Massive Pulmonary Embolism
Edgard Turnier, MD,* San Francisco, J. Donald Hill, MD, San Francisco,
California
California
William J. Kerth, MD, San Francisco, California Frank Gerbode, MD, San Francisco, California
The dramatic symptoms caused by massive pulmonary embolism are sudden excruciating chest pain with marked dyspnea and a shocklike state. Massive pulmonary embolism usually occurs in the hospitalized bedridden patient and frequently leads to sudden death. These attacks are often diagnosed incorrectly, and the diagnostic difficulties are compounded by the precarious state of the victim. Modern diagnostic means such as the pulmonary scan and angiograms have added to the accuracy of diagnosis. In addition, a better understanding of the technics of resuscitation and the develoi>ment of means of temporary support of the cardiopulmonary system have changed the outlook in situations that would otherwise have an almost uniformly fatal outcome. There is only limited experience among individual physicians or medical centers in the surgical management of these patients. Present attitudes are based on the accumulated experience of many centers. The purpose of this study is to report on the anatomic, clinical, and diagnostic information gathered from retrospective review of the cases of emboli seen in our institution, with emphasis ov a surgical approach to treatment. We will also rep.)rt on our opera-
From the Heart Research Institute of the Institute of Medical Sciences and Presbyterian Hospital of the Pacific Medical Center, San Francisco, California. This work was aided in part by USPHS Grant HE 06311 and the Bay Area Heart Research Committee. Reprint requests should be addressed to Dr Hill, Institute of Medical Sciences, 2200 Webster Street, San Francisco, California 94115. *Fellow in Cardiovascular Surgery, the Institute of Medical Sciences, 2200 Webster Street, San Francisco, California, and Recipient of Bay Area Heart Research Committee Award, 1971-1972.
Volume 125, May 1973
experience with eight cases of massive pulmonary embolism. In addition, we will review the literature on the results of the surgical treatment of massive pulmonary embolism. tive
Material and Method Material. The records of 473 patients from our center were reviewed for the period between 1963 and March 1971. In 269 of these patients, the diagnosis of pulmonary embolism was based only on clinical signs and symptoms, plain chest roentgenogram, electrocardiogram, and enzymes. There was no death among them. In addition to these 269 patients, 41 patients had pulmonary scans, performed by using macroaggregated albumin tagged with I131 or, more recently, selenium. During the same period, 1,373 autopsies were performed at our center. In 149, pulmonary emboli were found. The patients ranged in age from seventeen to ninety-eight, the mean being sixty-four. There were seventy-three males and seventy-six females. Table I gives the extent of involvement. Additional observations concerning t.he main associated diagnosis in these cases are summarized in Table II. Table’111 presents a summary of some of the relevant data concerning the eight patients operated upon. Method. In this presentation, the term, massive pulmonary embolism, will refer to emboli involving the main pulmonary artery and/or the right and left main branch. All the branches of the right and left pulmonary arteries may be similarly involved. References 1 to 44 represent a list of the publications reviewed. We are aware of the probability of overlooking some publications and wish to apologize in advance to the interested authors for such unintentional omissions. In 1967 Cross and Mowlem [43] published a survey of the surgical experience in the treatment of massive pulmonary em-
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et al
bolism in the United States and Canada. In 1969 Marion and Estanove [44] published a similar study of the French experience. To avoid duplicating data, we have added to their figures only those American and Canadian reports published after 1967, French reports published after 1969, and our own unreported cases. Results and Comments
