Severe pulmonary embolism:
surgical aspects
Oliver Reuthebuch
Clinic for Cardiac Surgery
University Hospital Basel
Switzerland
Severe pulmonary embolism
Acute pulmonary embolism
Chronic pulmonary thromboembolism
Acute pulmonary embolism: Surgical aspects
Lethality of >30%
2/3 of deaths within first 60 min
Most common cause of death without clinical diagnosis
Very unspecific clinical symptoms
• Dyspnoea
• Tachycardia
• Chest pain
• Hypotension
Unspecific laboratory parameters
• Elevation of D-dimer (90% of cases)
• Elevation of Troponin and pro-BNP
• Hypoxaemia
Acute pulmonary embolism: Surgical aspects
Causes for acute pulmonary embolism:
• Thrombus formation in venous system (90%)
Virchow Triad
Vessel wall lesion
Stasis
Hypercoagulability
• Fat- and bone particles
• Amnion fluid
• Tissue- and tumor cells
• Bacteria
• Parasites
• Foreign bodies
Acute pulmonary embolism: Surgical aspects
Diagnostic:
• Chest x-ray
• Pulmonary angiography
• Multi-slice CT
• MRI
• Echocardiography
Westermark sign
Acute pulmonary embolism: Surgical aspects
Diagnostic:
• Chest x-ray
• Pulmonary angiography
• Multi-slice CT
• MRI
• Echocardiography
Acute pulmonary embolism: Surgical aspects
Diagnostic:
• Chest x-ray
• Pulmonary angiography
• Multi-slice CT
• MRI
• Echocardiography
Acute pulmonary embolism: Surgical aspects
Diagnostic:
• Chest x-ray
• Pulmonary angiography
• Multi-slice CT
• MRI
• Echocardiography
Acute pulmonary embolism: Surgical aspects
Diagnostic:
• Chest x-ray
• Pulmonary angiography
• Multi-slice CT
• MRI
• Echocardiography
Diastole
Systole
Systolic D-shape sign
Acute pulmonary embolism: Surgical aspects
Treatment options:
Hemodynamically stable patient Hemodynamically unstable patient
Anticoagulation
IVC Filter
Thrombolytic therapy
Embolectomy
Ultrasound-assisted
Rheolytic embolectomy
Rotational embolectomy
Suction embolectomy
Thrombus fragmentation
Surgical embolectomy
Acute pulmonary embolism: Surgical aspects
Indication for Surgery:
5.8. 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
(iii) shock that is likely to cause death before thrombolysis can take effect
provided surgical expertise and resources are available (Grade 2C).
Antithrombotic therapy for VTE Diseases: Chest 2012;141(2) (Suppl.):e419S-e494S
Acute pulmonary embolism: Surgical aspects
Indication for Surgery:
Addendum to the guidelines:
Diagnosis of additional intracardial (floating) thromboembolisms
Patent foramen ovale
Antithrombotic therapy for VTE Diseases: Chest 2012;141(2) (Suppl.):e419S-e494S
Acute pulmonary embolism: surgical aspects
Historical Considerations:
Friedrich Trendelenburg (1844-1924)
Director of Department for Surgery, University Hospital Leipzig, 1895-1911
Acute pulmonary embolism: surgical aspects
Historical Considerations:
Acute pulmonary embolism: surgical aspects
Historical Considerations:
John Gibbon:
Experienced the death of a young lady due to pulmonary embolism
Initiation of a 23 years research program for ECC
(Artificial maintenance of circulation during experimental occlusion of pulmonary artery,
Arch Surg 1937:34)
1953 first clinical use of ECC
1961 first PE with ECC by D. Cooley
Acute pulmonary embolism: Surgical aspects
Surgical procedure:
Median sternotomy
Bicaval cannulation
Normothermic
Fibrillating heart vs. arrested heart
Incision of pulmonary trunk
Additional incisions if applicable
Grasping of emboli
Ventilation of lungs or manual pulmonary
massage to mobilize emboli
Closure with 5/0, 6/0
RA-incision: inspection of cavities
Control CT or Doppler of venous system
Heparin and consecutive Marcoumar for 6 months
Acute pulmonary embolism: Surgical aspects
Bicaval cannulation and inspection of cavities
Acute pulmonary embolism: Surgical aspects
Extraction of huge clot
Acute pulmonary embolism: Surgical aspects
Acute pulmonary embolism: Surgical aspects
Acute pulmonary embolism: Surgical aspects
