BOSTON—Surgical embolectomy should not be seen as a last resort for acute pulmonary embolism (PE) but as one of several viable treatments for the condition, says Samuel Z. Goldhaber, MD. Dr. Goldhaber was a principal investigator in a study of 29 consecutive patients with acute PE who underwent embolectomy at Brigham and Women’s Hospital in Boston from October 1999 through October 2001.[1]

“Embolectomy, previously considered extraordinarily high risk, was associated with an 89% survival rate in our series,” reported Dr. Goldhaber, a staff cardiologist and Director of the Venous Thromboembolism Research Group at Brigham and Women’s Hospital. He and his colleagues expressed hope that their findings will encourage other tertiary care centers to evaluate PE with an algorithm that includes surgical embolectomy.

Before October 1999, only one to three embolectomies were performed at Brigham and Women’s Hospital each year. Due to the high rate of major bleeding complications with thrombolysis, however, Dr. Goldhaber and colleagues decided to expand their criteria for embolectomy to include patients who had extensive PE and moderate to severe right ventricular dysfunction but who still exhibited stable hemodynamics.

The patients in the study, whose mean age was 61 years, all had large central emboli in the right and/or left pulmonary artery. Many presented with a true saddle embolism.

A PE diagnosis was established preoperatively by lung scan or chest computed tomography; only five patients underwent pulmonary angiography. All of the 26 patients who underwent preoperative echocardiography displayed moderate or severe right ventricular dysfunction.

Several factors contributed to this study’s high survival rate (26 patients survived surgery and were still alive a month later). First, the patients were carefully selected so that, on average, they were less critically ill than those in a previous series that associated pulmonary embolectomy with 30% mortality.[2]

Timely response was also crucial. Brigham and Women’s Hospital has a multidisciplinary team available 24 hours a day, seven days a week, throughout the year to rapidly evaluate pulmonary embolectomy candidates. “More than half of our patients had an embolectomy on the weekend, so it is important to be geared up around the clock,” stressed Dr. Goldhaber, who is also Director of the Anticoagulation Service at his institution.

Once identified, embolectomy candidates were rapidly transported to the operating room despite their apparent hemodynamic stability. There, the surgeons took steps to minimize perioperative morbidity and mortality, such as keeping the heart warm, beating, and well perfused to aid cardiac recovery and avoiding blind maneuvers near the pulmonary arteries to keep from damaging the fragile vessels.

The team also gleaned three caveats from patients who did not survive. First, always place a vena caval filter perioperatively to prevent recurrent PE. Second, patients who arrest outside the hospital do not survive unless a spontaneous heart rate can be restored before surgery. Third, octogenarians who have contraindications to surgery in addition to age are not suitable candidates for the procedure.

Another crucial factor in successful embolectomy is committing to the procedure without hesitation when it appears to be appropriate. “Do not wait too long,” advised Dr. Goldhaber. “If you wait until the patient develops multisystem organ failure or is dependent on high doses of pressor agents, it may be too late.”

—Timothy Begany

References
1. Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Acute pulmonary embolectomy: a contemporary approach. Circulation. 2002;105:1416-1419.
2. Aklog L. Emergency surgical pulmonary embolectomy. Semin Vasc Med. 2001;1:235-246.

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