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| __NOTOC__
| | #Redirect [[Pulmonary embolism embolectomy]] |
| {{Pulmonary embolism}}
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| {{PE editors}}
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| ==Overview==
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| Surgical management of acute pulmonary embolism ([[pulmonary thrombectomy]]) is uncommon and has largely been abandoned because of poor long-term outcomes. However, recently, it has gone through a resurgence with the revision of the surgical technique and is thought to benefit selected patients.<ref>{{cite journal | author=Augustinos P, Ouriel K | title=Invasive approaches to treatment of venous thromboembolism | journal=Circulation | year=2004 | volume=110 | issue=9 Suppl 1 | pages=I27-34 | id=PMID 15339878 }}</ref>
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| Chronic pulmonary embolism leading to [[pulmonary hypertension]] (known as ''chronic thromboembolic hypertension'') is treated with a surgical procedure known as a [[pulmonary thromboendarterectomy]].
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| ==Embolectomy==
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| Embolectomy is a process of removal of an embolus via a catheter or surgically. The procedure should be used when a high risk patient present with persistent hypotension and thrombolysis has either failed or is contraindicated.
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| To read more about embolectomy (types, procedure), click [[Pulmonary thrombectomy|'''here''']].
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| === ACC/AHA Guidelines- Recommendations for Catheter Embolectomy and Fragmentation (DO NOT EDIT) ===
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| <ref name="pmid21422387">{{cite journal|author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 |pmid=21422387 | doi=10.1161/CIR.0b013e318214914f| pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
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| | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''Catheter embolectomy and surgical thrombectomy are not recommended for patients with low-risk PE or submassive acute PE with minor RV dysfunction, minor myocardial necrosis, and no clinical worsening ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''Depending on local expertise, either catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE and contraindications to fibrinolysis''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''. <nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|
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| <nowiki>"</nowiki>'''2. '''Catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE who remain unstable after receiving fibrinolysis ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|
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| <nowiki>"</nowiki>'''3. '''For patients with massive PE who cannot receive fibrinolysis or who remain unstable after fibrinolysis, it is reasonable to consider transfer to an institution experienced in either catheter embolectomy or surgical embolectomy if these procedures are not available locally and safe transfer can be achieved ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1. '''Either catheter embolectomy or surgical embolectomy may be considered for patients with submassive acute PE judged to have clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory failure, severe RV dysfunction, or major myocardial necrosis) ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| |}
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| ==Inferior vena cava filter==
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| [[Image:Mar07 090.jpg|thumb|left|300px|Used inferior vena cava filter, presented with a British twenty pence coin for scale.]]
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| {{main|inferior vena cava filter}}
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| If anticoagulant therapy is [[contraindication|contraindicated]] and/or ineffective, an [[inferior vena cava filter]] should be implanted<ref name="pmid9459643">{{cite journal |author=Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G |title=A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group|journal=N Engl J Med |volume=338 |issue=7 |pages=409-15 |year=1998 |id=PMID 9459643}}</ref>. It provides a filter in the [[inferior vena cava]], allowing blood to pass through, while preventing large emboli from traveling from the lower extremities to the lung. IVC filters decreases PE recurrence but are not efficacious in preventing mortality<ref name="pmid16009794">{{cite journal |author=|title=Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study |journal=Circulation |volume=112 |issue=3|pages=416–22 |year=2005 |month=July |pmid=16009794 |doi=10.1161/CIRCULATIONAHA.104.512834|url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16009794 |accessdate=2011-12-13}}</ref>.
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| In a study group comprising of 400 patients with proximal deep-vein thrombosis, which were followed for 2 years, it was found that the initial beneficial effect of vena caval filters for the prevention of pulmonary embolism was counterbalanced by an excess of recurrent deep-vein thrombosis, without any difference in mortality<ref name="pmid9459643">{{cite journal |author=Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral FG, Huet Y, Simonneau G |title=A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prévention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group |journal=N. Engl. J. Med. |volume=338 |issue=7|pages=409–15 |year=1998 |month=February |pmid=9459643 |doi=10.1056/NEJM199802123380701|url=http://dx.doi.org/10.1056/NEJM199802123380701 |accessdate=2011-12-13}}</ref>.
