Pulmonary Embolectomy and Pulmonary Thromboendarterectomy

• Published in: Cardiac Surgery pp. 1041 - 1060
• Main Author: Iversen, Stein
• Format: Book Chapter
• Language: English
• Published: Berlin, Heidelberg Springer Berlin Heidelberg
• Subjects: Acute pulmonary embolism; Chronic thromboembolic pulmonary hypertension; Pulmonary embolectomy; Pulmonary thromboendarterectomy; Thrombolytic therapy
• ISBN: 9783662526705; 3662526700
• DOI: 10.1007/978-3-662-52672-9_35

In pulmonary embolism, multiple facets of clinical appearance with nonspecific symptoms may impede timely and correct diagnosis. Right heart strain is a decisive factor for outcome and ensues the aggressiveness of diagnostic and therapeutic measures. Echocardiography and pulmonary angio-CT secure diagnosis and direct therapy. ICU treatment is mandatory and includes full anticoagulation with circulatory and respiratory support when required. Thrombolysis is the treatment of choice for high-risk patients with persistent hypotension or even cardiogenic shock. The indication for pulmonary embolectomy has been modified to patients with massive right heart failure and contraindication to thrombolytic therapy and hemodynamic instability in spite ongoing thrombolytic treatment and should also be primarily considered when transit thrombi and/or a patent foramen ovale are diagnosed. Embolectomy is performed with cardiopulmonary bypass which provides immediate right ventricular relief, restoration of systemic circulation, and oxygen supply. Postoperative venous Doppler/CT examinations help decide whether a cava filter implantation is indicated. Anticoagulation is continued for at least 3 months and indefinitely in recurrent venous thromboembolism and persistent risk factors. Chronic thromboembolic pulmonary hypertension is rare with poor prognosis left untreated. Medical therapy is palliative, but surgical desobliteration by pulmonary thromboendarterectomy has been established as the therapy of choice. Timely diagnosis secured by pulmonary angiography and angio-CT together with early referral for surgery is indicated before advanced secondary pulmonary vasculopathy occurs. Surgery is performed utilizing extracorporeal circulation in deep hypothermia and circulatory arrest. The bilateral desobliteration of the pulmonary vessels is a true endarterectomy with extraction of the pathological intima containing the intraluminal obstructions. The postoperative ICU course may be complicated by residual pulmonary hypertension, pulmonary vasoconstriction, and development of reperfusion edema. Restricted fluid administration, subtle fluid balancing, and maintenance of diuresis are mandatory. Indefinite anticoagulation therapy is required and a cava filter should be inserted.