The endpoint in emergent management of acute massive pulmonary embolism (PE) has traditionally been with embolectomy through a standard median sternotomy. This approach is limited in both exposure and concomitant functional morbidity associated with sternotomy. In a previous publication, we described a novel minimally invasive, thoracoscopically assisted approach to pulmonary embolectomy. This approach utilized a small 5‐cm left upper parasternal thoracotomy and femoral cardiopulmonary bypass to conduct thoracoscopically assisted surgical pulmonary embolectomy. The first publication featured three patients that had a massive pulmonary embolus that was treated with minimally invasive pulmonary embolectomy, and the initial data was positive and suggested that this approach is safe and feasible. We now broaden our experience with another two patients who underwent this approach, and highlight a number of technical and management modifications that have been made to optimize the procedure. These lessons learned will ideally benefit future surgeons as this approach is more heavily implemented in practice.
Since publication of our initial experience with non-sternotomy minimally invasive pulmonary embolectomy (MIPE) via a left mini thoracotomy, we have expanded our experience, refined the operation and streamlined the post-operative management of patients. Our initial publication described three patients who underwent MIPE.1 We described our technique which included peripheral cardiopulmonary bypass (CPB) via femoral arterial and venous cannulation, left sided 5cm anterior thoracotomy in the 3rd intercostal space, identification and incision of the main pulmonary artery distal to the pulmonic valve, extraction of clot with subsequent primary closure of the pulmonary artery, and use of a 5mm, 30 degree laparoscope as an adjunct to assess clearance of the pulmonary artery.2 The patients included in this series had no post-operative complications, had a mean hospital length of stay of three days with mid-term follow-up up to 8-months revealing no untoward complications of the procedure. With early success of the MIPE at our institution, we began employing it preferentially over sternotomy with central CPB and pulmonary embolectomy. Since initial publication of our results, we have performed the MIPE in two additional patients with excellent outcomes. We herein present augmentations we've made to the procedure with a case-presentation which highlights these adaptations.
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