons. We conducted a single center, 1-year, prospectively collected, retrospectively reviewed original study of all patients who had percutaneous PA aspiration mechanical thrombectomy (PPAAMT) performed by vascular surgeons to treat acute, submassive PE. MethodsBetween January 2020 and January 2021, 5 vascular surgeons performed 21 percutaneous PPAAMTs, representing 72% of all the PPAAMT performed at our institution. The remaining 28% were performed by interventional radiology and cardiology physicians (4 patients each). Vascular surgeons used the Inari Flowtriever aspiration catheter in 90.4% of our cases. For the remaining 10% of cases, the Penumbra Indigo thrombectomy device was used. Device choice was determined by the surgeon. ResultsWe analyzed prospectively collected data and reviewed postprocedural outcomes including PA mean arterial pressures, interval improvement of respiratory function, and mortality. Among the patients treated with PPAAMT by vascular surgeons in this series, 76% demonstrated an improvement in oxygen requirements and 83% saw an improvement in their post-thrombectomy PA mean arterial pressure. There were three mortalities (16%), none of which were procedure related or attributable to the patients' acute presentation or to PE recurrence. ConclusionsIn this prospectively collected, retrospectively analyzed original study, vascular surgeons performed the majority of percutaneous PPAAMT to treat submassive PE at a single institution, with no procedure-related mortality and a high rate of clinical improvement as measured by improvements in oxygen requirements and PA mean arterial pressures. These results suggest that PPAAMT performed by vascular surgeons is safe and effective and can be strategically incorporated into an already busy tertiary care vascular surgery practice.

Risk factors and outcomes regarding the acute kidney injury after AngioJet thrombectomy for acute lower-extremity deep vein thrombosis

ObjectiveTo investigate the risk factors and outcomes regarding acute kidney injury (AKI) after AngioJet thrombectomy for acute lower-extremity deep vein thrombosis (DVT). MethodsPatients were divided into AKI and non-AKI groups according to whether AKI occurred postoperatively. The demographic data, pre-operative and post-operative laboratory data and surgical differences were compared between the two groups. Logistic regression and Wilcoxon signed-rank test were used to identify the AKI risk factors and outcomes, respectively. ResultsAmong the 341 patients who met the inclusion criteria, 45 developed AKI (AKI group) and 296 had normal renal function (non-AKI group) post-surgery. There were significant differences between the two groups in the course (t = 10.885, P = 0.000); preoperative history of a major surgery within 3 months (3M-MS) (odds ratio [OR] = 5.492, P = 0.001); duration of aspiration thrombectomy (Z = −8.803, P = 0.000); volumes of aspiration (Z = −8.215, P = 0.000); contrast volume (Z = −3.204, P = 0.001) and pulmonary thrombectomy (OR = 18.200, P = 0.002); and preoperative complications of hypertension (OR = 4.637, P = 0.002), diabetes (OR = 18.088, P = 0.000), or pulmonary embolism (OR = 0.085, P = 0.011). Wilcoxon signed-rank test showed that the renal function of every patient in the AKI group returned to normal 3 months after the surgery. ConclusionsThe course, preoperative complications of diabetes or hypertension, 3M-MS, contrast volume, duration and volume of aspiration thrombectomy, and pulmonary thrombectomy are risk factors for post–AngioJet-thrombectomy AKI, which is temporary.

Anticoagulant management for transition from failed thrombolysis to extra-corporeal membrane oxygenation in patients with high-risk pulmonary embolism: A thoughtful approach

Acute venous thromboembolism represents a spectrum of clinical syndromes of which high-risk pulmonary embolism (PE) with consecutive right ventricular failure and cardiogenic shock (CS) is the most severe presentation. First-line treatment options are surgical pulmonary embolectomy, systemic thrombolysis or catheter-based therapies. The role of mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is multifarious in this setting and can be considered as either a bridge to pulmonary artery reperfusion by any of the aforementioned options or as salvage bridge intervention for patients in refractory CS after failure of another treatment. In the subpopulation of patients that are placed on V-A-ECMO after failed thrombolysis, the mortality rates are among the highest, partially due to the high rates of bleeding events. The challenges in the interpretation of anticoagulant monitoring and, consequently, the titration of anticoagulation at least contribute to this high mortality. Here, we discuss the strengths and limitations of different anticoagulant parameters in this setting and propose an approach based on monitoring of Heparin anti-factor Xa (anti-Xa) assay and activated partial thromboplastin time (APTT) in parallel to drive unfractionated heparin (UFH) titration in patients with high-risk PE after fibrinolysis during the first 24 h on V-A-ECMO.

A RARE CASE OF THROMBUS IN TRANSIT MIGRATION TO THE MAIN PULMONARY ARTERY IN A PATIENT WITH SUBMASSIVE PULMONARY EMBOLISM

A RARE CASE OF THROMBUS IN TRANSIT MIGRATION TO THE MAIN PULMONARY ARTERY IN A PATIENT WITH SUBMASSIVE PULMONARY EMBOLISM

WHERE ARE YOU GOING: EMERGENCY MANAGEMENT OF A THROMBUS-IN-TRANSIT WITH PERCUTANEOUS MECHANICAL THROMBECTOMY AT A COMMUNITY HOSPITAL

WHERE ARE YOU GOING: EMERGENCY MANAGEMENT OF A THROMBUS-IN-TRANSIT WITH PERCUTANEOUS MECHANICAL THROMBECTOMY AT A COMMUNITY HOSPITAL