Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients

Neely, Robert C.; Byrne, John G.; Gošev, Igor; Cohn, Lawrence H.; Javed, Quratulain; Rawn, James D.; Goldhaber, Samuel Z.; Piazza, Gregory; Aranki, Sary F.; Shekar, Prem; Leacche, Marzia

doi:10.1016/j.athoracsur.2015.03.111

Cited by 122 publications

(92 citation statements)

References 26 publications

(37 reference statements)

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“…The largest case series of surgical embolectomy by neely et al 16 shows that outcomes for surgical pulmonary embolectomy have continued to improve. In a series of 115 patients undergoing surgical pulmonary embolectomy, the authors report an overall mortality rate of 6.6%.…”

Section: Surgical Pulmonary Embolectomy In Submassive Pementioning

confidence: 99%

Surgical Pulmonary Embolectomy

et al. 2015

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A 66-year-old man with a recent prosthetic knee infection, status postprosthesis removal, was admitted with recurrent septic arthritis. On his seventh hospital day, as he was signing his discharge paperwork, he developed acute respiratory distress. On physical examination, he was tachycardic to 118 beats/min, relatively hypotensive from 144/78 mm Hg earlier in the day to 94/54 mm Hg, and hypoxemic, with an oxygen saturation of 94% on a 100% nonrebreather facemask. The ECG showed sinus tachycardia. An urgent contrast-enhanced chest computed tomogram (CT) demonstrated large saddle pulmonary embolism (PE) and severe right ventricular (RV) enlargement, with an RV diameterto-left ventricular (LV) diameter ratio of 1.8 (Figure 1). The patient was administered a bolus of intravenous unfractionated heparin followed by a continuous infusion. An urgent bedside transthoracic echocardiogram showed severe RV dilation, moderateto-severe pulmonary hypertension, and RV pressure overload as suggested by systolic deviation of the interventricular septum toward the LV (Figure 2). The Vascular Medicine and Cardiac Surgery services were consulted for consideration of advanced therapies. Because of concern for major bleeding associated with fibrinolytic therapy in the setting of recent major surgery, surgical pulmonary embolectomy was recommended. IntroductionDespite advances in diagnostics and therapeutics, acute PE remains a life-threatening condition with an in-hospital mortality rate of ≈7% for all-comers and 31% for patients with hemodynamically unstable (massive) PE.1 Current management algorithms emphasize risk stratification to identify patients who may benefit from early advanced therapies in addition to anticoagulation.2-4 Risk categories of massive, submassive, and low-risk PE are based on clinical, radiological, and laboratory criteria. Massive PE is characterized by systemic arterial hypotension, syncope, cardiogenic shock, cardiac arrest, or respiratory failure. Submassive PE is defined by evidence of RV dysfunction on imaging (RV/LV diameter >0.9 on contrastenhanced chest CT or RV dilation and hypokinesis on echocardiography), elevated cardiac biomarkers (such as cardiac troponin), or both, in a patient with preserved systemic arterial pressure. Submassive PE comprises a patient population at increased risk of adverse outcomes and early mortality. Low-risk PE patients have none of these features and typically have an uneventful clinical course when treated with therapeutic anticoagulation alone.Advanced therapies are often considered for patients with submassive or massive PE to rapidly relieve RV pressure overload and avert hemodynamic deterioration. Advanced therapies for reperfusion include systemic fibrinolysis, catheter-based pharmacomechanical intervention, and surgical pulmonary embolectomy. A recent meta-analysis showed a 1.7% absolute mortality

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Section: Surgical Pulmonary Embolectomy In Submassive Pementioning

confidence: 99%

Surgical Pulmonary Embolectomy

et al. 2015

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“…Takahashi and colleagues reported a mortality rate of 12.5% (3 of 25 patients), including 16 cases with preoperative PCPS use. 17) In other studies, a mortality rate of 8% (2 of 25) was reported by Kadner et al 18) and a mortality rate of 6.6% (7 of 105) for patients with massive PE and submassive PE was reported by Neely et al 19) One risk factor for postoperative death following pulmonary embolectomy is preoperative cardiac arrest. Accurate diagnosis is important, and surgical indications should be decided based on the severity of PE.…”

Section: Discussionmentioning

confidence: 98%

Management of Pulmonary Thromboembolism Based on Severity and Vulnerability to Thrombolysis

et al. 2016

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“…The European Society of Cardiology recommends therapies that restore perfusion, such as CDI, thrombolysis, or surgical thromboembolectomy, for treatment of massive PE, and anticoagulation therapy for low risk and submassive PE (21). Surgical thromboembolectomy, recommended by AHA in the setting of massive PE and contraindication to fibrinolytics, is the most invasive therapy, carrying a mortality rate approaching 20% compared to 50% in the untreated population (4,17).…”

Section: Managementmentioning

confidence: 99%

“…The Food and Drug Administration (FDA)-approved treatments for PE include oral anticoagulants, systemic thrombolysis, aspiration thrombectomy using a Greenfield suction embolectomy catheter, and ultrasound-accelerated catheterdirected thrombolysis (3). Surgical thrombectomy can be performed for certain patients without significant comorbidities (4). Due to lack of universal surgical expertise and comorbidities commonly precluding surgery, surgical intervention is not ubiquitous.…”

Section: Introductionmentioning

confidence: 99%

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Catheter-directed interventions for pulmonary embolism

Zarghouni

Charles

Maldonado

et al. 2016

Cardiovasc. Diagn. Ther.

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Pulmonary embolism (PE), a potentially life-threatening entity, can be treated medically, surgically, and percutaneously. In patients with right ventricular dysfunction (RVD), anticoagulation alone may be insufficient to restore cardiac function. Because of the morbidity and mortality associated with surgical embolectomy, clinical interest in catheter-directed interventions (CDI) has resurged. We describe specific catheter-directed techniques and the evidence supporting percutaneous treatments.

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Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients

Cited by 122 publications

References 26 publications

Surgical Pulmonary Embolectomy

Surgical Pulmonary Embolectomy

Management of Pulmonary Thromboembolism Based on Severity and Vulnerability to Thrombolysis

Catheter-directed interventions for pulmonary embolism

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