Surgical alternatives in pulmonary embolism

Surgical intervention in pulmonary embolism (PE) is still associated with an overall fatal outcome of 30-60% depending on the hemodynamic condition of the patient when operated. Thus conservative treatment using heparin or fibrinolytic agents has become the treatment of choice. In grade IV PE, however, surgical treatment might be a live-saying option in cases of shock or contraindication to fibrinolysis. The objective of this study was to evaluate the results of a modified surgical approach to treat fulminant PE. From May 1993 to June 1996 12 patients with fulminant PE were operated under emergency conditions, with six patients (50%) under or after cardiopulmonary resuscitation (CPR). A modified surgical approach was performed allowing for selective thrombectomy from both pulmonary artery systems down to the segmental artery level as well as simultaneous closed venous thrombectomy with clearance of the major body veins during extracorporeal circulation (ECC). In two cases the acute form of PE was associated with unilateral, chronic and subtotal obstructing embolization requiring deep hypothermic circulatory arrest and pulmonary thrombendarterectomy. In six patients systolic pulmonary artery pressure (PAP) was measured immediately prior to start of ECC, prior to closure of the chest and after an interval of 3-6 days. It could be demonstrated that an ad hoc fall from 53.3 ± 10.8 mmHg to 29.7 ± 13.1 mmHg (P = 0.007) resulted, which continued during the first postoperative days to 23.3 ± 6.5 mmHg. All but one polytraumatized patient, in whom no pulmonary embolism was found at surgery, survived (92%). One patient died after prolonged preoperative CPR 4 months after surgery due to permanent neurologic damage, another patient died 20 months after surgery due to malignancy. All other patients (follow-up range 9-45 months) are fully rehabilitated and free of PE recurrency under coumadin medication, with three patients having required the placement of a LGM caval filter for ongoing iliac vein thrombosis. Fast and accurate diagnosis of grade IV PE still is problematic in an emergency situation. However, this study concluded that the modified surgical approach with complete desobliteration of the pulmonary artery system as well as simultaneous venous thrombectomy represents a safe and highly efficient therapeutic option in grade IV PE to immediately relieve acute pulmonary artery hypertension and to prevent early embolic recurrence. Long-term freedom from re-embolization is warranted by the differentiated use of caval filters and continued anticoagulation.