Pulmonary embolectomy: its place in the management of pulmonary embolism

Improved outcome of surgical pulmonary embolectomy by aggressive intervention for critically ill patients

BACKGROUND

Acute massive pulmonary thromboembolism is a life-threatening disorder, and prompt treatment is necessary. We analyzed the outcome of pulmonary embolectomy for massive pulmonary embolism.

METHODS

Nineteen patients who underwent pulmonary embolectomy were retrospectively investigated. Average age of patients was 59 years, and 79% were female. Most patients had massive or submassive pulmonary thromboemboli dislodging into the main pulmonary trunk or bilateral main pulmonary arteries. Hemodynamics of most patients were unstable. Two patients required percutaneous cardiopulmonary support before embolectomy, and 4 required cardiopulmonary resuscitation. In 6 patients, thrombolysis was ineffective.

RESULTS

All patients underwent emergent pulmonary embolectomy. Operative mortality was 5.3%. No patients exhibited newly developed neurologic damage. Ten-year survival rate was 83.5% ± 8.7%.

CONCLUSIONS

Pulmonary embolectomy saves critically ill patients having acute massive pulmonary thromboembolism. We must evaluate pulmonary embolism patients with an algorithm that includes surgical embolectomy as one of several therapeutic options.

Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.

Massive pulmonary thromboembolism during elective spine surgery

Massive pulmonary thromboembolism (PTE) is a condition that can still be seen in the operating room despite the use of thromboprophylaxis. A high degree of suspicion of this condition is necessary to achieve an early diagnosis and a rapid treatment to improve patient outcome. We report on a 27-year-old patient who sustained a massive PTE while undergoing a second-stage anterior release and posterior fusion of his thoracolumbar spine for idiopathic scoliosis.

Massive pulmonary embolism: percutaneous emergency treatment by pigtail rotation catheter

OBJECTIVES

This study was designed to assess the feasibility, efficacy and safety of mechanical fragmentation of pulmonary emboli using a new rotational pigtail catheter system.

BACKGROUND

Acute massive pulmonary embolism associated with right ventricular dysfunction is frequently lethal, despite high-dose thrombolytic therapy. Adjunctive catheter fragmentation may prevent a fatal outcome.

METHODS

In 20 patients (age 58.9+/-10.5 years) with severe hemodynamic impairment, massive pulmonary emboli were fragmented by mechanical action of the rotating pigtail. Fifteen patients received thrombolysis after embolus fragmentation or no thrombolysis at all (noninterference group).

RESULTS

Prefragmentation pulmonary arterial occlusion was 68.6 +/- 11.3% for both lungs. Pulmonary placement and navigation of the fragmentation catheter was easy and rapid. Fragmentation time was 17+/-8 min. The noninterference group showed a decrease pre- to postfragmentation of shock index from 1.28+/-0.53 to 0.95+/-0.38 (p = 0.011), mean pulmonary artery pressure from 31+/-5.7 to 28+/-7.5 mm Hg (p = 0.02) and a recanalization by fragmentation of 32.9+/-11.8% (mean angiographic score per treated lung from 7.4 to 5.0). Overall mortality was 20%.

CONCLUSIONS

Fragmentation by pigtail rotation catheter provided for a rapid and safe improvement of the hemodynamic situation and an average recanalization of about one-third of the pulmonary embolic occlusion. The method appears useful especially in high-risk patients threatened by right ventricular failure, to accelerate thrombolysis, and as a minimal-invasive alternative to surgical embolectomy.

Fragmentation of massive pulmonary embolism using a pigtail rotation catheter

STUDY OBJECTIVES

The purpose of this study was the evaluation of the efficacy and safety of mechanical fragmentation of acute massive pulmonary emboli with a rotatable pigtail catheter.

MATERIAL AND METHODS

Ten patients (4 female, 6 male, age 53.8+/-9.5 years) with acute massive pulmonary embolism with hemodynamic impairment were included in the study. The fragmentation catheter device (William Cook Europe A/S; Bjaerverskov, Denmark) consisted of a 5F catheter embedded in a flexible 5.5F sheath. Pulmonary emboli were fragmented by mechanical action of the recoiled rotating pigtail, while the guide wire was exiting an oval side hole proximal to the pigtail tip. In eight cases, an additional thrombolysis was performed.

RESULTS

Fragmentation was successful in 7 of 10 patients. Average percentage of recanalization by fragmentation was 29.2+/-14.0%, and 36.0+/-10.0% exclusively of the seven successful cases. Average shock index decreased significantly prefragmentation to postfragmentation from 1.52 to 1.22 (p = 0.03) and to 0.81 48 h later (p < 0.001). Decrease of the average mean arterial pulmonary pressure prefragmentation to postfragmentation was insignificant (from 33 to 31 mm Hg, p = 0.14); further decrease within the 48 h follow-up was highly significant (from 31 to 21 mm Hg, p < 0.001) due to a synergy of fragmentation and thrombolysis (average dose 63+/-25 mg plasminogen activator). There were no procedure-related complications. Overall mortality rate was 20%.

