Ann Phlebology 2022; 20(1): 15-18
Published online June 30, 2022
https://doi.org/10.37923/phle.2022.20.1.15
© Annals of phlebology
Correspondence to : Tae Sik Kim, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea, Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital
Tel: 02-2626-1180, Fax: 02-2626-1188
E-mail: kmdphd@gmail.com
Treatment for acute pulmonary embolism includes anticoagulation, thrombolysis, catheter-directed therapy, and surgical pulmonary embolectomy. Surgical embolectomy is indicated in select patients based on a risk/benefit assessment and when other treatment options are contraindicated. A multidisciplinary approach along with a meticulous surgical technique might significantly lower the mortality associated with surgical embolectomy.
Keywords Acute, Deep vein thrombosis, Pulmonary embolectomy, Surgery, Thromboembolism
The Society of Interventional Radiology defines acute proximal pulmonary embolism (PE) as a new main or lobar embolism identified on radiographic imaging within 14 days of PE symptoms (
According to data published in the International Coo-perative Pulmonary Embolism Registry, 17.4% of patients suffering from acute PE died within 90 days. This registry included 2452 patients from 52 centers in 7 countries (
Treatment options for pulmonary embolism include oral anticoagulation, systemic thrombolysis, catheter-directed the-rapy (CDT), and surgical pulmonary embolectomy with or without extra-corporeal life support. In a recent study that included 58974 patients with acute PE, 33553 patients were treated with systemic thrombolysis, 22336 with CDT, and 3085 with surgical embolectomy from 2010 to 2014 (
Several reports have indicated favorable surgical out-comes in high-risk (massive) PE and/or intermediate-risk (sub-massive) PE (
The indications for surgical embolectomy in patients with massive PE might include contraindications to thrombolysis, right ventricle (RV) dysfunction, failed medical treatment, and large intracardiac thrombi (
In a single-center, 25 patients (17 men, mean age 60 years) underwent emergency open embolectomy for acute PE (
Other investigators also considered hemodynamically stable patients with massive PE and moderate-to-severe RV dysfunction for surgical embolectomy (
In critically ill PE patients, veno-arterial extracorporeal membrane oxygenation (VA ECMO) could be applied for life-saving support. Indeed, ECMO is commonly utilized as an important strategy before surgical embolectomy (
Surgical embolectomy in acute PE is performed through a median sternotomy with mild hypothermic cardiopulmo-nary bypass using bicaval cannulation, followed by an incision of the pulmonary artery (
The main pulmonary artery is opened with a longitudinal incision, which is extended into the right or left pulmonary artery branches, if necessary. All branches are inspected, and then the thrombotic material is extracted using forceps and assisting suction. Furthermore, the right atrium and ventricle are explored, and the clot is carefully removed (
The clot is extracted using suction catheters, forceps, and/or Fogarty balloon catheters. Fogarty catheter extraction of peripheral clots must be done carefully to avoid injuring the thin-walled pulmonary artery branches (
For complete clot removal, bilateral lung manual compressions or massage can be performed (
The distal segmental pulmonary arteries might be more carefully visualized through a flexible videoscope (
An analysis of peer-reviewed literature suggested that the mortality rates in patients treated with surgical embolectomy have decreased substantially over time (
The large-cohort analysis of more than 2700 adult patients undergoing surgical embolectomy for acute PE from 1999 to 2008 demonstrated a nationwide inpatient mortality rate of 27.2% (
In comparison with the medical treatment of massive PE, surgical embolectomy was found to have lower mortality rates, a lower number of hemorrhagic events, and recurrent thrombosis (
Significantly higher mortality rates among patients with massive PE were observed in patients who underwent cardiopulmonary resuscitation (CPR) (
RV dysfunction alone has been implicated as an early and late independent risk factor for RV failure and mortality in numerous studies, and recovery of its function has been identified as an early predictor of a favorable in-hospital course (
Additionally, age greater than 60 years, presence of atrial fibrillation, congestive heart failure, and non-saddle PE were associated with an increase in in-hospital mortality among patients who underwent surgical embolectomy (
Early surgical intervention might be an important prog-nostic factor. Ahmed et al. suggested that patients who have undergone a surgical intervention in the first 24 hour of the event experienced a 40% relative reduction in mortality rates (
The indications for surgical embolectomy in patients with massive PE might include contraindications to thrombolysis, right ventricle (RV) dysfunction, failed medical treatment, and large intracardiac thrombi (
In a single-center, 25 patients (17 men, mean age 60 years) underwent emergency open embolectomy for acute PE (
Other investigators also considered hemodynamically stable patients with massive PE and moderate-to-severe RV dysfunction for surgical embolectomy (
In critically ill PE patients, veno-arterial extracorporeal membrane oxygenation (VA ECMO) could be applied for life-saving support. Indeed, ECMO is commonly utilized as an important strategy before surgical embolectomy (
The author declares no potential conflict of interest.
Ann Phlebology 2022; 20(1): 15-18
Published online June 30, 2022 https://doi.org/10.37923/phle.2022.20.1.15
Copyright © Annals of phlebology.
