Surgical Pulmonary Embolectomy.

Surgical pulmonary embolectomy has a storied history in the domain of cardiothoracic surgery. This article provides insight on the history, current data, and future directions of surgical pulmonary embolectomy.

Impact of Multidisciplinary Pulmonary Embolism Response Team Availability on Management and Outcomes.

Treatment strategies for complex patients with pulmonary embolism (PE) are often debated given patient heterogeneity, multitude of available treatment modalities, and lack of consensus guidelines. Although multidisciplinary Pulmonary Embolism Response Teams (PERT) are emerging to address this lack of consensus, their impact on patient outcomes is not entirely clear. This analysis was conducted to compare outcomes of all patients with PE before and after PERT availability. We analyzed all adult patients admitted with acute PE diagnosed on computed tomography scans in the 18 months before and after the institution of PERT at a large tertiary care hospital. Among 769 consecutive inpatients with PE, PERT era patients had lower rates of major or clinically relevant nonmajor bleeding (17.0% vs 8.3%, p = 0.002), shorter time-to-therapeutic anticoagulation (16.3 hour vs 12.6 hour, p = 0.009) and decreased use of inferior vena cava filters (22.2% vs 16.4%, p = 0.004). There was an increase in the use of thrombolytics/catheter-based strategies, however, this did not achieve statistical significance (p = 0.07). There was a significant decrease in 30-day/inpatient mortality (8.5% vs 4.7%, p = 0.03). These differences in outcomes were more pronounced in intermediate and high-risk patients (mortality 10.0% vs 5.3%, p = 0.02). The availability of multidisciplinary PERT was associated with improved outcomes including 30-day mortality. Patients with higher severity of PE seemed to derive most benefit from PERT availability.

Triage and optimization: A new paradigm in the treatment of massive pulmonary embolism.

BACKGROUND: Massive pulmonary embolism (PE) remains a highly fatal condition. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) and surgical pulmonary embolectomy in the management of massive PE have been reported previously, the outcomes remain less than ideal. We hypothesized that the institution of a protocolized approach of triage and optimization using VA-ECMO would result in improved outcomes compared with historical surgical management. METHODS: All patients with a massive PE referred to the cardiac surgery service between 2010 and 2017 were retrospectively reviewed. Patients were stratified by treatment strategy: historical control versus the protocolized approach. In the historical control group, the primary intervention was surgical pulmonary embolectomy. In the protocol approach group, patients were treated based on an algorithmic approach using VA-ECMO. The primary outcome was 1-year survival. RESULTS: A total of 56 patients (control, n = 27; protocol, n = 29) were identified. All 27 patients in the historical control group underwent surgical pulmonary embolectomy, whereas 2 of 29 patients in the protocol approach group were deemed appropriate for direct surgical pulmonary embolectomy. The remaining 27 patients were placed on VA-ECMO. In the protocol approach group, 15 of 29 patients were treated with anticoagulation alone and 14 patients ultimately required surgical pulmonary embolectomy. One-year survival was significantly lower in the historical control group compared with the protocol approach group (73% vs 96%; P = .02), with no deaths occurring after surgical pulmonary embolectomy in the protocol approach group. CONCLUSIONS: A protocolized strategy involving the aggressive institution of VA-ECMO appears to be an effective method to triage and optimize patients with massive PE to recovery or intervention. Implementation of this strategy rather than an aggressive surgical approach may reduce the mortality associated with massive PE.

Outcomes After Surgical Pulmonary Embolectomy for Acute Pulmonary Embolus: A Multi-Institutional Study.