Stein PD et al. Outcome of Pulmonary Embolectomy. Am J Cardio 2007;99:421-423
41 series reviewed
Data between 1961 and 2005
Mortality ranged between 6% and 64%, average mortality of 30%
• between 1961 and 1984: average mortality 32%
• between 1985 and 2006: average mortality 20%
Indication for surgery
• 74% hemodynamic instability
• 32% cardiac arrest
• 19% contraindication to thrombolytic therapy
Results 1:
Acute pulmonary embolism: Surgical aspects
Stein PD et al. Outcome of Pulmonary Embolectomy. Am J Cardio 2007;99:421-423
Acute pulmonary embolism: Surgical aspects
Results 2:
Meneveau N, et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006;129(4):1043-50
Acute pulmonary embolism: Surgical aspects
Conclusion 1:
Surgery is indicated
in hemodynamically unstable patients
In the presence of huge emboli in cardiac cavities
In the presence of anatomical abnormalities
High mortality (salvage treatment)
Advisable in the subset of recurrent embolism
Chronic pulmonary embolism: Surgical aspects
Chronic pulmonary embolism
Chronic pulmonary embolism: Surgical aspects
Nature of chronic thromboembolic pulmonary hypertension (CTEPH)
Obstruction of pulmonary arteries by single or recurrent pulmonary emboli
without complete resolution
5-year survival is pressure dependent (mPAP)
>50mmHg 10%
>30mmHg 30%
<30mmHg 90%
Endothelialized residues obliterate or significantly narrow pulmonary arteries
Incidence of 0.57% to 3.8% in survivors of acute pulmonary embolism (PE)
Incidence of >10% in patients with recurrent PE
Incidence of 0.1% for surgical treatment in all patients with PE
First PEA in 1957, since then >3000 cases
Bilateral procedure
Total removal of thromboembolic material
Chronic pulmonary embolism: Surgical aspects
Pathophysiology
Chronic thromboembolic lesions in vessel wall
change into fibrous and elastic fibers and finally
become endothelialized
Development of a precapillary vasculopathy in
over-perfused vessels
• reactive, Eisenmenger-like reaction
• vasoconstriction of small vessels
• hypertrophy of media
• final sclerosis
Mixed form of mechanical obstruction of lobar-, segmental and sub-segmental
arteries (surgically accessible) in conjunction with irreversible vasculopathy
(no surgical access)
Chronic pulmonary embolism: Surgical aspects
Indication:
New York Heart Association (NYHA) functional class III or IV
Preoperative pulmonary vascular resistance (PVR) of greater
than 300 dyn · s · cm-5
Surgically accessible thrombus in the main lobar or segmental
pulmonary arteries
No severe co-morbidities
• obstructive or restrictive chronic lung disease
• Advanced secondary arteriopathy
Chronic pulmonary embolism: Surgical aspects
Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:508-518
Diagnostic:
Chronic pulmonary embolism: Surgical aspects
Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:508-518
A1: Tech-99m-aerosol ventilation scan; B1: perfusion scan; C1: high-resolution CT scan;
D1: spiral CT angiography; E1/F1 and G1/H1: pulmonary angiography in a.-p. and lateral aspect
Diagnostic: Central Obstruction (amenable for surgery)
Chronic pulmonary embolism: Surgical aspects
Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:508-518
A1: Tech-99m-aerosol ventilation scan; B1: perfusion scan; C1: high-resolution CT scan;
D1: spiral CT angiography; E1/F1 and G1/H1: pulmonary angiography in a.-p. and lateral aspect
Diagnostic: Peripheral Obstruction (not amenable for surgery)
Chronic pulmonary embolism: Surgical aspects
Kim NH et al. Chronic Thromboembolic Pulmonary Hypertension. JACC 2013;62(25):D92-D99
Diagnosis:
Chronic pulmonary embolism: Surgical aspects
Surgery:
Median sternotomy
Total circulatory arrest (18°-20°)
• visibility diminished due to back-bleeding as result of
systemic-to-pulmonary artery circulation
Arrest less < 20min per side
Chronic pulmonary embolism: Surgical aspects
Surgery:
Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic
