Indication margins for pulmonary embolectomy]

Pulmonary embolectomy is the most effective form of treatment in acute, massive pulmonary embolism. Persistent cardio-respiratory failure, in spite of intensive medical therapy, presents a clear indication for embolectomy. A relative indication is given with the occlusion of more than 50% of the pulmonary arterial tree, especially in the case of beginning circulatory failure and contraindications to fibrinolytic therapy. Preoperative angiography is essential and should be performed whenever possible. A dramatic deterioration of the patient's condition may, however, require a prior reestablishment of sufficient circulation with relief of the right ventricle. According to the clarity of symptoms, either immediate thoracotomy or peripheral canulation and partial cardio-pulmonary bypass with subsequent angiography on the operating table should be preferred. Even a long resuscitation with persistently dilated, non-reactive pupils does not exclude operative success, and justifies neither the ommission nor the premature discontinuance of a resolute and consistent therapy.     

Anaesthetic technique for transvenous pulmonary embolectomy

Transvenous pulmonary catheter embolectomy is being used as a method of treatment for patients suffering from massive pulmonary embolism. The anaesthetic management of these patients can be complex. Presented is a case of transvenous pulmonary embolectomy in a patient who also had an intravascular volume deficit secondary to haemorrhage and possible reperfusion oedema. A discussion of appropriate monitoring during procedure follows.     

Open pulmonary embolectomy for treatment of major pulmonary embolism

BACKGROUND: Inadequate data exist regarding the management of acute major pulmonary embolism. Various modalities that are used, including thrombolytics and embolectomy, have not been shown to conclusively improve mortality when compared to heparin. In the past, open pulmonary embolectomy was reserved for patients with severe hemodynamic instability because of its high mortality rate. Our objective was to analyze our experience with early embolectomy as an alternative for the treatment of major pulmonary embolism. METHODS: A retrospective review of charts of all patients undergoing pulmonary embolectomy at our institution over the last two years was performed. Patients were followed until their discharge from hospital. RESULTS: There were 13 patients (7 women and 6 men). Four had massive and 9 had submassive pulmonary embolism. There was one mortality. Postoperative echocardiography showed no evidence of pulmonary hypertension in 7. CONCLUSIONS: Open pulmonary embolectomy can be performed in patients with major pulmonary embolism with minimal mortality and morbidity. It may prevent the development of chronic thromboembolic pulmonary hypertension and should be a part of the algorithm in the treatment of major pulmonary embolism.     

Indication of pulmonary embolectomy for acute pulmonary embolism]

During the past 7 years, 15 patients with acute pulmonary embolism (APE) were treated at Kagawa Medical School and 10 patients were survived. Nine patients had an embolus in a right or left pulmonary trunk (group A) and 6 patients were peripheral APE (group B). In group A abnormal findings in a chest x-ray film and an electrocardiogram were observed in many patients, but in group B these findings were slight. In group A a shock was observed in 89% and cardiac arrest in 4 patients, although in group B neither shock nor death were observed. Marked hypoxia with hypocapnia was observed in 8 patients in group A and only in 2 in group B. All patients in group B were recovered by medical therapy. In group A, however, only 3 patients were recovered by medical therapy. Two patients in group A were performed pulmonary embolectomy (PER), but one of them, who had been in nonreversible shock, died. We conclude that the patient who had marked hypoxia (PO2 less than or equal to 50 mmHg) with hypocapnia (PCO2 less than or equal to 35 mmHg) early at an attack should be taken a pulmonary angiography, and when a large embolus is found out in the proximal pulmonary artery, the PER should be performed as soon as possible.     

Transvenous catheter pulmonary embolectomy

Acute cardiovascular collapse in the hospitalized patient is associated with a high mortality rate and remains a therapeutic dilemma. Survival could be improved in the subgroup of patients with massive pulmonary thromboembolism if prompt surgical intervention is undertaken. This report presents the cases of two patients with cardiovascular collapse who survived transvenous catheter pulmonary embolectomy (herein described in detail). This procedure can be performed in any hospital with angiographic facilities and personnel trained in the technique. In our opinion it is the procedure of choice in patients with refractory cardiovascular collapse from massive pulmonary thromboembolism.     

