Surgical Embolectomy Research Articles

Advances in Percutaneous Management of Pulmonary Embolism.

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE with hemodynamic compromise (massive/high-risk PE). A significant number of patients are not candidates for systemic thrombolysis due to the bleeding risk associated with thrombolytics. Historically, surgical pulmonary embolectomy (SPE) was recommended for massive PE with hemodynamic compromise for these patients. In the last decade, catheter-directed thrombolysis (CDT) has largely replaced SPE in the patient population with intermediate risk PE (submassive), defined as right heart strain (as evidenced by right ventricle enlargement on echocardiogram and/or computed tomography, usually along with elevation of troponin or B-type natriuretic peptide). Use of CDT increased in the last few years due to high incidence of PE in hospitalized patients with coronavirus disease 2019 pneumonia, and the use of mechanical thrombectomy (initially reserved for those with contraindications to thrombolysis) has also grown. In this article, we discuss the value of the PE response team, our approach to management of submassive (intermediate risk) and massive (high risk) PE with systemic thrombolytics, CDT, mechanical thrombectomy, and surgical embolectomy.

Acute Massive and Submassive Pulmonary Embolism: Historical Considerations/Surgical Techniques of Pulmonary Embolectomy/Novel Applications in Donor Lungs with Pulmonary Emboli.

Pulmonary embolectomy has a chequered history but the quest to surgically treat a patient diagnosed with pulmonary embolism effectively spurred the development of cardiopulmonary bypass and a new dawn for cardiac surgery. The advent of cardiopulmonary bypass, extracorporeal membrane oxygenation, and computed tomography pulmonary angiogram has allowed rapid diagnosis and made surgical pulmonary embolectomy a relatively safe procedure that should be considered when indicated. Pulmonary emboli in donor lungs, often get rejected for transplantation. Ex vivo lung perfusion is among newly available technology with the ability to not only recondition marginal lungs but also treat donor lung pulmonary embolisms, effectively increasing the donor pool.

Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism.

Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism.

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.

Persistent Sciatic Artery: A Case Report

Persistent sciatic artery (PSA) is a very rare congenital vascular anomaly, occurs in 0.025% to 0.04% of the population, and occasionally associated with thromboembolic events or aneurismal diseases. We herein share experience of diagnosis and successful treatment of a Vietnamese patient with PSA complicated with distal thromboembolism. A 70-year-old woman was admitted to the hospital for acute lower limb ischemia. A computed tomography angiography (CTA) revealed complete occlusion of the left common iliac artery. Surgical embolectomy was carried out and abnormal distal left femoral artery was noted intraoperatively. Postoperative CTA showed a persistent sciatic artery (PSA) on the left and adequate perfusion of the left lower limb. During 2 years follow-up, the patient remained symptom-free with good perfusion to the distal left popliteal artery, anterior and posterior tibial arteries.

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.

Impact of pulmonary embolism response teams on acute pulmonary embolism: a systematic review and meta-analysis.

The impact of pulmonary embolism response teams (PERTs) on treatment choice and outcomes of patients with acute pulmonary embolism (PE) is still uncertain. To determine the effect of PERTs in the management and outcomes of patients with PE. PubMed, Embase, Web of Science, CINAHL, WorldWideScience and MedRxiv were searched for original articles reporting PERT patient outcomes from 2009. Data were analysed using a random effects model. 16 studies comprising 3827 PERT patients and 3967 controls met inclusion criteria. The PERT group had more patients with intermediate and high-risk PE (66.2%) compared to the control group (48.5%). Meta-analysis demonstrated an increased risk of catheter-directed interventions, systemic thrombolysis and surgical embolectomy (odds ratio (OR) 2.10, 95% confidence interval (CI) 1.74-2.53; p<0.01), similar bleeding complications (OR 1.10, 95% CI 0.88-1.37) and decreased utilisation of inferior vena cava (IVC) filters (OR 0.71, 95% CI 0.58-0.88; p<0.01) in the PERT group. Furthermore, there was a nonsignificant trend towards decreased mortality (OR 0.87, 95% CI 0.71-1.07; p=0.19) with PERTs. The PERT group showed an increased use of advanced therapies and a decreased utilisation of IVC filters. This was not associated with increased bleeding. Despite comprising more severe PE patients, there was a trend towards lower mortality in the PERT group.