Autopsy Review. Some salient features are apparent from an analysis of the data related to the 149 autopsy cases in which emboli were found. 1. The mean age of the patients was sixty-four years. The result of treatment in this age group is limited by that factor. 2. In 54 per cent of the 149 autopsy subjects, the embolic phenomenon was the main or one of the main causes of death. If to those cases are added cases of unilateral embolization, which presented with an acute clinical picture, and cases of scattered emboli (apparently involving more than 50 per cent of the pulmonary tree), then in 65 per cent of the cases the embolism contributed substantially to the cause of death. 3. In 37 per cent of the cases there was an organizing infarct or emboli adherent to the pulmonary artery, suggesting that embolization occurred in stages. This implies that preventive treatment applied after the first stage or stages would have had better results. 4. An analysis of Table II strongly indicates that a poor result would have occurred regardless of the type of treatment, since many of the patients with massive pulmonary embolism had additional serious illnesses. In fact, it was apparent that 75 per cent were virtually hopeless cases, the patients having metastatic carcinoma, recent myocardial infarct, cerebrovascular accident, infarct of peripheral organ or vessels, generalized severe atherosclerosis, cardiomyopathy, TABLE I
Summary
of Autopsy
Findings
(1963-l
Number of Cases Massive emboli Right or left pulmonary artery Multiple emboli, not all branches Emboli involving: One lobe Two lobes Three lobes Four lobes Organizing infarct only Total Infarct associated Adherent emboli Total
612
with emboli
69 12 3 19 14 4 3 5 129 37 9 46 (37%)
971) Per cent
54 9 2 15 11 3 2 4 100
superior vena cava syndrome, degeneration of the spinal cord, and car pulmonale. 5. Table IV presents the forty-seven cases of bilateral embolization in which an acute onset of symptoms permitted an accurate determination of the time elapsed between the onset and the time of death. In view of the minimal time required, under the best conditions, to establish support of the cardiopulmonary system, such a factor is of obvious importance and has been mentioned often before. In five cases the mean survival time was six days (intravenous heparin treatment in three of these patients probably repre-
TABLE II
Main Associated Diagnoses
Metastatic carcinoma Peripheral vein thrombosis Mural thrombosis, heart Recent myocardial infarction Pneumonia Old myocardial infarction Cerebrovascular accident Pulmonary hypertension (car pulmonale) Status postoperatively Congestive heart failure Infarction of peripheral organ or vessel Liver disease Rheumatic heart disease Generalized severe atherosclerosis Septicemia Prosthetic valve replacement Carcinoma (no metastasis) Hip fracture Pancreatitis Peritonitis Bleeding ulcer Endocarcfitis Retroperitoneal hemorrhage Pericarditis Brown atrophy of heart Cardiomyopathy (idiopathic) Superior vena cava syndrome Myocarditis Degeneration of spinal cord Kidney disease (pyelonephritis)
Total Cases
Per cent of 129
Massive Emboli
30
23.25
17
25 23
19.37 17.82
19 14
21 19 18 18
16.27 14.72 13.95 13.95
10 9 6 11
11 8 7
8.52 6.20 5.42
5 3 3
6 5 5
4.65 3.87 3.87
3 2 2
5 4
3.87 3.10
3 3
4
3.10
1
3 2 2 2 2 2
2.32 1.55 1.55 1.55 1.55 1.55
2 1 1 1 1 1
2 1 1
1.55 0.77 0.77
1
0.77
1 1
0.77 0.77
1
0.77
1
0.77
The American Journa\ 01 Surgery
Massive
TABLE III
Embolism
Summary of Data on Patients Operated Upon
Age W) Patients
and Sex
Status before Emboli
1. KC
46, F
2. VB
54, F
3. PB
71, F
4. SA
62, M
5. DS
33. F
6. GT
56, M
7. WC
75. M
a. PP
58, M
2 wk post abdominal hysterectomy 4 wk post fractured ankle, cast 2 wk history of shortness of breath 4 days after heavy lifting 7 wk history of shortness of breath, treated for asthma 1 wk post exploratory laparotomy Diabetic, treated 1 wk for upper respiratory infection 1.5 wk first osteotomy femur, cast
Pulmonary Angiogram
PAP Mean P
Clots
Yes
29
Bilateral
Hypotensive
Alive
Yes
69
Bilateral
Hypotensive
Alive
Yes
40
Bilateral
Hypotensive
Alive
Bilateral
Cardiac arrest
Dead
Bilateral
Cardiac arrest
Dead
Bilateral
Cardiac arrest
Dead
Bilateral
Hypotensive
Dead
Bilateral
Cardiac arrest
Dead
Yes No
.
