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

Abstract

<jats:p> 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. </jats:p>

Lessons learned on a new procedure: Non-Sternotomy Minimally Invasive Pulmonary Embolectomy

“…3 Most clinical guidelines only recommend surgical embolectomy for massive PE and only when thrombolysis has failed, is contraindicated, or for patients presenting in extremis with cardiopulmonary collapse. 1,4 Emerging data from our institution and others support the extended utility of surgical embolectomy for treatment of massive PE. As we previously wrote, recent reports highlighting improved surgical techniques have shown that surgical pulmonary embolectomy yields similar 30-day and 5-year mortality rates compared to thrombolytic therapy.…”

“…In summary, we have detailed several augmentations to our original description of the MIPE. 1 We believe the operation and results are reproducible and can be a valuable tool in the armamentarium of the cardiothoracic surgeon.…”

“…Our surgical approach was as previously described. 1 We positioned the patient supine with a bump underneath the left shoulder blade to elevate the left hemithorax and extend the neck. Double lumen endotracheal intubation was used to achieve left lung isolation and a transesophageal echocardiography (TEE) probe was placed.…”

“…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 3 rd 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.…”

Lessons learned on a new procedure: Nonsternotomy minimally invasive pulmonary embolectomy

“…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 5‐cm 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 5 mm, 30° laparoscope as an adjunct to assess clearance of the pulmonary artery 2 .…”