BACKGROUND: Surgical pulmonary embolectomy (SPE) has been sparingly used for the successful treatment of massive and submassive pulmonary emboli. To date, all data regarding SPE have been limited to single-center experiences. The purpose of this study was to document short-term outcomes after SPE for acute pulmonary emboli (PE) at four high-volume institutions. METHODS: A retrospective review of multiple local Society of Thoracic Surgeons databases of adults undergoing SPE from 1998 to 2014 for acute PE was performed (n = 214). Demographic, operative, and outcomes data were collected and analyzed. Patients were summarily categorized as having either massive or submassive PEs based on the presence or absence of preoperative vasopressors. RESULTS: A total of 214 patients with acute PE were treated by SPE. The mean age was 56.0 ± 14.5 years, and 92 (43.6%) patients were female. Of those, 176 (82.2%) PEs were submassive and 38 (17.8%) were massive. Fifteen (7.0%) patients underwent concomitant cardiac procedures, with 10 (4.7%) having simultaneous valvular interventions and 5 (2.4%) undergoing concomitant bypass grafting. Cardiopulmonary bypass (CPB) was used for all cases. Cardioplegic arrest was used for 80 (37.4%) patients. The median CPB and aortic cross clamp times were 71.5 (interquartile range [IQR], 47.0-109.5) and 46.0 (IQR, 26.0-74.5), respectively. Notably, only 25 (11.7%) patients died in the hospital. Mortality was highest among the 28 patients who experienced preoperative cardiac arrest (9, 32.1%) CONCLUSIONS: These data represent the first multicenter experience with SPE for acute pulmonary emboli. Surgical pulmonary embolectomy for acute massive and submassive PE is safe and can be performed with acceptable in-hospital outcomes; the procedure should be included in the multimodality treatment of life-threatening pulmonary emboli.

Direct Microsurgical Embolectomy for Acute Occlusion of the Internal Carotid Artery and Middle Cerebral Artery.

BACKGROUND: Surgical embolectomy is the most promising therapy for physically removing emboli from major cerebral arteries. However, it requires an experienced surgical team, time-consuming steps, and is not incorporated into acute stroke therapy. METHODS: We established seamless collaboration between services, refined surgical techniques, and conducted a prospective trial of emergency surgical embolectomy. Surgical indications included the presence of acute hemispheric symptoms, absence of low-density area on computed tomography, evidence of internal carotid artery terminus or proximal middle cerebral artery occlusion, and availability of resources to start surgery within 3 hours of symptom onset. The indications were confirmed by an interdisciplinary team. We assessed revascularization rates, time from admission to surgery and from surgery to recanalization, procedural complications, and clinical outcomes. RESULTS: Between 2005 and 2014, 14 consecutive patients with acute proximal middle cerebral artery or internal carotid artery terminus occlusion underwent emergency surgical embolectomy. All patients showed complete recanalization. Twelve patients survived and 7 had fair functional outcome (Rankin Scale score, ≤3). No significant procedural adverse events occurred. The mean times from admission to start of surgery, from surgery to recanalization, and from onset to recanalization were 14 minutes, 79 minutes, and 223 minutes, respectively. CONCLUSIONS: Our results suggest that microsurgical embolectomy can rapidly, safely, and effectively retrieve clots and deserves reappraisal, although the choice largely depends on local institutional expertise.

Regional availability of mechanical embolectomy for acute ischemic stroke in California, 2009 to 2010.

BACKGROUND AND PURPOSE: We sought to assess the geographic proximity of patients with stroke in California to centers that performed specific threshold volumes of mechanical embolectomy procedures each year. METHODS: We identified all patients who were hospitalized for acute ischemic stroke at all nonfederal acute care hospitals in California from 2009 to 2010, and all hospitals that performed any mechanical embolectomy procedures by case volume during the same period, using nonpublic data from the Office of Statewide Health Planning and Development. We computed geographic service areas around each hospital on the basis of prespecified ground transport distance thresholds. We then calculated the proportion of hospitalized patients with stroke who lived within service areas for centers that performed a low volume and high volume of mechanical embolectomy procedures each year. RESULTS: During the 2-year study period, 15% (53/360) of hospitals performed at least 1 mechanical embolectomy for acute stroke, but only 19% (10/53) performed >10 cases per year. Most hospitalized patients with stroke (94%) lived within a 2-hour transport time (65 miles) to a hospital that performed ≥1 procedure during the 2-year period. Approximately 93% of the patients with stroke who received mechanical embolectomy lived within 20 miles from an embolectomy-capable hospital compared with 7% of those who lived >20 miles. CONCLUSIONS: In California, most patients with stroke lived within reasonable ground transport distances from centers that performed ≥1 mechanical embolectomy in a 2-year period. The probability of receiving mechanical embolectomy for acute ischemic stroke was associated with living in close geographic proximity to these hospitals.