No Yes
Intravenous angiogram -
sents an important factor in their long survival). In the remaining forty-two cases the mean survival time was approximately eleven hours. A breakdown of these cases shows that 36 per cent survived less than one hour; the chances of establishing cardiopulmonary support were very limited. The chances were better for the 6 per cent who survived between one and two hours. For the remaining 58 per cent who survived more than two hours, the establishment of partial cardiopulmonary bypass might have been lifesaving. Table IV presents the main associated diagnosis and the age of the forty-seven patients in order to stress once more the importance of age and serious illness in evaluating the patient’s over-all condition. 6. In a similar manner, Table V describes twentytwo patients with 50 per cent or less of the pulmonary tree obstructed by emboli. As a whole, these patients are a decade younger; however, their mean survival time was quite comparable to that of the patients with massive emboli and the clinical picture was similar. This further emphasizes the importance of associated conditions. 7. There were twenty-three patients with associated mural thrombosis of the different heart chambers (Table III), representing 18 per cent of the total autopsy group reviewed. Twelve of the twentythree cases involved the right heart chambers. The remainder was distributed as follows: left atrium, three; left ventricle, eight. Peripheral or cerebral embolization from a detached thrombus represents a threat in the postoperative course of such patients. These findings further emphasize the fact that cardiopulmonary bypass is a necessity in surgical
Volume125,May1973
Pulmonary
37
Status before Surgery
Result
treatment since it permits exploration of the right heart. 8. A 19 per cent incidence of peripheral vein thrombosis (Table II) is probably an incomplete tabulation since it refers only to thrombi found in the iliac, periurethral, periprostatic, and ovarian veins. The peripheral veins of arms and legs are usually not dissected during routine autopsy. Ligation of the inferior vena cava, anticoagulant therapy, or both have been advocated in dealing with such cases. We agree with such an approach; an evaluation of its merits is beyond the scope of this paper. 9. The finding of microscopic emboli in twenty cases (Table I) is difficult to assess with certainty. In patients without gross embolization, a random biopsy specimen of the lung was usually submitted for section. In some cases the specimen was taken from a suspicious area or an area with gross pathologic changes such as those caused by pneumonia. The possibility of widespread or total involvement cannot be confirmed or denied at the present time. The consequences of this form of embolization would be similar to those of gross massive embolization. In the future more attention should be paid to microembolization. 10. In twenty cases with autopsy confirmation of pulmonary embolism, some enzyme determinations (serum glutamic oxalacetic transaminase, serum glutamic pyruvic transaminase, and lactic dehydrogenase) were made. We considered the serum enzyme elevated when the level was twice or more the accepted upper limit of normal. In seventeen of these twenty cases the serum enzyme levels were elevated.
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TABLE
IV
Time of Survival
after Massive
Time between Diagnosis and Death
Pulmonary
Embolism
Associated
Type
48 hrs
Saddle
50 min
Saddle
1 hr
All secondary
6 hrs 48 hrs
All small branches All secondary branches
15 min 48 hrs
Right and left pulmonary artery Main pulmonary artery partially adherent
40 min 20 min 15 min 15 min 30 min 5 hrs 42 min 5 hrs 2 hrs
Saddle Saddle Saddle Right and left pulmonary Saddle All secondary branches Saddle Right and left pulmonary Secondary branches
15 min 24 hrs
Saddle Right and left pulmonary
artery
24 hrs
Right and left pulmonary
artery
30 min
All secondary
branches
48 hrs 15 min
All secondary Saddle
branches
8 hrs, 30 min
Right and left pulmonary
48 hrs
Main pulmonary branches
15 min
Secondary
35 min
Main pulmonary
50 min 15 min
All secondary branches Left pulmonary artery and small branches on the right
branches
artery
artery
artery
artery and all
branches artery
Clinical Diagnosis. Eighteen of the forty-one patients in the clinical group who had a pulmonary scan also had determination of the serum enzyme level. There was a positive correlation between the two methods in seven cases. In the remaining eleven patients with a positive pulmonary scan, the serum enzyme levels were not elevated.