Thromboembolic PH. Proc Am Thorac Soc 2006;3:589-593
Iversen S. Pulmonale Thrombeembolektomie und pulmonale
Thrombendarterektomie. Springer Verlag
Chronic pulmonary embolism: Surgical aspects
Surgery:
Dartevelle P et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J 2004;23:637-648
Chronic pulmonary embolism: Surgical aspects
Surgery:
Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic PH. Proc Am Thorac Soc 2006;3:589-593
Chronic pulmonary embolism: Surgical aspects
Surgery (angioscopic):
Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic PH. Proc Am Thorac Soc 2006;3:589-593
Chronic pulmonary embolism: Surgical aspects
Surgery:
Reperfusion of appr. 15min during closure of arteriotomy
De-airing of cardiac chambers
Unclamping of aorta
Rewarming to 37°
• additional procedures:
• aorto-coronary bypass
• valve surgery
• combined procedures
Chronic pulmonary embolism: Surgical aspects
Postoperative management:
Persistent PAH (mean >25mmHg)
• inadequate endarterectomy in 10% patients
• significant vasculopathy
Reperfusion edema
• incidence of 10-15%
• adequate ventilation (tidal volume < 8ml/kg, I:E 3:1, PiP <18cmH2O)
• fluid restriction
• avoidance of inotropes
• ECMO
Rupture of arteriotomy
Nosocomial pneumonia
Hemoptysis
Intrapulmonary bleeding (0.5-1%)
Rethrombosis (rare)
Chronic pulmonary embolism: Surgical aspects
Outcome (perioperative):
Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic PH. Proc Am Thorac Soc 2006;3:589-593
Chronic pulmonary embolism: Surgical aspects
Outcome (perioperative/longterm):
UpToDate 2016: Chronic thrombembolic pulmonary hypertension: Surgical Treatment
Chronic pulmonary embolism: Surgical aspects
Outcome (long-term):
Freed DH et al. Survival after pulmonary thrombendarterctomy. JTCVS 2011;141:383
Chronic pulmonary embolism: Surgical aspects
Outcome (long-term):
Freed DH et al. Survival after pulmonary thrombendarterctomy. JTCVS 2011;141:383
Chronic pulmonary embolism: Surgical aspects
Outcome (long-term):
Cannon JE. Dynamik Risk stratification of Patient Long-Term Outcome. Circ 2016;133:1761
Chronic pulmonary embolism: Surgical aspects
Outcome (long-term):
Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:508-518
Chronic pulmonary embolism: Surgical aspects
Percutaneous Pulmonary Angioplasty
First publication in 2001 (Feinstein)
Reestablishing of method in 2012 (Japan)
• data published of >127 patients
Multiple procedures
• smaller balloons
• average 4.8 sessions needed
• vessel rupture
• reperfusion lung injury
Increasing interest
Amenable for peripheral PE
Chronic pulmonary embolism: Surgical aspects
Percutaneous Pulmonary Angioplasty
Andreassen AK et al. Balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension. Heart 2013;99:1415-1420
Chronic pulmonary embolism: Surgical aspects
Representative angiographic and intravascular ultrasound (IVUS) images of
balloon pulmonary angioplasty (BPA).
Hiroki Mizoguchi et al. Circ Cardiovasc Interv. 2012;5:748-755
Chronic pulmonary embolism: Surgical aspects
Representative pulmonary angiograms before and after balloon pulmonary
angioplasty (BPA).
Hiroki Mizoguchi et al. Circ Cardiovasc Interv. 2012;5:748-755
Chronic pulmonary embolism: Surgical aspects
Correlation between the number of opened segments and the decrease in
mean pulmonary arterial pressure.
Hiroki Mizoguchi et al. Circ Cardiovasc Interv. 2012;5:748-755
Acute and Chronic pulmonary embolism: Surgical aspects
Conclusion
Surgery for acute pulmonary embolism is last treatment option
• Contraindication/failed thrombolysis
• Shock
PEA in chronicTEPH is standard and recommended treatment
ECMO should be a standard of care in PEA centers
Role of percutaneous pulmonary angioplasty needs further evaluation
and so far can`t replace PEA
CTEPH team assess operability before other treatments are considered
Acute and Chronic pulmonary embolism: Surgical aspects
Thank you very much for your attention!