Pulmonary embolism embolectomy

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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:  Rim Halaby, M.D. [2]

Synonyms and keywords: Pulmonary thrombectomy, surgical pulmonary embolectomy, percutaneous catheter embolectomy

## Overview

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Pulmonary embolectomy is an emergency procedure that removes blood clots from the pulmonary arteries. There are two types of pulmonary embolectomy: surgical pulmonary embolectomy and percutaneous catheter embolectomy. Pulmonary embolectomy is indicated for the treatment of pulmonary embolism (PE) in patients with massive PE among whom fibrinolytic therapy is contraindicated or who fail to improve after the initial treatment with fibrinolytic therapy. In addition, pulmonary embolectomy is indicated in patients with submassive PE who fail to improve on the initial treatment and have contraindications to fibrinolytic therapy.[1][2][3]

## Pulmonary Embolism Embolectomy

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### Indications

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Pulmonary embolectomy is indicated for the treatment of:[1][2][3]

* Patients with massive PE among whom fibrinolytic therapy is contraindicated or who fail to improve after the initial treatment with fibrinolytic therapy
* Patients with submassive PE who fail to improve on the initial treatment and have contraindications to fibrinolytic therapy

### Therapeutic Goal

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The goals of catheter-based therapy are:

* To rapidly reduce pulmonary artery pressure, right ventricular strain, and pulmonary vascular resistance (PVR)
* To improve hemodynamical status of the patient
* To facilitate the right ventricular recovery

### Types

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#### Percutaneous Thrombectomy

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Percutaneous thrombectomy is a treatment option for patients having contraindications to fibrinolytics or who are at institutions where surgical embolectomy is not available. It is broadly divided into three types:

* Rheolytic thrombectomy
* Thrombus fragmentation
* Rotational thrombectomy

##### Rheolytic Thrombectomy

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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.[4] Insertion of a large catheter increases the risk of bleeding which is the major disadvantage of this procedure.

##### Rotational Thrombectomy

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As the name suggests, a rotational device is used to fragment the thrombus. In rotational thrombectomy, cardiac catheters are used and venotomy is not required at the puncture site. The fragments are continuously aspirated.

Major complications:

Perforation is a major complication of this procedure. 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 operated.

Minor complications:

* Puncture or dissection of cardiopulmonary structures
* Pulmonary hemorrhage
* Pericardial tamponade
* Distal thrombus embolization

##### Thrombus Fragmentation

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Thrombus fragmentation can be performed with balloon angioplasty, a pigtail rotational catheter, or a more advanced fragmentation device, the Amplataze catheter which uses an impeller to homogenize the thrombus.

#### Surgical Thrombectomy

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Surgical thrombectomy is typically limited to large medical centers (as it requires experienced surgeon and cardiopulmonary bypass). Among patients failing initial thrombolysis, surgical embolectomy was found to have fewer death rates and fewer major bleedings.[5]

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).[6] 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.

### Pulmonary Embolectomy vs Pulmonary Thromboendarterectomy

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Pulmonary embolectomy and pulmonary thromboendarterectomy (PTEs) aim to remove the thrombus in the pulmonary artery; however, they differ in many ways.

* PTE is performed non-emergently whilst pulmonary embolectomy is typically performed as an emergency procedure.
* PTE is typically performed using hypothermia and full cardiac arrest.
* PTE is done for chronic pulmonary embolism, while embolectomy is performed for severe acute pulmonary embolism.

## 2012 American College of Chest Physicians Evidence-Based Clinical Practice Guidelines on Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis (DO NOT EDIT)[1]

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### Recommendations for Initial Treatment of Acute PE (DO NOT EDIT)[1]

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Class IIa

"1. In patients with acute PE associated with hypotension, we suggest surgical pulmonary embolectomy over no such intervention if they have (i) contraindications to thrombolysis, (ii) failed thrombolysis or catheter-assisted embolectomy, or (iii) shock that is likely to cause death before thrombolysis can take effect (e.g., within hours), provided surgical expertise and resources are available. (Level of Evidence: C)"

## 2011 AHA Scientific Statement- Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension (DO NOT EDIT)[2]

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### 2011 ACC/AHA Guidelines- Recommendations for Catheter Embolectomy and Fragmentation (DO NOT EDIT)[2]

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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). "

"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)."

"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)."

## 2008 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) (DO NOT EDIT)[3]

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### Treatment of High-Risk Pulmonary Embolism (DO NOT EDIT)[3]

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Class I

"1. Surgical pulmonary embolectomy is a recommended therapeutic alternative in patients with high-risk PE in whom thrombolysis is absolutely contraindicated or has failed.(Level of Evidence: C)"

## References

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1. ↑ 1.0 1.1 1.2 1.3 Kearon C, Akl EA, Comerota AJ; et al. (2012). "Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e419S–94S. doi:10.1378/chest.11-2301. PMID 22315268. Unknown parameter `|month=` ignored (help)CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
2. ↑ 2.0 2.1 2.2 2.3 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.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
3. ↑ 3.0 3.1 3.2 3.3 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 (2008). "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)". Eur. Heart J. 29 (18): 2276–315. doi:10.1093/eurheartj/ehn310. PMID 18757870. Retrieved 2011-12-07. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
4. ↑ Koning R, Cribier A, Gerber L, Eltchaninoff H, Tron C, Gupta V; et al. (1997). "A new treatment for severe pulmonary embolism: percutaneous rheolytic thrombectomy". Circulation. 96 (8): 2498–500. PMID 9355883.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
5. ↑ Meneveau N, Séronde MF, Blonde MC, Legalery P, Didier-Petit K, Briand F; et al. (2006). "Management of unsuccessful thrombolysis in acute massive pulmonary embolism". Chest. 129 (4): 1043–50. doi:10.1378/chest.129.4.1043. PMID 16608956.CS1 maint: Explicit use of et al. (link) CS1 maint: Multiple names: authors list (link)
6. ↑ Rosenberger P, Shernan SK, Mihaljevic T, Eltzschig HK (2004). "Transesophageal echocardiography for detecting extrapulmonary thrombi during pulmonary embolectomy". Ann Thorac Surg. 78 (3): 862–6, discussion 866. doi:10.1016/j.athoracsur.2004.02.069. PMID 15337008.CS1 maint: Multiple names: authors list (link)

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