614
Main Diagnosis
Age (yr)
Chronic pulmonary emphysema; thrombosis of periurethral and prostatic vein Status post Smith-Peterson nailing for right hip fracture; atrial fibrillation Pericarditis with pericardial effusion (1,000 cc); bilateral femoral vein thrombosis, treated with heparin Cor pulmonale thrombosis of right atrial appendage Arteriosclerotic heart disease with congestive heart failure Metastatic adenocarcinoma of endometrium Mitral stenosis, myocardial infarction, aortic stenosis, mitral insufficiency, emergency valve replacement, died in operating room Adenocarcinoma of esophagus with metastasis Cerebrovascular accident, acute Pulmonary arteriolar sclerosis, bronchiectasis Cerebrovascular accident Degeneration of spinal cord Pancreatitis, acute myocardial infarction Cerebrovascular accident, arrhythmia Cancer of stomach with metastases Acute myocardial infarction, thrombosis of right vein, peripheral vein thrombosis Cirrhosis of liver, Laennec pulmonary abscess Arteriosclerotic heart disease, congestive heart failure 2 days post endarterectomy. bifurcation of aorta, thrombosis of renal artery Acute myocardial infarction, cerebrovascular accident, status post resuscitation for cardiac arrest 5 days Cor pulmonale Widespread metastasis from breast cancer, car pulmonale Cellulitis of right leg, thrombosis of ileofemoral vein. treated with heparin Admitted in severe shock, biventricular dilatation, diabetes melitus, postoperative below the knee amputation for gangrene Acute anterolateral myocardial infarction, pulmonary fibrosis Pulmonary emphysema, thrombosis, recent periurethral periprostatic venous thrombosis Myocardial infarction, recent, septal Pneumonitis with microabscesses septicemia serratia
78 a7 68
46 61 77 63
59 75 77 69 40 67 62 63 56 67 71 62 70
68 66 75 72
67 78 87 57
The correlation between pulmonary scan and plain chest roentgenogram was also examined. It was considered strong when identical areas of involvement were described for both. A correlation was considered weak when there was a partial overlapping of areas involved. A positive correlation with time refers to the development of positive roentgenographic findings
The American Journal of Surgery
Massive Pulmonary Embolism
TABLE IV
Continued
Time between Diagnosis #and Death
Associated
Type
24 hrs 30 min 15min
Saddle All branches All secondary
branches
1 hr, 33 min
All secondary
branches
4 hrs, 40 min 4 days
All secondary branches Right and left pulmonary artery adherent Right and left pulmonary artery branches Saddle Left pulmonary artery and all secondary adherent organ All secondary branches
3 days 15 min 11 days 4 hrs
5 hrs
Right and left pulmonary adherent organizing Right and left pulmonary Right and left pulmonary organizing Left and right pulmonary
2.5 hrs
Left pulmonary
48 hrs 15 min
Left and right pulmonary artery Left pulmonary artery and scattered emboli, right and left Saddle, small infarcts Main, left, and right pulmonary artery and branches, infarct
9 days 6 hrs 4 days
30 min 3 hrs
artery, artery artery, artery
artery branches
Main Diagnosis
Age (yr)
Metastatic melanoma, thrombosis of iliac vein Myocardial infarction, recent Postoperative 4 day resection with ventricular aneurysm, bilateral bronchial pneumonia, congestive heart failure Rheumatic heart disease, subacute bacterial endocarditis; thrombosis of iliac and pelvic vein Cerebrovascular accident Ligation of inferior vena cava, 3 wk before cerebral atherosclerosis Metastasis, cancer of colon, resected 3 mo before
62 70 62
Pneumonitis, severe bilateral abscess formation Cerebrovascular accident treated with heparin
60 61
Metastasis from cancer of lung, pneumonia, subacute resolving Primary cardiomyopathy, infarction, thrombosis right and left ventricle Status postoperatively (2 days) Metastatic adenocarcinoma of rectum
54 of
48 a3
64
19 61 64
Astrocytoma spinal cord, status 10 days, postoperatively, thrombosis of periprostatic and femoral vein Status 4 wk post right middle lobe, right lower lobe lobectomy. extension of carcinoma to left Carcinoma of stomach, ascites, chronic alcoholism Pneumonitis with microabscesses, septicemia (serratia); infarct, spleen, kidney
46
Pericolic abscess, septicemia Adenocarcinoma of right lower lobe with metastases to hilum
70 65
78 63 57
Total number of cases: 47 Mean age: 63 years Age range: 46 to 67 years 42 cases 11 hours 5 cases 6 days Number
Per cent
17 3 27
36 6 58
Cases surviving: Less than 1 hr Between 1 and 2 hrs More than 2 hrs
similar to those of the pulmonary scan with repeated examination. The results are as follows: total number of cases, thirty-six; strong correlations, twelve; weak correlations, eight; positive correlations with time, eleven; no correlation, five. The overlapping of autopsy findings, pulmonary scan, and pulmonary angiogram amounted to less