Analysis of risk factors for amputation in 822 cases with acute arterial emboli.

BACKGROUND: We retrospectively examined the records of 822 patients who underwent a total of 901 operations for acute peripheral arterial occlusion of the upper or lower extremities between 1999 and 2009. We analyzed the effects of atherosclerotic structure, the time of admission to hospital, and re-embolectomies on amputation in the early postoperative period. METHODS: There were 466 (56.7%) men and 356 (43.3%) women. The time of admission to hospital was in the range of 58 hours. There were lower extremity emboli in 683 (83%). Bypass procedures were done in 27 (3.3%) patients. Fasciotomy, patchplasty, and endarterectomy were made in 19 (2.3%), 9 (1.1%), and 7 (0.8%) patients, respectively. RESULTS: Early revision (re-embolectomy) was performed in 77 (9.3%) patients. Amputation was performed in 112 (13.6%) patients. Delay after six hours from the onset of complaints and re-embolectomies increased the risk of amputation and rates. CONCLUSION: If the embolectomy, which is a rapid and easy technique for treatment of acute arterial emboli, is performed by experienced surgeons without delay, the complications associated with the emboli may be prevented. Otherwise, delayed operation and repeated re-embolizations in acute arterial play important roles in morbidity.

Upper-limb thrombo-embolectomy: national cohort study in Denmark.

OBJECTIVES: We investigated the incidence of thrombo-embolectomy in upper-limb and prognosis with respect to arm amputation, stroke and death. METHODS: We performed a national cohort study of individuals, aged 40-99 years, and undergoing first-time thrombo-embolectomy in the brachial, ulnar or radial artery in Denmark from 1990 to 2002. The data were retrieved from the National Vascular Registry and from the National Registry of Patients and the Civil Registration System. Patients were followed until 2006 to ascertain the occurrence of amputation and stroke and until 2007 with respect to death. RESULTS: In total, 1377 incident cases of thrombo-embolectomy were registered, comprising 504 (36.6%) males with a mean age of 72.0 (standard deviation (SD) 12.4) years and 873 (63.4%) females with a mean age of 77.2 (SD 11.7) years. Incidence was 3.3 (95% confidence interval (CI): 3.1-3.7) for males and 5.2 (95% CI: 4.9-5.6) for females per 100000 person-years. After thrombo-embolectomy, upper-limb amputation was performed in 11 (incidence 2.2%; 95% CI: 1.2-3.4) males and 31 (3.6%; 95% CI: 2.5-4.9) females. Age- and sex-specific risk of stroke was 2-16 times higher, and risk of death 3-11 times higher, than in the general population. CONCLUSIONS: Upper-limb thrombo-embolectomy is associated with an increased risk of limb amputation, stroke and death.

Acute pulmonary embolism registry in the Malopolska region - clinical course.

