Expedient pulmonary embolectomy for acute pulmonary embolism: improved outcomes

Abstract

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.

Pulmonary Embolectomy in the Treatment of Submassive and Massive Pulmonary Embolism

“…who are hemodynamically stable but show signs of right ventricular dysfunction on echocardiography or CT) have documented mortality rates of 6-8% [1,4]. However, several other case series demonstrate much higher mortality rates, with the majority of deaths occurring in patients who require preoperative cardiopulmonary resuscitation [5,13] as well as in those undergoing delayed pulmonary embolectomy [6] or prior failed thrombolysis [3]. In our series, all patients undergoing echocardiography had findings of right ventricular failure, indicating a high risk for subsequent deterioration.…”

“…Strategies include thrombolysis, catheter embolectomy and surgical pulmonary embolectomy. In recent years as the outcomes for surgical embolectomy have improved, the range of indications has broadened, and some groups now consider it the treatment of choice for submassive PE [1,4,5,6]. We reviewed our experience with pulmonary embolectomy over the past 12 years, with an emphasis on presenting characteristics, indications for surgery, operative findings and outcomes.…”

Aggressive Approach to Pulmonary Embolectomy for Massive Acute Pulmonary Embolism: A Historical and Contemporary Perspective

“…tricular dysfunction. [35][36][37][38][39] Treatment of most patients with PE will remain systemic anticoagulation and IVC filters, used either alone or in combination with thrombolytic or rheolytic therapy. Treatment of severely compromised patients with the current multidisciplinary approach, including early emergent pulmonary embolectomy as proposed by the Mayo Clinic investigators, shows great promise in improving patient survival.…”

Tough decisions in pulmonary embolism: thrombolysis or embolectomy?

“…Interestingly, the ESC guidelines state that surgical embolectomy should normally be reserved for high-risk PE and for selected patients with intermediate- to high-risk PE when haemodynamic instability is imminent or if thrombolysis is contraindicated or has failed [1]. However, with improving outcomes following surgical embolectomy, clinicians are increasingly considering early surgical intervention [10–13]. This case raises a number of important questions.…”

“…With regard to thrombolysis in high-risk PE, a careful and timely risk–benefit analysis is vital in determining whether an absolute contraindication, such as recent surgery, is likely to cause mortality or significant morbidity when proceeding with thrombolytic treatment. In terms of surgical embolectomy, while studies have found this to be an effective treatment for submassive PE [10, 12, 13], literature comparing thrombolysis and embolectomy in this subgroup of patients is lacking and randomized control trials are needed to compare these interventions. In addition, there may be an important role for early echocardiography in detecting RV dysfunction in order to best guide PE treatment.…”