Superficial Temporal Artery:Middle Cerebral Artery Bypass Technique as the Basis for Emergency Revascularization

The superficial temporal artery-middle cerebral artery(STA-MCA)bypass technique is extremely important as the basis for both cerebral revascularization in chronic-stage ischemia and emergency surgical revascularization, including open surgical embolectomy. The sophisticated technique of microvascular bypass could also contribute to rescuing inadvertent vascular injuries, such as those occurring in difficult tumor surgery. Therefore, novice neurosurgeons should practice mastering the microvascular suturing technique.

Surgical Embolectomy of Acute Pulmonary Embolism

Other SectionsAbstractINTRODUCTIONINDICATIONS FOR SURGERYSURGICAL TECHNIQUESSURGICAL RESULTSINDICATIONS FOR SURGERYCONFLICT OF INTERESTReferences

Treatment strategies for thromboembolism-in-transit with pulmonary embolism.

A 46-year-old obese woman undergoing treatment for bipolar disorder presented with acute shortness of breath, chest pain and palpitations. She was tachypnoea and tachycardia, but blood pressure was stable. Computed tomography angiogram revealed bilateral pulmonary embolism. Echocardiogram revealed thrombus-in-transit. She underwent surgical embolectomy only for thrombus-in-transit and closure of the patent foramen ovale. However, pulmonary hypertension worsened, haemodynamical instability prolonged and hepatic congestion progressed. After veno-arterial extracorporeal membrane oxygenation insertion, we performed thrombectomy by catheter and anticoagulation therapy. One month later, the patient was transferred to another hospital for rehabilitation.

OPTIMAL REPERFUSION STRATEGY IN ACUTE HIGH-RISK PULMONARY EMBOLISM REQUIRING EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT: A SYSTEMATIC REVIEW AND META-ANALYSIS

TYPE: Late Breaking Abstract TOPIC: Pulmonary Vascular Disease PURPOSE: Optimal pulmonary revascularization strategy in acute high-risk pulmonary embolism (PE) requiring implantation of extracorporeal membrane oxygenation (ECMO) remains controversial. METHODS: We conducted a systematic review and meta-analysis of available evidence comparing mechanical embolectomy and other strategies, including systemic or catheter-directed thrombolysis, or ECMO as stand-alone therapy, with regard to mortality and bleeding outcomes. RESULTS: We identified 835 studies;17 were included, comprising 353 PE ECMO-treated patients. Overall, 30.8% had mechanical pulmonary reperfusion, (of whom 89.9% surgical embolectomy), while 69.1% received other strategies. Mortality rate was 23.0% in the mechanical reperfusion group and 43.1% in the other strategy group. The pooled OR for mortality with mechanical reperfusion was 0.46 (95%CI, 0.213-0.997; I2 = 28.3%) versus other reperfusion strategies; and 0.37 (95% CI, 0.18-0.78; p = 0.009; I 2 = 14.8%) for any surgical embolectomy vs thrombolysis. The bleeding rate in ECMO patients was 29.1% in the mechanical reperfusion group and 26.0% in the other reperfusion group (OR, 1.09; 95% CI, 0.46-2.54; I2, 0.0%) among 10 eligible studies with available bleeding data. Meta-regression did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy” and “ECMO implantation before pulmonary reperfusion therapy”, and associated outcomes. CONCLUSIONS: The results of this meta-analysis and meta-regression suggest that mechanical reperfusion, notably surgical embolectomy, yields favorable results regardless of the timing of ECMO implantation in the reperfusion timeline, and independent of thrombolysis administration. CLINICAL IMPLICATIONS: Mechanical pulmonary reperfusion, especially surgical embolectomy, seems to be more effective than other strategies, especially thrombolysis, for mitigating mortality risk, at similar bleeding risk. DISCLOSURE: Grants from BMS/Pfizer, BSC, Amgen, Bayer, Janssen, Portola (GP); Honoraria from Getinge, Drager, Fresenius (MS); Honoraria from Abbott, BMS-Pfizer, Bayer, Edwards Lifesciences, Terumo (NM); Travel support from Daiichi Sankyo, Pfizer (ISC) KEYWORD: pulmonary embolism

Venoarterial Extracorporeal Membrane Oxygenation in High-Risk Pulmonary Embolism: A Case Series and Literature Review.