Tae Sik Kim, M.D., Ph.D.
Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Seoul, Korea
Correspondence to:Tae Sik Kim, 148 Gurodong-ro, Guro-gu, Seoul 08308, Korea, Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital
Tel: 02-2626-1180, Fax: 02-2626-1188
E-mail: kmdphd@gmail.com
Treatment for acute pulmonary embolism includes anticoagulation, thrombolysis, catheter-directed therapy, and surgical pulmonary embolectomy. Surgical embolectomy is indicated in select patients based on a risk/benefit assessment and when other treatment options are contraindicated. A multidisciplinary approach along with a meticulous surgical technique might significantly lower the mortality associated with surgical embolectomy.
Keywords: Acute, Deep vein thrombosis, Pulmonary embolectomy, Surgery, Thromboembolism
The Society of Interventional Radiology defines acute proximal pulmonary embolism (PE) as a new main or lobar embolism identified on radiographic imaging within 14 days of PE symptoms (
According to data published in the International Coo-perative Pulmonary Embolism Registry, 17.4% of patients suffering from acute PE died within 90 days. This registry included 2452 patients from 52 centers in 7 countries (
Treatment options for pulmonary embolism include oral anticoagulation, systemic thrombolysis, catheter-directed the-rapy (CDT), and surgical pulmonary embolectomy with or without extra-corporeal life support. In a recent study that included 58974 patients with acute PE, 33553 patients were treated with systemic thrombolysis, 22336 with CDT, and 3085 with surgical embolectomy from 2010 to 2014 (
Several reports have indicated favorable surgical out-comes in high-risk (massive) PE and/or intermediate-risk (sub-massive) PE (
The indications for surgical embolectomy in patients with massive PE might include contraindications to thrombolysis, right ventricle (RV) dysfunction, failed medical treatment, and large intracardiac thrombi (
In a single-center, 25 patients (17 men, mean age 60 years) underwent emergency open embolectomy for acute PE (
Other investigators also considered hemodynamically stable patients with massive PE and moderate-to-severe RV dysfunction for surgical embolectomy (
In critically ill PE patients, veno-arterial extracorporeal membrane oxygenation (VA ECMO) could be applied for life-saving support. Indeed, ECMO is commonly utilized as an important strategy before surgical embolectomy (
Surgical embolectomy in acute PE is performed through a median sternotomy with mild hypothermic cardiopulmo-nary bypass using bicaval cannulation, followed by an incision of the pulmonary artery (
The main pulmonary artery is opened with a longitudinal incision, which is extended into the right or left pulmonary artery branches, if necessary. All branches are inspected, and then the thrombotic material is extracted using forceps and assisting suction. Furthermore, the right atrium and ventricle are explored, and the clot is carefully removed (
The clot is extracted using suction catheters, forceps, and/or Fogarty balloon catheters. Fogarty catheter extraction of peripheral clots must be done carefully to avoid injuring the thin-walled pulmonary artery branches (
For complete clot removal, bilateral lung manual compressions or massage can be performed (
The distal segmental pulmonary arteries might be more carefully visualized through a flexible videoscope (
An analysis of peer-reviewed literature suggested that the mortality rates in patients treated with surgical embolectomy have decreased substantially over time (
The large-cohort analysis of more than 2700 adult patients undergoing surgical embolectomy for acute PE from 1999 to 2008 demonstrated a nationwide inpatient mortality rate of 27.2% (
In comparison with the medical treatment of massive PE, surgical embolectomy was found to have lower mortality rates, a lower number of hemorrhagic events, and recurrent thrombosis (
Significantly higher mortality rates among patients with massive PE were observed in patients who underwent cardiopulmonary resuscitation (CPR) (
RV dysfunction alone has been implicated as an early and late independent risk factor for RV failure and mortality in numerous studies, and recovery of its function has been identified as an early predictor of a favorable in-hospital course (
Additionally, age greater than 60 years, presence of atrial fibrillation, congestive heart failure, and non-saddle PE were associated with an increase in in-hospital mortality among patients who underwent surgical embolectomy (
Early surgical intervention might be an important prog-nostic factor. Ahmed et al. suggested that patients who have undergone a surgical intervention in the first 24 hour of the event experienced a 40% relative reduction in mortality rates (
The indications for surgical embolectomy in patients with massive PE might include contraindications to thrombolysis, right ventricle (RV) dysfunction, failed medical treatment, and large intracardiac thrombi (
In a single-center, 25 patients (17 men, mean age 60 years) underwent emergency open embolectomy for acute PE (
Other investigators also considered hemodynamically stable patients with massive PE and moderate-to-severe RV dysfunction for surgical embolectomy (
In critically ill PE patients, veno-arterial extracorporeal membrane oxygenation (VA ECMO) could be applied for life-saving support. Indeed, ECMO is commonly utilized as an important strategy before surgical embolectomy (
The author declares no potential conflict of interest.
Mi Jin Kim, M.D.
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