Pulmonary Embolism - Is There Still a Surgical Treatment Option?

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Abstract

Abstract
Thanks to improvements in the prophylaxis of deep venous thrombosis, pulmonary embolism has become less common during recent years. Moreover, advanced therapeutic options such as thrombolysis and catheter embolectomy have led to a further decrease in the number of surgical interventions. Looking at recent literature and some recent guidelines, the question arises of whether there is any role left for surgical therapy of pulmonary embolism. This article will deal with this question based on some typical clinical examples and some newer publications.

Keywords
Acute pulmonary embolism, surgery, embolectomy

Disclosure: The author has no conflicts of interest to declare.
Received: 23 November 2010 Accepted: 16 February 2011 Citation: European Cardiology, 2011;7(1):48├óÔé¼ÔÇ£50
Correspondence: Rainer Moosdorf, Department of Cardiovascular Surgery, University Hospital Giessen and Marburg, Campus Marburg, Baldingerstrasse, 35043 Marburg, Germany. E: moosdorf@med.uni-marburg.de

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Pulmonary embolism is mainly caused by deep venous thrombosis in the lower extremities, mostly due to longer immobilisation and/or restricted venous backflow. Thus, most patients have a typical history; however, symptoms may be misinterpreted and therapy delayed. While smaller or fragmented thrombi in the peripheral segments of the pulmonary arteries may only cause dyspnoea and hardly any cardiovascular impairment, large thrombi in the pulmonary trunk or the origin of the main pulmonary arteries may present with severe dyspnoea and haemodynamic instability, often necessitating cardiopulmonary resuscitation. Severe pulmonary embolism is considered to be one of the main reasons for sudden death of unknown origin, not only after long immobilisation due to illness but also due to long flights or bus journeys.

Laboratory tests for pulmonary embolism concentrate mainly on blood gas analysis and D-dimers as typical markers of venous thrombosis. A computed tomography scan is considered the first choice among the imaging procedures, while in experienced hands transoesophageal echocardiography may also be appropriate, especially in emergency situations.

The established therapeutic options today are heparinisation, preferably with low-molecular-weight heparins, systemic thrombolysis and transcatheter embolectomy. In most emergency units, in accordance with recent literature, surgery is considered to be the last choice and only in cases of severe haemodynamic instability or in patients under cardiopulmonary resuscitation.

Surgical Therapy
The first pulmonary embolectomy was performed by Trendelenburg in 1908. In brief, the chest is opened by a median sternotomy and, after making an incision in the pericardium, both caval veins are encircled. Two sutures are placed close to the pulmonary valve and in the middle of the pulmonary bifurcation; these sutures serve as stay sutures during embolectomy and may later be used for closure of the arterial incision. If necessary, cardiopulmonary resuscitation is continued throughout the preparations. After tying the two caval snares, the pulmonary artery is incised longitudinally between the two stay sutures and the thrombus is extracted under direct vision by special forceps with the assistance of suction. Both lungs are manually compressed after liberal opening of the pleural spaces to mobilise the remaining smaller thrombi out of the peripheral branches. After this procedure, the inflow occlusion is stopped and the pulmonary incision is closed with the aid of a side-biting clamp to avoid major blood loss. This operation can be performed anywhere and by any general surgeon without the back-up of a cardiac surgical unit.

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