High-risk Pulmonary Embolism (PE) has an ominous prognosis and requires emergent reperfusion therapy, primarily systemic thrombolysis (ST). In deteriorating patients or with contraindications to ST, Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) may be life-saving, as supported by several retrospective studies. However, due to the heterogeneous clinical presentation (refractory shock, resuscitated cardiac arrest (CA) or refractory CA), the real impact of VA-ECMO in high-risk PE remains to be fully determined. In this study, we present our centre experience with VA-ECMO for high-risk PE. From 2008 to 2020, we analyzed all consecutive patients treated with VA-ECMO for high-risk PE in our tertiary 35-bed intensive care unit (ICU). Demographic variables, types of reperfusion therapies, indications for VA-ECMO (refractory shock or refractory CA requiring extra-corporeal cardiopulmonary resuscitation, ECPR), hemodynamic variables, initial arterial blood lactate and ICU complications were recorded. The primary outcome was ICU survival, and secondary outcome was hospital survival. Our cohort included 18 patients (9F/9M, median age 57 years old). VA-ECMO was indicated for refractory shock in 7 patients (2 primary and 5 following resuscitated CA) and for refractory CA in 11 patients. Eight patients received anticoagulation only, 9 received ST, and 4 underwent surgical embolectomy. ICU survival was 1/11 (9%) for ECPR vs 3/7 (42%) in patients with refractory shock (p = 0.03, log-rank test). Hospital survival was 0/11 (0%) for ECPR vs 3/7 for refractory shock (p = 0.01, log-rank test). Survivors and Non-survivors had comparable demographic and hemodynamic variables, pulmonary obstruction index, and amounts of administered vasoactive drugs. Pre-ECMO lactate was significantly higher in non-survivors. Massive bleeding was the most frequent complication in survivors and non-survivors, and was the direct cause of death in 3 patients, all treated with ST. VA-ECMO for high-risk PE has very different outcomes depending on the clinical context. Furthermore, VA-ECMO was associated with significant bleeding complications, with more severe consequences following systemic thrombolysis. Future studies on VA-ECMO for high-risk PE should therefore take into account the distinct clinical presentations and should determine the best strategy for reperfusion in such circumstances.

Optimal reperfusion strategy in acute high-risk pulmonary embolism requiring extracorporeal membrane oxygenation support: a systematic review and meta-analysis.

The optimal pulmonary revascularisation strategy in high-risk pulmonary embolism (PE) requiring implantation of extracorporeal membrane oxygenation (ECMO) remains controversial. We conducted a systematic review and meta-analysis of evidence comparing mechanical embolectomy and other strategies, including systemic thrombolysis, catheter-directed thrombolysis or ECMO as stand-alone therapy, with regard to mortality and bleeding outcomes. We identified 835 studies, 17 of which were included, comprising 327 PE patients. Overall, 32.4% were treated with mechanical pulmonary reperfusion (of whom 85.9% had surgical embolectomy), while 67.6% received other strategies. The mortality rate was 22.6% in the mechanical reperfusion group and 42.8% in the "other strategies" group. The pooled odds ratio for mortality with mechanical reperfusion was 0.439 (95% CI 0.237-0.816) (p=0.009; I2=35.2%) versus other reperfusion strategies and 0.368 (95% CI 0.185-0.733) (p=0.004; I2=32.9%) for surgical embolectomy versus thrombolysis. The rate of bleeding in patients under ECMO was 22.2% in the mechanical reperfusion group and 19.1% in the "other strategies" group (OR 1.27, 95% CI 0.54-2.96; I2=7.7%). The meta-regression model did not identify any relationship between the covariates "more than one pulmonary reperfusion therapy", "ECMO implantation before pulmonary reperfusion therapy", "clinical presentation of PE" or "cancer-associated PE" and the associated outcomes. The results of the present meta-analysis and meta-regression suggest that mechanical reperfusion, notably by surgical embolectomy, may yield favourable results regardless of the timing of ECMO implantation in the reperfusion timeline, independent of thrombolysis administration or cardiac arrest presentation.

Surgical embolectomy as a promising treatment of acute pulmonary embolism

Highlights. The article presents current literature data on the results of surgical treatment of acute pulmonary embolism.Abstract. The review article throws light on up to date approaches to the treatment of acute pulmonary embolism. The great variety of treatment methods and controversial results do not allow us to conclusively decide on which method to choose. Traditionally, pharmacological therapies have been favored over invasive methods because of the lower mortality rate. However, based on new studies, it can be established that interventional embolectomy is an effective option, showing good immediate and long-term results. Undoubtedly, additional studies are needed in order that surgical embolectomy developed from a rescue therapy of acute pulmonary embolism into a first-line or priority treatment.

