|
|
| (33 intermediate revisions by 5 users not shown) |
| Line 1: |
Line 1: |
| __NOTOC__
| | #Redirect [[Pulmonary embolism embolectomy]] |
| {{Pulmonary embolism}}
| |
| | |
| {{CMG}}
| |
| | |
| ==Overview==
| |
| In [[thoracic surgery]], a '''pulmonary thrombectomy''', is an [[emergency procedure]] that removes [[blood clot|clotted]] [[blood]] ([[thrombus]]) from the [[pulmonary artery|pulmonary arteries]]. Embolectomy can be done via a catheter or surgically.
| |
| ==Indications==
| |
| *Pulmonary embolism patient (formed from venous embolisms). Embolectomy is used for patients with persisting shock despite supportive care and who have an absolute contraindication for thrombolytic therapy.
| |
| *Arterial embolisms in acute limb ischemia.<ref name="pmid19298929">{{cite journal |author=Rutherford RB |title=Clinical staging of acute limb ischemia as the basis for choice of revascularization method: when and how to intervene |journal=Semin Vasc Surg |volume=22 |issue=1 |pages=5–9 |year=2009 |month=March |pmid=19298929 |doi=10.1053/j.semvascsurg.2008.12.003 |url=http://linkinghub.elsevier.com/retrieve/pii/S0895-7967(08)00074-4 |accessdate=2011-12-14}}</ref>
| |
| *Other ischemias due to embolism ([[mesenteric ischemia]] and [[stroke]]).<ref name="pmid18695052">{{cite journal |author=Stead LG, Gilmore RM, Bellolio MF, Rabinstein AA, Decker WW |title=Percutaneous clot removal devices in acute ischemic stroke: a systematic review and meta-analysis |journal=Arch. Neurol. |volume=65 |issue=8 |pages=1024–30 |year=2008 |month=August |pmid=18695052 |doi=10.1001/archneur.65.8.1024 |url=http://archneur.ama-assn.org/cgi/pmidlookup?view=long&pmid=18695052 |accessdate=2011-12-14}}</ref>
| |
| | |
| Transcatheter procedures can be performed as an alternative to [[thrombolysis]] when
| |
| *[[Thrombolysis]] is contraindicated.
| |
| *When emergency surgical thrombectomy is unavailable or contraindicated.
| |
| *When thrombolysis has failed to improve the patient's hemodynamics in the acute setting.
| |
| | |
| ==Therapeutic Goal==
| |
| The goals of catheter-based therapy include
| |
| *Rapidly reduce [[pulmonary artery pressure]], [[RV strain]], and [[pulmonary vascular resistance]] ([[PVR]]).
| |
| *Improve hemodynamics.
| |
| *Facilitate right ventricular recovery.
| |
| | |
| ==Types==
| |
| *Catheter embolectomy. It is further divided into :
| |
| **|. Rheolytic embolectomy
| |
| **||. Rotational embolectomy
| |
| *Surgical embolectomy
| |
| | |
| ==Description==
| |
| '''Rheolytic embolectomy''': Pressurized saline is passed through a catheter's distal tip, which breaks-down the emboli. The saline and clot fragments are then sucked back into an exhaust lumen of the catheter and disposed off.
| |
| | |
| Insertion of a large catheter increases the risk of bleeding which pose as the major disadvantage.
| |
| | |
| '''Rotational embolectomy''': As the name suggest, a rotational device is used to fragment the thrombus. In this, cardiac catheters are used, which does not require venotomy at the puncture site. The fragments are continuously aspirated.
| |
| | |
| Mechanical thrombectomy should be limited to the main and lobar pulmonary arterial branches, because the risk of perforation increases, when vessels smaller than 6 mm in diameter are treated.
| |
| | |
| '''Surgical embolectomy''': This procedure is typically limited to large medical centers (as it requires experienced surgeon and cardiopulmonary bypass).
| |
| *Indications
| |
| **Hypotensive patients in which thrombolysis is contraindicated.
| |
| **Embolus trapped within patent foramen ovale, right atrium or the right ventricle, as evident on Echocardiography.
| |
| *Benefits
| |
| **Among patients failing initial thrombolysis, surgical embolectomy was found to have fewer death rates and fewer major bleedings.<ref name="pmid16608956">{{cite journal| author=Meneveau N, Séronde MF, Blonde MC, Legalery P, Didier-Petit K, Briand F et al.| title=Management of unsuccessful thrombolysis in acute massive pulmonary embolism. | journal=Chest | year= 2006 | volume= 129 | issue= 4 | pages= 1043-50 | pmid=16608956 | doi=10.1378/chest.129.4.1043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16608956 }} </ref>
| |
| *Special Considerations
| |
| **A study had shown the presence of extrapulmonary thrombus in 13 out of 50 patients undergoing surgical embolectomy, thus emphasizing the need of [[transesophageal echocardiography]] (TEE).<ref name="pmid15337008">{{cite journal| author=Rosenberger P, Shernan SK, Mihaljevic T, Eltzschig HK| title=Transesophageal echocardiography for detecting extrapulmonary thrombi during pulmonary embolectomy. | journal=Ann Thorac Surg | year= 2004 | volume= 78 | issue= 3 | pages= 862-6; discussion 866 | pmid=15337008 | doi=10.1016/j.athoracsur.2004.02.069 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15337008 }} </ref> TEE should be performed before or during the procedure to look for extrapulmonary thrombus. Extrapulmonary thrombus are thrombus present in [[right atrium]], [[right ventricle]], or [[inferior vena cava]].
| |
| | |
| ==Guidelines==
| |
| To read about about AHA/ACC Guidelines for surgical and catheter embolectomy, click [[Pulmonary embolism ACC/AHA guidelines surgical embolectomy|here]].
| |
| | |
| ==Relation to PTE==
| |
| Pulmonary thrombectomies and [[pulmonary thromboendarterectomy|pulmonary thromboendarterectomies]] (PTEs) are both operations that remove thrombus. Aside from this similarity they differ in many ways.
| |
| *PTEs are done non-emergently whilst pulmonary thrombectomies are typically done as an emergency procedure.
| |
| *PTEs typically are done using hypothermia and full cardiac arrest.
| |
| *PTEs are done for chronic pulmonary embolism, thrombectomies for severe acute pulmonary embolism.
| |
| *PTEs are generally considered a very effective treatment, surgical thrombectomies are an area of some controversy and their effectiveness a matter of some debate in the medical community.
| |
| | |
| ==See also==
| |
| *[[Pulmonary embolism surgery|Pulmonary embolism Surgical Therapy]]
| |
| | |
| *[[Pulmonary embolism]]
| |
| *[[Heart-lung machine]]
| |
| *[[Pulmonary embolism ACC/AHA guidelines surgical embolectomy|ACC/AHA Guidelines Surgical Embolectomy]]
| |
| | |
| ==References==
| |
| {{Reflist|2}}
| |
| | |
| [[Category:Thoracic surgery]]
| |
| [[Category:Surgical procedures]]
| |