Volume 125, May 1973
than ten cases for each and therefore will not be presented. Surgical Experience. Eight patients were operated on. (Table III.) The age range was thirty-three to seventy-one years, with a mean age of fifty-seven. There were four male and four female patients. All had clots in both pulmonary arteries. Four had hy-
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potension and four had cardiac arrest prior to surgery. All the patients except one (number 8) had been transferred from other hospitals after prolonged periods of hypotension. Most of them were in severe distress on admission. Confirmation of the clinical diagnosis was based mainly on cardiac catheterization data and selective pulmonary angiography. In patients 5, 6,
TABLE V
Time of Survival after Limited Pulmonary Embolism
Time between Diagnosis and Death
Associated
Type
20 min
Right pulmonary
5 hrs 24 hrs 1 wk
Right pulmonary artery Multiple pulmonary emboli, small peripheral, bilateral Scattered emboli and infarction
12 hrs
Right pulmonary
14 hrs, 35 min 4 hrs
Left pulmonary artery and branches Emboli and infarct left upper and lower lobes, right lower lobe Emboli, right upper and lower lobes, left lower lobe Emboli, right upper and lower lobe; scattered infarct
1 hr 40 min
15 min 15 min
artery branches
artery branches
16 hrs 48 hrs 4 hrs
Emboli left lower lobe Emboli right lower lobe, left lower lobe, and scattered small infarct right lower lobe Emboli and infarct, left lower lobe Emboli and infarct Right pulmonary artery branches Left pulmonary artery
1 hr, 17 min 15 min 24 hrs
Emboli and infarct, right lower lobe Left pulmonary artery Emboli, right lower lobe
15 min 15 min 24 hrs
Right pulmonary artery Bilateral scattered Branches right pulmonary artery, infarct, right lower lobe Scattered embolism and infarct
15 min
5 hrs
and 8 the urgency of the situation prevented such an approach. An initial groin cannulation for partial cardiopulmonary bypass was performed in patients 4, 6, and 8. For those in whom cannulation was not performed, an increase in the severity of hypotension after induction of anesthesia occurred. There were three survivors. Ligation of the inferior vena cava
Main Diagnosis
616
57
Status postoperatively: 2 wk, carotid endarterectomy; 10 hrs, aortorenal anastomosis; 3 hrs, femoral endarterectomy; thromboembolism of right iliac vein Degeneration of spinal cord with paraplegia Myocarditis acute, subacute, mural thrombus, left ventricle, right ventricle, renal artery Arteriosclerotic heart disease, congestive heart failure, arrhythmia, old myocardial infarction Malignant lymphoma of stomach: widespread thrombosis of left common iliac vein Car accident: multiple fractures, contusion of heart, resuscitation Rheumatic heart disease, chronic congestive heart failure Bronchogenic carcinoma, metastasis; thrombosis renal and periprostatic vein Atrial stenosis; chronic congestive heart failure; mural thrombus of renal artery, thrombosis of periprostatic vein Cerebrovascular accident, bronchopneumonia Metastatic carcinoma of pancreas, status post abdominal exploration, 12 days Chronic alcoholism,
acute intoxication
59 48 57 43 72 46
of
60 50
67 63
57
Arteriosclerotic heart disease, cardiomegaly Cardiovascular accident; pulmonary fibrosis Bleeding gastric ulcer, left ventricular hypertrobhy, old myocardial infarction
a2 58 98
Intractable congestive heart failure, old extensive myocardial infarction
70
Acute myocardial infarction of left ventricle, septicemia Widespread metastasis, carcinoma of colon Cor pulmonale Old and recent myocardial infarction, anterior, lateral, and septal Fever of undetermined origin, thrombosis of inferior
69
vena cava below ligation, Total number M.ean time: Mean age: Age range:
Age fyr)
54 17 81
status postop 24 hrs
of cases: 22 8.76 hours; 1 case, 7 days 55 years 17 to 98 years
The American Journal of Surgery
Massive Pulmonary Embolism
was performed in all of them at the end of the procedure. There were no late deaths. Autopsy in patients 5 and 7 revealed the presence of remaining clots. The plain chest roentgenogram in patient 2 and a pulmonary scan in patient 3 suggested the presence of remaining clots. Literature Review. Table VI shows the accumulated number of reported cases of massive pulmonary emboli in which operation was performed, with and without cardiopulmonary bypass, up to October 1971. The percentage of survivors is indicated. The cases reported since 1967 (1969 for France) are presented in the lower part of the table.