Age Does Not Matter: Utilization of Veno-Arterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism in the Elderly Population

<h3>Purpose</h3> Management of massive and submassive pulmonary embolism (PE) remains a challenge. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a useful strategy in select patients with pulmonary emboli (PE) to provide hemodynamic support; however, age remains a relative contraindication based on prior literature as safety is controversial. <h3>Methods</h3> We retrospectively reviewed all patients with pulmonary emboli who were placed on peripheral VA-ECMO from 2015- 2021 at a single institution. Patients were identified and stratified into two groups with an age cutoff of 65 years of age. Demographics, pre-cannulation data, ECMO data, and echocardiographic results were obtained. Primary endpoints included 30-day, 6-month, and one-year survival. <h3>Results</h3> Sixty-nine patients <65 years of age (median age 58) and twenty patients ≥65 of age (median age 69) received VA-ECMO for PE. Hypertension incidence was higher in the ≥65 group; there were no differences in sex, BMI, pre-cannulation arrest, or in pre-cannulation ejection fraction or presence of right ventricular dysfunction. The median duration on ECMO was 5 days in both groups (p=0.503). 14.5% (10/69) of patients <65 and 25.0% (5/20) of patients ≥65 required surgical embolectomy after 5-7 days of VA-ECMO support (p=0.313). There was no difference in 30-day survival (91.3% (63/69, A) in <65 vs 90.0% (18/20) in ≥65, p=<0.999), 6-month survival (92.3% (60/65) in <65 vs 85% (17/20) in ≥65, p=0.385), and one-year survival (92.1% (58/63, B) in <65 vs 83.3% (15/18) in ≥65, p=0.367). There was no difference in ICU or hospital length of stay, need for renal replacement therapy, and rate of stroke between the groups. <h3>Conclusion</h3> There is no difference in 30-day, 6-month, or one-year survival in patients with a PE who are supported with VA-ECMO as compared to younger patients in our experience. As such, age should not be a contraindication for VA-ECMO use for cardiopulmonary support in management of pulmonary embolism.

Use of Venoarterial Extracorporeal Membrane Oxygenation in the Management of Massive Pulmonary Embolism

<h3>Purpose</h3> The management of massive pulmonary embolism with hemodynamic instability remains challenging with high mortality rate, Using Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is used in general as salvage therapy. Here we report a single center experience. <h3>Methods</h3> Medical records of all patients who underwent VA-ECMO support for massive pulmonary emboli and presented with cardiogenic shock and severe right ventricle dysfunction between January 2015-December 2018 were retrospectively reviewed. All patients who continue to have signs of right ventricle strain after 3 days of VA-ECMO support underwent surgical embolectomy. <h3>Results</h3> Thirty-nine patients were identified; one patient underwent Surgical Embolectomy removal 4 days after support. The remaining 38 included, there were 22 (58%) males. Median age was 58 years (range 17-88), the mean support time was 4 days (range 1-10). Overall, 29 (76%) patients were successfully separated off ECMO, 3 patients underwent comfort care measures due to severe neurologic injury. Twenty (53%) patients were discharged from the hospital, 3 with mild or moderate right ventricle dysfunction, nineteen patients were alive after 6 months follow up all have normalized right ventricle function. Ten patients from the series received E-CPR at the time of initiation, 4 (40%) were separated from ECMO and three were discharged home. 28 patients underwent catheter-based therapy prior to ECMO or while on support, 5 received angiovac debulking prior to ECMO support. The major ECMO complications included 3 patients with vascular injury from ECMO placement and 3 with irreversible neurological injury and PA catheter rupture. <h3>Conclusion</h3> VA-ECMO support is an effective method of support for patients with massive PE and hemodynamic instability. It could be used as a first line of treatment in selected patients or could be used to stabilize the patient as bridge to alternative treatment.

Pulmonary Embolism and Pregnancy-Challenges in Diagnostic and Therapeutic Decisions in High-Risk Patients.

