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

Abstract

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.

Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association

“…Anoxic brain injury from preoperative cardiac arrest or exacerbation of underlying illness such as coronary artery disease, cancer, or infection more frequently causes mortality. 10,18,35–38…”

“…10,11,33,34 A pulmonary arteriotomy is performed through which the clot is extracted. Surgeons have described a variety of techniques, including a single incision in the main PA or 2 incisions, 1 in the main PA extending toward the left PA and a second incision in the right main PA. 10,11,[33][34][35] The 2-incision approach facilitates visualization of both left and right PAs and their major branches, allowing optimal distal clot extraction, whereas the single-incision approach does not provide right PA visualization, which may lead to suboptimal clot extraction. Clot extraction has been augmented by a variety of procedures, including suction, perfusion of blood retrograde through the pulmonary veins with the intention of flushing out the clot from distal branches, manual manipulation of the lung to massage out the clot from distal branches, or the use of balloon-tipped embolectomy catheters to extract the clot from distal branches.…”

“…35 Although none of these studies specifically analyzed the effect of failed thrombolysis on postoperative outcomes, the authors describe postoperative bleeding complications among those with failed ST as a key contributor to postoperative morbidity and mortality. 17,35,37,38 More recent series report SE performed after failed catheter-directed therapies, but existing data are insufficient to make evidence-based conclusions on the impact on postsurgical outcomes. Because current data indicate that failure of ST is a marker of increased postoperative morbidity and mortality, future research is needed to prospectively identify patients who are likely to fail ST or to identify patients who should be referred to SE earlier to optimize outcomes.…”

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

“…29,30,31 A single-center study in China reported excellent results with an overall mortality 7.31%, with all three mortal-ities occurring in the massive PE group. 32 CPB has become synonymous with open heart procedures, and results continue to show that preoperative hemodynamic support may improve results of surgical pulmonary embolectomy, especially high-risk patients experiencing cardiac arrest. 33,34 John Gibbon would be proud to see how far we have come in the treatment of PEs; results continue to show that surgery could be offered as a safe and effective primary approach in both submassive and massive PE patients.…”

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism - from Modern Recommendations to Clinical Application

“…Stein et al reported that the mortality of pulmonary embolectomy for acute PE was 20% in a meta-analysis of 1,300 cases [76]. Case series have also been published that have shown variable results with perioperative mortality ranging from 2.3% to 27.2% [77].…”