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| === ACC/AHA Guidelines- Recommendations on IVC Filters in the Setting of Acute PE (DO NOT EDIT) ===
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| <ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 |pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Adult patients with any confirmed acute PE (or proximal DVT) with contraindications to anticoagulation or with active bleeding complication should receive an IVC filter. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Anticoagulation should be resumed in patients with an IVC filter once contraindications to anticoagulation or active bleeding complications have resolved. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Patients who receive retrievable IVC filters should be evaluated periodically for filter retrieval within the specific filter's retrieval window. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
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| | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' An IVC filter should not be used routinely as an adjuvant to anticoagulation and systemic fibrinolysis in the treatment of acute PE. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''. <nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with recurrent acute PE despite therapeutic anticoagulation, it is reasonable to place an IVC filter ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For DVT or PE patients who will require permanent IVC filtration (eg, those with a long-term contraindication to anticoagulation), it is reasonable to select a permanent IVC filter device. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' For DVT or PE patients with a time-limited indication for an IVC filter (eg, those with a short-term contraindication to anticoagulation therapy), it is reasonable to select a retrievable IVC filter device. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Placement of an IVC filter may be considered for patients with acute PE and very poor cardiopulmonary reserve, including those with massive PE. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| |}
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| === ACC/AHA Guidelines- Recommendations for Use of IVC Filters in Patients With Iliofemoral DVT (DO NOT EDIT) ===
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| <ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. | journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 |pmid=21422387 | doi=10.1161/CIR.0b013e318214914f | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Adult patients with any acute proximal DVT (or acute PE) with contraindications to anticoagulation or active bleeding complication should receive an IVC filter ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''. <nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Anticoagulation should be resumed in patients with an IVC filter once contraindications to anticoagulation or active bleeding complications have resolved ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''.<nowiki>"</nowiki>
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Patients who receive retrievable IVC filters should be evaluated periodically for filter retrieval within the specific filter's retrieval window ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
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| | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' An IVC filter should not be used routinely in the treatment of iliofemoral DVT ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''.<nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with recurrent PE despite therapeutic anticoagulation, it is reasonable to place an IVC filter ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For iliofemoral DVT patients who are likely to require permanent IVC filtration (eg, long-term contraindication to anticoagulation), it is reasonable to select a permanent nonretrievable IVC filter device ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' For iliofemoral DVT patients with a time-limited indication for an IVC filter (eg, a short-term contraindication to anticoagulant therapy), placement of a retrievable IVC filter is reasonable ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with recurrent DVT (without PE) despite therapeutic anticoagulation, it is reasonable to place an IVC filter''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki>
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| |}
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| === ESC Guidelines - Recommendations for Use of IVC Filters (DO NOT EDIT) ===
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| <ref name="pmid18757870">{{cite journal |author=Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJ, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP |title=Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=29 |issue=18 |pages=2276–315 |year=2008 |month=September |pmid=18757870 |doi=10.1093/eurheartj/ehn310 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18757870 |accessdate=2011-12-07}}</ref>
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LightCoral"|[[European society of cardiology#Classes of Recommendations|Class III]]
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| | bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.'''The routine use of IVC filters in patients with PE is not recommended.''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |}
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| {| class="wikitable"
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| | colspan="1" style="text-align:center; background:LemonChiffon"|[[European society of cardiology#Classes of Recommendations|Class IIb]]
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''IVC filters may be used when there are absolute contraindications to anticoagulation and a high risk of VTE recurrence.''([[European society of cardiology#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |}
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| ==Guidelines Resources==
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| *Guidelines on the management of Pulmonary embolism: Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension<ref name="pmid21422387">{{cite journal| author=Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ et al.| title=Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association.| journal=Circulation | year= 2011 | volume= 123 | issue= 16 | pages= 1788-830 | pmid=21422387 | doi=10.1161/CIR.0b013e318214914f |pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21422387 }} </ref>
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| ==References==
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| {{reflist|2}}
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| [[Category:Hematology]]
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| [[Category:Pulmonology]]
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| [[Category:Cardiology]]
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| [[Category:Emergency medicine]]
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| {{WH}}
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| {{WS}}
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