Diagnosis of acute PE in pregnant women with haemodynamic instability is following the general integrated risk-adapted diagnostic algorithm and starts with bedside echocardiography to assess RV function. If RV dysfunction is identified, a prompt and immediate reperfusion without further imaging should be initiated. Although pregnancy is listed as a relative contraindication of systemic thrombolysis, in pregnant women with acute PE and haemodynamic instability thrombolysis must be considered. In those cases, other treatment strategies as surgical embolectomy or catheter-directed low-dose thromboylysis or percutaneous thrombectomy should be taken into consideration as well. A multidisciplinary team with experience of PE management in pregnancy should be consulted to reach consensus on the best treatment approach.

Masquerade presentation of acute type B aortic dissection as isolated acute limb ischaemia treated with endovascular fenestration with angioplasty: A case report.

Introduction and importanceMasquerade presentation of acute type B aortic dissections (TBAD) as acute limb ischaemia (ALI) is rare. Holistic clinical assessment, preferably with the help of scoring systems and timely computer tomographic angiogram (CTA), is needed for early diagnosis. Acute TBAD and its complications are increasingly treated with endovascular therapies.Case presentationA 21-year-old male with poorly controlled essential hypertension was admitted with prominent clinical features of ALI. No clinical pointers of a TBAD were present. Doppler ultrasound revealed an arterial occlusive pattern, and an urgent surgical embolectomy was performed. On failure to retrieve any thrombi, a CTA was performed, and diagnosis of TBAD complicated with ALI was made. The limb was revascularised with guidewire directed aortic fenestration with angioplasty. TBAD was managed conservatively.Clinical discussionWe report a case of acute TBAD presented as isolated ALI, which was initially diagnosed and treated as an ALI unrelated to aortic dissection. TBAD with typical or atypical clinical features presented with ALI as a malperfusion syndrome is not uncommon. However, masquerade presentations of TBAD as ALI are rare in the literature. Endovascular fenestration with or without stenting has fewer neurological complications and long-term mortality than thoracic endovascular aortic repair (TEVAR). Moreover, they become convenient in resource-poor settings without dedicated aortic centres.ConclusionMasquerade presentation of TBAD should be recognised in the differential diagnosis of ALI. Timely CTA would prevent unnecessary interventions and help diagnose TBAD complicated with ALI. Despite their availability, outcomes will depend on proper patient selection for endovascular, surgical, and TEVAR options.

Surgical Treatment of Pulmonary Embolism and Chronic Thromboembolic Pulmonary Hypertension.

Venous thromboembolism clinically presents as deep venous thrombosis or acute pulmonary embolism and is globally recognized as the third most frequent acute cardiovascular syndrome after myocardial infarction and stroke. Although pulmonary embolism does not typically cause severe pulmonary hypertension in the acute setting, thrombus organization and fibrosis can lead to stenosis or obliteration of pulmonary arteries in a minority of patients, which in turn result in severe pulmonary hypertension and right heart failure. This disease is labeled chronic thromboembolic pulmonary hypertension and can occur after a single episode or multiple ones of pulmonary embolism. The cornerstone of pulmonary embolism treatment is medical therapy, whereas systemic thrombolytic therapy has to be considered for patients with hemodynamic instability. Given the current acceptable short-term surgical mortality, the potential of first-line surgical embolectomy as an alternative to medical thrombolysis has gained momentum as far as pulmonary embolism treatment is concerned. In contrast to pulmonary embolism, bilateral complete pulmonary endarterectomy under short deep hypothermic circulatory arrest intervals is the treatment of choice against chronic thromboembolic pulmonary hypertension, given patients' operability. Pulmonary endarterectomy is suggested in every operable patient when the operation is offered by an experienced multidisciplinary team, including at least one experienced surgeon. Surgical embolectomy should also be limited to large institutions since it also requires an experienced heart team. This review concerns a thorough discussion regarding surgical treatment of pulmonary embolism and chronic thromboembolic pulmonary hypertension. Eligibility criteria, operation-related complications and postoperative outcomes are discussed in detail.

9. The Effect Of L-Arginine On Decreasing Foam Cell Development Post Surgical Embolectomy With Fogarty Balloon Catheter On Iliac Arteries Of Rabbit

9. The Effect Of L-Arginine On Decreasing Foam Cell Development Post Surgical Embolectomy With Fogarty Balloon Catheter On Iliac Arteries Of Rabbit