Pulmonary embolectomy for acute massive pulmonary thromboembolism

Acute pulmonary thromboembolism is a frequently lethal and acute-onset in-hospital complication after surgery. Absolute indications for surgical embolectomy are acute massive pulmonary embolism with deep shock, refractory circulatory collapse, and continuous hypoxemia. Although thrombolytic therapy is indicated for patients with pulmonary thromboembolism with right ventricular overload, it is contraindicated for patients after major surgery or with stroke due to the high risk of rebleeding. Therefore surgical embolectomy should be considered in those patients. Pulmonary embolectomy relieves the right ventricular overload, and immediate restoration of right ventricular function contributes to the recovery of hemodynamics. A recent study revealed improved outcome for massive pulmonary embolism with early diagnosis with multidetector-row computed tomography, risk stratification using echocardiography, and surgical embolectomy. Surgical pulmonary thromboembolectomy should be considered for critically ill patients with massive pulmonary thromboembolism.     

Catheter technique for pulmonary embolectomy or thrombofragmentation

The management of acute massive pulmonary embolism (PE) constitutes a major clinical problem because of the associated derangement of hemodynamic and respiratory functions from obstruction to pulmonary blood flow. Despite advances in management with thrombolytic therapy or open embolectomy, the mortality rate remains high. To improve the chance of survival, catheter techniques that are capable of removing or fragmenting the clot have been developed. These include catheter pulmonary embolectomy and thrombofragmentation. The former involves the introduction of a suction catheter from a femoral or jugular venotomy through the right heart into the appropriate pulmonary artery under fluoroscopic guidance. The technique for the latter involves the percutaneous introduction of a fragmentation catheter from a femoral vein through a guiding catheter into the appropriate pulmonary artery. The success of the catheter technique in removing pulmonary emboli varies with different devices. The overall success rate is approximately 76%, with a mortality rate of 25%. Transvenous pulmonary embolectomy and thrombofragmentation are safe and effective techniques for treating patients with massive PE. The success of each of the techniques depends on a thorough understanding of the mechanism of action of each of the devices used and a facile catheterization technique.     

Off-pump open pulmonary embolectomy for patients with major pulmonary embolism

Acute major pulmonary artery embolism (AMPE) requires rapid diagnosis and early intensive treatment to optimize patient outcomes. Most patients with AMPE and hemodynamic instability need open pulmonary embolectomy (OPE). We modified the technique of OPE to include a minimally invasive procedure without the use of cardiopulmonary bypass (CPB). From March 1988 to April 2006, we performed OPE on a total of 12 patients (21 sides) with AMPE. Seven patients (13 sides) underwent conventional OPE with CPB and 5 patients underwent off-pump OPE (OPPE), 4 (8 sides) with AMPE and 1 with catheter embolus with thrombosis. In patients who underwent conventional OPE, there was 1 hospital death in a patient with severe right ventricle dysfunction and 2 significant cases of airway bleeding. In patients who underwent OPPE, there was 1 case of minimal airway bleeding. Mean systolic pulmonary artery pressure in conventional OPE and OPPE patients, respectively, decreased from 50.3 +/- 14 mmHg and 35.4 +/- 6.6 mmHg pre-operatively to 41.7 +/- 20 and 28 +/- 3 mmHg postoperatively. During the long-term follow-up, there were 2 cancer-related deaths but no recurrence of PE. All surviving patients maintained functional class I (n = 10) or II (n = 1). Compared with conventional OPE, OPPE was effective for treating AMPE in our selected cases. Modification of conventional CPB and systemic full heparinization to minimal use of systemic heparinization without CPB may be helpful in treating selected patients with AMPE.     

Emergent pulmonary embolectomy: the treatment for massive pulmonary embolus

Massive pulmonary embolus usually leads to in-hospital mortality if not treated aggressively. Four patients were seen with severe cardiorespiratory compromise resulting from massive pulmonary emboli. Emergent pulmonary embolectomy was followed by marked clinical improvement, and 3 patients were subsequently discharged from the hospital. The clinical courses of these patients are described, and massive pulmonary embolus and its management are discussed.     

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.     

Fatal intra-alveolar pulmonary bleeding complicating pulmonary embolectomy

Two patients are reported in whom fatal alveolar pulmonary haemorrhage occurred after pulmonary embolectomy. Possible causes and methods of prevention are discussed.     

Retrograde pulmonary embolectomy in massive pulmonary embolism

The purpose of this study was introduction and evaluation of efficacy and safety of retrograde thromboembolectomy in acute massive pulmonary emboli. The method is described in a 56-year-old woman with acute massive pulmonary thromboemboli. Postoperative course was uneventful. The described surgical technique is not a panacea and definitely not the whole answer, but is a big part of the solution and may be accompanied with less adverse effects. Additionally, there is a need of being reviewed further in large experimental studies and measurements before it could be used safely as a new technique.     

Minimally invasive off-pump pulmonary embolectomy

We report the case of a 35-year-old female with acute massive right pulmonary embolism, successfully treated by a minimally invasive off-pump pulmonary embolectomy-the first case in the literature implemented via the J-ministernotomy.