Pulmonary embolism surgery
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Pulmonary embolism surgery On the Web |
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
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.[1]
Chronic pulmonary embolism leading to pulmonary hypertension (known as chronic thromboembolic hypertension) is treated with a surgical procedure known as a pulmonary thromboendarterectomy.
Embolectomy
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.
To read more about embolectomy (types, procedure), click here.
ACC/AHA Guidelines- Recommendations for Catheter Embolectomy and Fragmentation (DO NOT EDIT)
| Class III (No Benefit) |
| "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 (Level of Evidence: C)" |
| Class IIa |
| "1. Depending on local expertise, either catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE and contraindications to fibrinolysis(Level of Evidence: C). " |
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"2. Catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE who remain unstable after receiving fibrinolysis (Level of Evidence: C)." |
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"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 (Level of Evidence: C)." |
| Class IIb |
| "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) (Level of Evidence: C)." |
Inferior vena cava filter
If anticoagulant therapy is contraindicated and/or ineffective, an inferior vena cava filter should be implanted[3]. 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[4].
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[3].
References
- ↑ Augustinos P, Ouriel K (2004). "Invasive approaches to treatment of venous thromboembolism". Circulation. 110 (9 Suppl 1): I27–34. PMID 15339878.
- ↑ Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ; et al. (2011). "Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association". Circulation. 123 (16): 1788–830. doi:10.1161/CIR.0b013e318214914f. PMID 21422387.
- ↑ 3.0 3.1 Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral F, Huet Y, Simonneau G (1998). "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". N Engl J Med. 338 (7): 409–15. PMID 9459643.
- ↑ "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". Circulation. 112 (3): 416–22. 2005. doi:10.1161/CIRCULATIONAHA.104.512834. PMID 16009794. Retrieved 2011-12-13. Unknown parameter
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