BACKGROUND: Acute pulmonary embolism (APE) is a life-threatening disease. Mortality in APE still remains very high in spite of progress in diagnostic tools. Mortality rate is about 30% in patients with unrecognised APE. APE is one of the main causes of in-hospital mortality. AIM: To asses management of patients with APE in the Malopolska region. METHODS: This registry consists of 205 consecutive patients who were hospitalised in 6 cardiology departments between 1 January 2005 and 30 September 2007, with the mean age of 65.1 +/- 15.3 years (124 females and 81 males). Mean hospitalisation duration 14.6 days (1-52 days). RESULTS: During hospitalisation 23 (11.2%) patients died. Complications (death, cardiogenic shock, cardiac arrest, use of catecholamines, respiratory therapy and ventilation) during in-hospital stay were observed in 57 (27.8%) patients. Fifty-three patients were haemodynamically unstable (cardiogenic shock or hypotension). The troponin I or T level was assessed in 147 (71.7%) patients and in 50 (34.0%) was positive. In patients with positive troponin we observed 11 (22.0%) deaths, while in patients with normal troponin T or I level 6 (6.2%) deaths occurred. In patients with normal blood pressure we observed a significant difference in mortality in patients with elevated vs. normal troponin level (14.3 vs. 2.5%, p = 0.02). Thrombolytic therapy was used in 20 (9.8%) patients. In patients treated with thrombolytic therapy 9 (45%) deaths were observed. We divided patients according to the ESC 2008 guidelines risk stratification. The 'non-high risk' group consisted of 152 (74.1%) patients, and mortality was 3.9%. The 'high-risk' group consisted of 53 (26.8%) patients. The 'non-high risk' group was divided into the following subgroups: 1. moderate-high (with 2 risk factors: both RV dysfunction and positive injury markers) mortality - 8.1%; 2. moderate subgroup with one risk factor, mortality - 3.6%; 3. low risk - no risk factors - 0% mortality. CONCLUSIONS: 1. In our registry mortality rate in patients with APE was 11%. 2. In about 30% of patients APE was under mask of acute coronary syndrome or syncope, 34% of patients had elevated troponin level, and 30% of patients had complication during hospitalisation. 3. In patients treated with thrombolytics mortality rate was 45%. 4. Reperfusion strategy (trombolysis or embolectomy) in the high risk group was used in only 41% of patients. 5. Elevated troponin level in normotensive patient was associated with 4-fold times higher risk of death. 6. New risk stratification according to the ESC guidelines 2008 correctly predicts prognosis in everyday clinical practise.

Outcome predictors of open embolectomy in middle cerebral artery occlusion.

OBJECTIVE: The purpose of this paper was to analyse the outcome of the patients with acute middle cerebral artery (MCA) occlusion treated by open embolectomy. METHODS: A clinical chart review was retrospectively conducted for 30 patients who had MCA occlusion and were treated with open embolectomy. According to the Glasgow Outcome Scale, the patients' outcome at discharge is divided in two groups: favorable outcome (good recovery and moderate disability) or unfavorable outcome (severe disability, vegetative state and death). The following variables between the favorable and unfavorable outcomes were analysed: age, sex, Glasgow Coma Scale score on admission, affected side, occlusion site, occlusion time, atrial fibrillation on electrocardiogram, fibrinolysis, aphasia, hemiparesis and hemorrhagic infarction after surgery. RESULTS: The outcomes of 30 patients were favorable in 16 patients (good recovery in nine and moderate disability in seven) and unfavorable in 14 patients (severe disability in 12, vegetative state in one and death in one). The M1 occlusion and fibrinolysis performance were more frequent in the unfavorable outcome group than in the favorable one. Logistic regression analysis with a stepwise method indicated that the only occlusion site was independently associated with the unfavorable outcome. The occlusion time >360 minutes was not the predictor of the unfavorable outcome. DISCUSSION: The outcome of patients with MCA occlusion treated by the open embolectomy depends on the occlusion site and the fibrinolysis performance in the present study. The M1 occlusion is also the independent risk factor of the unfavorable outcome. However, the occlusion time itself has no relation to the unfavorable outcome. These results indicate that therapeutic time windows vary in individuals probably due to the collateral blood flow.

Trends in embolectomy of the extremities: a population-based study.

BACKGROUND: There is anecdotal evidence that fewer brachial and femoral embolectomies are being carried out. This may be because of the greater use of anticoagulation in patients with atrial fibrillation. The aim of the present study was to assess community-wide temporal trends in embolectomy of the extremities and of warfarin usage. METHODS: The Western Australian Linked Data System was used to identify cases of extremity embolectomy with a combination of diagnosis (upper or lower limb embolus) and procedure (embolectomy and revascularization) codes. Trends in age-specific and age-standardized rates were assessed over the period 1992-2003. Data regarding warfarin prescriptions were acquired from the Pharmaceutical Benefits Schedule database for the period 2000-2005. RESULTS: One thousand and five patients aged 30 years and more underwent an embolectomy of the extremity during the study period. The age-specific rate of embolectomy increased from 0.78 per 100,000 in the 30- to 49-year-old group to 46.1 per 100,000 for those aged 80 years and more. There was a significant downward trend between 1992 and 2003 (Cuzik's trend test P = 0.015). This pattern was seen for all age groups. Prescriptions for warfarin increased by 50.4% over the period 2000-2005. CONCLUSION: The rates of embolectomy of the extremity appear to be falling. Although the cause for this trend is not known, one possible explanation is increasing prescription of warfarin.

Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy.

Patients undergoing pulmonary embolectomy often experience hemodynamic deterioration during induction of general anesthesia (GA). Therefore, we studied the incidence and possible risk factors for hemodynamic deterioration during GA induction. Fifty-two consecutive patients undergoing emergent pulmonary embolectomy at our institution were included. Hemodynamic collapse after GA induction was defined as hypotension refractory to vasopressor, inotrope, or fluid administration, requiring cardiopulmonary resuscitation followed by urgent institution of cardiopulmonary bypass (CPB). Demographic variables, comorbidities, specific location of thromboemboli, preoperative inotropic support, and anesthetic drugs used for GA induction were evaluated as possible risk factors. After GA induction, hemodynamic collapse occurred in 19% of patients (n = 10). However, the occurrence of hemodynamic instability was not predicted by any of the evaluated risk factors. In addition, the incidence of in-hospital mortality did not differ between hemodynamically stable or unstable patients (10%; 4 of 42 versus 10%; 1 of 10 patients, respectively). In conclusion, hemodynamic deterioration after GA induction develops frequently during emergent pulmonary embolectomy. On the basis of our experience from this study and the unpredictable nature of hemodynamic deterioration, we suggest that patients undergoing pulmonary embolectomy should be prepared and draped before GA induction, and a cardiac surgical team should immediately be available for emergent institution of cardiopulmonary bypass.

Long-term outcome following thrombembolectomy in the upper extremity.

OBJECTIVES: To evaluate short- and long-term mortality and morbidity in patients that were treated for acute upper extremity ischemia. DESIGN: Single center retrospective study. PATIENTS: A consecutive series of 148 patients who were admitted with a diagnosis of acute ischemia of the upper extremity during an 11-year period. METHODS: All charts were reviewed retrospectively and 96% of all survivors participated in clinical follow-up. RESULTS: The median age was 78 years and 64% of patients were females. The 30-day mortality was 8% and the overall 5-year survival 37%. The observed mortality during the follow-up period was significantly higher than expected. Survival was not significantly different in patients who received anticoagulant drugs following discharge from the hospital. The duration of ischemia did not significantly influence long-term arm-function. CONCLUSIONS: Acute embolic episodes in the upper extremity primarily occur in elderly and the peri-operative mortality is high. Mortality following discharge from the hospital remains significantly higher than that of the background population.

In-hospital and long-term outcome after sub-massive and massive pulmonary embolism submitted to thrombolytic therapy.

BACKGROUND: From a registry of 249 confirmed pulmonary embolism (PE) patients submitted to thrombolytic therapy (TT), we analysed predictors of in-hospital course and long-term mortality. METHODS AND RESULTS: The combined clinical end point of in-hospital course associated death, recurrent PE, repeat thrombolysis, surgical embolectomy or bleeding complications. The long-term follow-up included analysis of survival, and occurrence of PE-related events, defined as recurrent deep vein thrombosis, recurrent PE, occurrence of congestive heart failure or change of New York Heart Association functional class to class III or IV in patients who survived the acute phase.In-hospital clinical course was uneventful in 165 (66.3%) patients. Initial right ventricular (RV) dysfunction was reversible in 80% within 48 h following TT. Initial pulmonary vascular obstruction >70% (RR=5.3 [2.1; 13.6]); haemodynamic instability at presentation (RR=2.6 [1.1; 6]); persistence of septal paradoxical motion after TT (RR=5.9 [1.4; 25.9]); and insertion of intracaval filter (RR=3.7 [1.4; 9.4]) were independent predictors of poor in-hospital course. Mean follow-up was 5.3+/-2.6 years. Of the 227 patients alive after the hospital stay, the probability of survival was 92% at 1 year, 79% at 3 years and 56% at 10 years. Multivariate predictors of long-term mortality were age >75 years (RR=2.73 [2.18; 3.21]; P=0.0002), persistence of vascular pulmonary obstruction >30% after thrombolytic treatment (RR=2.22 [1.69; 2.74]; P=0.003), and cancer (RR=2.03 [1.40; 2.65]; P=0.04). CONCLUSION: The recovery of RV function should be considered as a marker of thrombolysis efficacy, while residual pulmonary vascular obstruction and cancer are independent predictors of long-term mortality. These results advocate the identification of high-risk patients by means of systematic lung-scan and echocardiography pre- and post-thrombolysis, and raise the question of the need for thromboendarterectomy in patients with residual pulmonary vascular obstruction.