CONCLUSION

Fragmentation of massive pulmonary emboli with the pigtail rotation catheter achieved rapid partial recanalization in most cases, with ease of instrumentation, and without complications. Hemodynamic stabilization was completed in synergy with thrombolysis.

Massive pulmonary embolism in late pregnancy

PURPOSE

To describe the management problems presented by a case of acute massive pulmonary embolism in a labouring woman.

CLINICAL FEATURES

A case of massive pulmonary embolism is described in a woman who presented in early labour at thirty-eight weeks gestation. Immediate management involved the administration of oxygen and intravenous heparin, and transfer to the regional cardiothoracic centre. Pulmonary angiography confirmed the diagnosis of massive pulmonary embolism, but attempts at percutaneous catheter disruption of the clot were of only temporary benefit. The patient subsequently underwent Caesarean section under general anaesthesia, followed minutes later (because of an abrupt deterioration in her condition) by surgical pulmonary embolectomy. The outcome was successful for both mother and child.

CONCLUSION

In cases of acute massive pulmonary embolism presenting in late pregnancy and in labour, the risks and benefits of surgical embolectomy, pharmacological thrombolysis, or attempts at mechanical clot disruption have to be weighed on an individual basis. Management at the referral centre was facilitated by having cardiothoracic and obstetric facilities on the same site.

Surgical emergency embolectomy for the treatment of fulminant pulmonary embolism in a preterm infant

A massive pulmonary embolism, demonstrated by echocardiography developed in a 3-week-old preterm infant. An etiologic explanation could not be obtained from either history or clinical and laboratory findings. Pulmonary embolectomy was performed as an emergency procedure because of severe hemodynamic impairment despite intensive medical therapy. In children who have massive pulmonary embolism who remain in a compromised hemodynamic state despite intensive medical therapy, pulmonary embolectomy may be considered the alternative emergency treatment.

Use of thrombolytics for the treatment of thromboembolic disease during pregnancy

The incidence of thromboembolic disease is increased during pregnancy. Prevention and treatment of thromboembolic disease can have a significant impact on the morbidity and mortality of pregnant women. Anticoagulation with heparin is the treatment of choice; however, in some instances this is inadequate or contraindicated. In the nonpregnant patient, alternative therapies have included surgical intervention or fibrinolytic agents. Traditionally, thrombolytic therapy has been considered a relative contraindication during pregnancy due to the maternal and fetal risk of hemorrhagic complications. Hence, no controlled trials of agents such as streptokinase, urokinase, or tissue plasminogen activator for the treatment of thromboembolic events during pregnancy, have been performed, or are currently feasible. Since 1961, 36 reports have been published describing the use of thrombolytic agents during pregnancy. In a review of the world's literature, 172 pregnant women affected with thromboembolic conditions were treated with thrombolytic medications. A maternal mortality rate of 1.2 percent was observed. Approximately 10 pregnancy losses were noted (5.8 percent). Hemorrhagic complications were reported in 8.1 percent of patients. We summarize the published literature on the use of thrombolytic agents during pregnancy and discuss the treatment success and reported complications.

Transesophageal echocardiography to diagnose and demonstrate resolution of an acute massive pulmonary embolus

A 54-yr-old man presented with acute respiratory failure and hemodynamic collapse. Acute massive pulmonary embolus was confirmed with visualization of the thrombus by transesophageal echocardiography. Successful resolution after thrombolysis was confirmed by a repeat study. Transesophageal echocardiography can be used for both diagnosis and assessment of therapy in select cases of acute massive pulmonary embolism.

Fulminant pulmonary embolism: symptoms, diagnostics, operative technique, and results

Fulminant pulmonary embolism associated with cardiac arrest has an extremely high mortality. The feasibility of pulmonary embolectomy initiated during resuscitation is still under discussion. Between January 1975 and January 1991, pulmonary embolectomy was performed in 27 patients, 21 to 79 years old. The diagnosis was established primarily by clinical findings in 18 patients, by angiography and ventilation-perfusion mismatch in 4 patients, and by transesophageal echocardiography in 1 patient seen recently. Eleven patients did not require resuscitation (group 1); 5 patients had to be resuscitated and underwent operation after circulation was reestablished without need of further cardiac massage (group 2); and 11 patients were connected to extracorporeal circulation devices during cardiopulmonary resuscitation (30 to 210 minutes) (group 3). Embolectomy was performed using extracorporeal circulation with the heart beating (n = 2) or fibrillating (n = 15) or using cardioplegia (n = 10). Fifteen patients received a caval clip or ligature at the end of the procedure. Twelve patients died early postoperatively; the mortality rates were 36%, 60%, and 45% for groups 1, 2, and 3, respectively. Eight patients died of right heart failure, and 2 patients each died of brain death and sepsis. Of the surviving patients, only 1 showed ischemic brain damage. Mean stay in the intensive care unit was 5.1, 7.0, and 9.75 days for groups 1, 2, and 3, respectively. There were no recurrent embolisms during the 15-year follow-up (mean follow-up, 4.6 years). This experience demonstrates that even with subtotal obstruction of the pulmonary arteries, effective cardiopulmonary resuscitation with maintenance of uncompromised brain function is possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary embolectomy by catheter device in massive pulmonary embolism

