Acute Pulmonary Thromboembolism: 14 Years of Surgical Experience

Massive pulmonary embolism after caesarean section managed with surgical thrombectomy bridged with extracorporeal membrane oxygenation: A case report

INTRODUCTION

Pulmonary embolism (PE) is a rare but fatal complication in postpartum women. Mortality is as high as 65% in massive PE, in which systemic hypotension persists or circulatory collapse occurs. This case report describes a patient who underwent a caesarean section complicated by massive PE. The patient was managed with early surgical embolectomy and bridged with extracorporeal membrane oxygenation (ECMO).

PRESENTATION OF CASE

A 36 years old postpartum patient with an unremarkable medical history had sudden cardiac arrest due to PE on the day after a caesarean section. The patient recovered spontaneous cardiac rhythm after cardiopulmonary resuscitation; however, hypoxia and shock persisted. Cardiac arrest and spontaneous circulation recovery were repeated twice per hour. Veno-arterial (VA) ECMO rapidly improved the patient's condition. Surgical embolectomy was conducted 6 h after the initial collapse by the experienced cardiovascular surgeon. The patient's condition improved rapidly, and was weaned from ECMO on postoperative day three. The patient recovered normal heart function and no pulmonary hypertension was observed on follow-up echocardiography performed 15 months later.

DISCUSSION

Timely intervention is important in the management of PE because of its rapid progression. VA ECMO is a useful bridge therapy to prevent derangement and severe organ failure. Surgical embolectomy is appropriate following the use of ECMO in postpartum patients because of the risk of major haemorrhagic complications or intracranial haemorrhage.

CONCLUSION

In patients who have undergone caesarean section complicated by massive PE, surgical embolectomy is preferred because of the risk of haemorrhagic complications and their relatively young age.

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

INTRODUCTION

Acute 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 is a certain recurrence rate after surgery. Some scholars use retrograde pulmonary vein perfusion as an adjunct to conventional pulmonary artery embolectomy. However, whether this method can be used safely for acute pulmonary embolism and its long-term effects remains unclear. Therefore, we plan to conduct a systematic review and meta-analysis to investigate whether retrograde pulmonary vein perfusion combined with pulmonary artery thrombectomy can be safely used in acute pulmonary embolism.

METHODS AND ANALYSIS

We will search key databases (Ovid MEDLINE, PubMed, Web of Science, Cochrane Library, China Science and Technology Journals and Wanfang) for studies on acute pulmonary embolism treated with retrograde pulmonary vein perfusion from January 2002 to December 2022. The useful information will be consolidated into a piloting spreadsheet. The Cochrane Risk of Bias Tool will be used to assess the bias. Data will be synthesised and heterogeneity will be evaluated. The dichotomous variables will be determined by using risk ratio with 95% CI, and weighted mean differences (with 95% CI) or standardised mean differences (95% CI) will be used for continuous variables. Χ² test and I² test will be used to assess the statistical heterogeneity. Meta-analysis will be conducted when strong homogeneous data are accessible.

ETHICS AND DISSEMINATION

Approval of the ethics committee is not needed for this review. While results will be disseminated electronically, effective dissemination will be done through presentations and peer-reviewed publication.

PROSPERO REGISTRATION NUMBER

CRD42022345812; pre-results.

Initial Experience with Non-Sternotomy Minimally Invasive Pulmonary Embolectomy with Thoracoscopic Assistance

The endpoint in emergent management of acute massive pulmonary embolism (PE) has traditionally been with embolectomy through standard median sternotomy. This approach is limited in both exposure and concomitant functional morbidity associated with sternotomy. Herein we describe a novel minimally invasive, thoracoscopically assisted approach to pulmonary embolectomy. This utilizes a small 5-cm left parasternal thoracotomy and femoral cardiopulmonary bypass to conduct thoracoscopically assisted surgical pulmonary embolectomy. This novel minimally invasive approach has been developed and successfully utilized in 3 patients with massive PE at our institution. The assistance of the thoracoscope allowed for complete visualization and clot extraction of the main and segmental pulmonary arteries bilaterally. The use of a non-sternotomy approach sped both functional and pulmonary recovery times and decreased length of stay. These initial data suggest that non-sternotomy minimally invasive surgical pulmonary embolectomy with thoracoscopic assistance is a feasible and safe approach for acute massive PE that may result in enhanced recovery times and decreased hospital length of stay.

Clinical outcomes of acute pulmonary embolectomy as the first-line treatment for massive and submassive pulmonary embolism: a single-centre study in China

Background

Acute pulmonary embolism (PE) is one of the most critical cardiovascular diseases. PE treatment ranges from anticoagulation, and systemic thrombolysis to surgical embolectomy and catheter embolectomy. Surgical pulmonary embolectmy (SPE) indications and outcomes are still controversial. Although there have been more favourable SPE reports over the past decades, SPE has not yet been considered broadly as an initial PE therapy and is still considered as a reserve or rescue treatment for acute massive PE when systemic thrombolysis fails. This study aimed to evaluate the early and midterm outcomes of SPE, which was a first-line therapy for acute central major PE in one Chinese single centre.

Methods

A retrospective review of patients who underwent SPE for acute PE was conducted.Patients with chronic thrombus or who underwent thromboendarterectomy were excluded. SPE risk factors for morbidity and mortality were reviewed, and echocardiographic examination were conducted for follow-up studies to access right ventricular function.

Results

Overall, 41 patients were included; 17 (41.5%) had submassive PE, and 24 (58.5%) had massive PE. Mean cardiopulmonary bypass time was 103.2 ± 48.9 min, and 10 patients (24.4%) underwent procedures without aortic cross-clamping. Ventilatory support time was 78 h (range, 40–336 h), intensive care unit stay was 7 days (range, 3–13 days), and hospital stay was 16 days (range, 12–23 days). Operative mortalities occurred in 3 massive PE patients, and no mortality occurred in submassive PE patients. The overall SPE mortality rate was 7.31% (3/41). If two systemic thrombolysis cases were excluded, SPE mortality was low (2.56%,1/39), evenlthough there were 2 cases of cardiac arrest preoperatively. Patients’ right ventricle function improved postoperatively in follow-ups.There were no deaths related to recurrent PE and chronic pulmonary hypertension in follow-ups, though 3 patients died of cerebral intracranial bleeding, gastric cancer,and brain cancer at 1 year, 3 years, and 8 years postoperatively, respectively.

Conclusions

SPE presented with a low mortality rate when rendered as a first-line treatment in selected massive and submassive acute PE patients. Favorable outcomes of right ventricle function were also observed in the follow-ups. SPE should play the same role as ST in algorithmic acute PE treatment.

Massive pulmonary embolism: embolectomy or extracorporeal membrane oxygenation?

PURPOSE OF REVIEW

To highlight updates on the use of extracorporeal membrane oxygenation (ECMO) and surgical embolectomy in the treatment of massive pulmonary embolism.

RECENT FINDINGS

Outcomes for surgical embolectomy for massive pulmonary embolism have improved in the recent past. More contemporary therapeutic options include catheter embolectomy, which although offer less invasive means of treating this condition, need further study. The use of ECMO as either a bridge or mainstay of treatment in patients with contraindications to fibrinolysis and surgical embolectomy, or have failed initial fibrinolysis, has increased, with data suggesting improved outcomes with earlier implementation in selected patients.

SUMMARY

Although surgical embolectomy continues to be the initial treatment of choice in massive pulmonary embolism with contraindications or failed fibrinolysis, the use of ECMO in these high-risk patients provides an important tool in managing this often fatal condition.