[The in-vitro evaluation of different embolectomy catheters for the treatment of acute pulmonary embolism]. / In-vitro-Evaluation verschiedener Embolektomiekatheter zur Behandlung der akuten Lungenembolie.

INTRODUCTION: Pulmonary embolism (PE) is one of the most common cardiovascular diseases and frequently causes death. As a rule, PE is treated with thrombolytic therapy or surgical thrombectomy. MATERIALS AND METHODS: In an in vitro model of the right lung, we tested four different percutaneous transluminal thrombectomy devices: a pigtail-catheter with an angled 3-cm (40 degrees) distal tip, the clot-buster, the hydrolyser catheter, and a modified hydrolyser. In 16 consecutive and repetitive experiments fresh thrombi were inserted and we evaluated the effectiveness of the system with respect to time, fragment size, reduction of the Miller score, and handling. RESULTS: Mean intervention times of the catheter systems were 23 min (pigtail), 14.4 min (modified hydrolyser), 13.8 min (clot-buster), and 10.8 min (hydrolyser). The maximum size of the produced fragments range from 0.5 to 3.5 mm by the pigtail and from 0.5 to 1 mm by the other systems. The Miller score reduction was from 14.4 to 2.8 (pigtail), 13.8 to 1.8 (clot-busters), 14.6 to 1.2 (hydrolyser), and 16.4 to 1 (modified hydrolyser). DISCUSSION: All four catheter systems were effective in the treatment of pulmonary embolism. The pigtail catheter is the most simple system but more time consuming and less effective in the fragmentation of emboli and reduction of the Miller score compared to the other three catheter systems. These systems were comparable in our model but especially the handling of the hydrolyser was encouraging.

Current management of acute leg ischaemia: results of an audit by the Vascular Surgical Society of Great Britain and Ireland.

BACKGROUND: Management of acute leg ischaemia has changed in recent years. This study aimed to elucidate current practice throughout the UK and Ireland. METHODS: Surgeons and audit departments were asked to return a questionnaire about every episode of acute leg ischaemia seen in the hospital between 1 January and 31 March 1996. RESULTS: A total of 539 episodes were reported in 474 patients (248 men) aged 19-96 (median 73) years. Common causes were thrombosis in situ (41 per cent), embolism (38 per cent) and graft or angioplasty occlusion (15 per cent). Vascular surgical advice was requested in 95 per cent of cases. Initial management was: immediate embolectomy in 21 per cent, anticoagulants in 13 per cent and no vascular intervention in 10 per cent. Arteriography was done in 56 per cent, followed by 186 endovascular and 165 surgical interventions. At 30 days, 70 per cent of limbs were definitely viable and 16 per cent had been amputated. The mortality rate was 22 per cent. Cases were reported by 86 of 182 hospitals contacted, but some referred no patients, and a supplementary audit of 54 cases (10 per cent size of the original sample) from non-contributing hospitals showed no important differences. CONCLUSION: Patients with acute leg ischaemia are generally treated by vascular specialists, with modern methods and acceptable results. This is being achieved despite insufficient vascular surgeons and radiologists for formal emergency rotas in most hospitals.