From 1982 to 1989, ECD was performed on 18 patients suffering from poorly-tolerated massive pulmonary embolism, for whom classic treatments (fibrinolytics and surgery) were impossible. Eleven of these 18 patients immediately improved (S group). This procedure was unsuccessful in other seven patients (F group). Thirteen patients survived (72 percent). The time lag between the first episode of pulmonary embolism and ECD was significantly shorter in the S group than in the F group (4.7 +/- 5.4 days vs 18.3 +/- 6.9 days, p = 0.0004). So was the elapsed time between the onset of hemodynamic impairment and ECD (13 +/- 12 hours vs 59 +/- 38 hours, p = 0.003). We conclude that ECD should be considered when other treatments are impossible especially when the first symptoms date back less than 15 days and the hemodynamic impairment less than 48 h.

Pulmonary embolectomy: a 20-year experience at one center

Between 1968 and 1988, 96 consecutive patients with acute massive pulmonary embolism underwent pulmonary embolectomy under cardiopulmonary bypass. The operative mortality rate was 37.5%. We analyzed 12 clinical and hemodynamic variables by univariate and multivariate analyses to assess the predictive factors of postoperative outcome. Multivariate analysis disclosed that cardiac arrest and associated cardiopulmonary disease were independent predictors of operative death. Long-term follow-up (range, 2 to 144 months; mean, 56 months) information was available for 55 of the 60 discharged patients: 6 had died, and 5 complained of persistent mild or severe exertional dyspnea (New York Heart Association class II). These results help assess the preoperative risk in patients undergoing pulmonary embolectomy. They also show that, in the few patients who do not benefit from optimal medical therapy, pulmonary embolectomy remains an acceptable procedure in view of the long-term results.

Successful treatment of massive pulmonary embolism with recombinant tissue type plasminogen activator (rt-PA) in a pregnant woman with intact gravidity and preterm labour

We report a patient with massive pulmonary embolism and circulatory shock during pregnancy (31st gestational week) and preterm labour who has been successfully treated with recombinant tissue type plasminogen activator. Thrombolysis was performed using 10 mg.h-1 over 4 h followed by 2 mg.h-1 for 1 h 30 min resulting in complete resolution of cardio-respiratory symptoms. Except for slight bleeding from one puncture site no complications occurred. At 48 h after the end of thrombolytic therapy the patient was delivered spontaneously of a male preterm healthy infant. The relevance of this new thrombolytic agent in the treatment of massive life-threatening pulmonary embolism during pregnancy is discussed.

The role of thrombolytic therapy in surgical practice

The ability of streptokinase and urokinase to lyse intravascular fibrin-based clots is firmly established. However, there is a lack of enthusiasm for these agents because of serious haemorrhagic complications and a lack of controlled randomized studies indicating their efficacy. Thrombolytic therapy is suitable in only 15 per cent of patients with acute deep venous thrombosis. It restores the venous circulation to normal in up to 95 per cent of these patients if therapy is instituted within 5 days of the onset of symptoms. These patients have significantly fewer symptoms on follow-up than patients treated with heparin although the ability of thrombolytic therapy to preserve venous valvular function and to prevent the post-phlebitic syndrome is now in question. Thrombolytic therapy is as effective as heparin in preventing pulmonary embolism and may be superior in its treatment. Pulmonary haemodynamics are rapidly improved, diffusion capacity is restored and, although the evidence is inconclusive, long-term pulmonary hypertension may be prevented. Although the mortality rate is not decreased, controlled studies show that thrombolytic therapy may be beneficial in massive pulmonary embolism with clinical shock. Thrombolytic therapy is indicated for acute arterial and acute bypass graft occlusion when the surgical alternative is associated with a higher morbidity and mortality. Partial thrombolysis is achieved in up to 90 per cent of cases and the need for further therapeutic intervention is eliminated in one-third of the patients treated. New thrombolytic agents with greater specificity and potentially greater efficacy and fewer complications are being developed. Tissue plasminogen activator has been successfully used. Prourokinase, fibrin-seeking urokinase and acetylated streptokinase-plasminogen complex may expand the role of thrombolytic therapy in surgical practice.