TABLE VI
TABLE VII
Survivors
Total Cases Cardiopulmonary bypass Trendelenburg Inflow occlusion Unilateral pulmonary clamping Total
Per cent
306 110 25 21
158 23 16 13
51.63 20.90 64.00 62.00
462
210
45.45
Cases Published Since 1967* Cardiopulmonary bypass No assisted circulation
Comments Incidence. Several objections can be raised to the method of autopsy review as a means of estimating the incidence of pulmonary embolism. These include: (I) the sample population consists only of the patients who died; (2) an autopsy was not performed in all the fatal hospital cases; and (3) the population already represents a selection since the hospital is predominantly private with no obstetric or pediatric service. The incidence of 11 per cent found in our study, if not the true incidence of emboli cases, nonetheless represents the situation faced by many clinicians. Diagnosis. It is of interest that of the 129 cases with gross autopsy findings of embolization, pulmonary infarct, or both, the diagnosis had been made in only sixteen patients (12.4 per cent). Associated Illnesses. Formerly, only those cases of almost total occlusion of the pulmonary vascular tree were classified as massive emboli.* In 1923 Haggart and Walker [45], in a well conceived experiment, demonstrated that obstruction of as much as 50 to 60 per cent of the pulmonary vascular system can be tolerated with minimal or no hemodynamic and respiratory changes. Several other investigators have since confirmed and expanded those findings both experimentally and surgically. It is also known, however,
Compiled Statistics for Pulmonary Embolectomy
104
74
71.15
26
16
61.53
* Since 1969 for France.
that the degree of cardiopulmonary compensation is dependent on the integrity of the cardiovascular and pulmonary system. This is illustrated by the cases reviewed which had 50 per cent or less obstruction of the pulmonary tree, but which, when their status was precarious, presented a clinical picture comparable to that of the massive emboli cases. The age group of the patients in whom embolus occurred with greatest frequency was also the one with more frequent associated cardiac and pulmonary impairment. Survival Rate. A survival rate of less than 50 per cent among patients undergoing embolectomy with cardiopulmonary bypass in the United States and Canada was reported by Cross and Mowlem [43] in 1967; however, since 1967 (since 1969 for France), the over-all survival has markedly improved (Table VI), reflecting the greater familiarity of the different centers with the technics of open heart surgery and the methods of resuscitation. Mechanisms sf Change. Two explanations are usually given for the changes occurring with massive
Possible Influential Factors in Surviving Cases* Cardiopulmonary Number of Cases
Survivors
No Assisted Circulation
Bypass
Per cent
Number of Cases
Survivors
Per cent
Clots Bilateral Unilateral
30 12
24 10
80 83.33
23 16
8 14
34.78 87.50
Status before surgery Hypotension Cardiac arrest
39 14
27 7
69.23 56
15 6
7 4
46.66 66.66
*Cases reported
since 1967.
Volume 125, May 1973
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Turnier et al
Figure IA. Pulmonary angiogram taken on January 72, 1970 showing complete occlusion of the left pulmonary artery, saddle embolus at the bifurcation of the right pulmonary artery, and additional peripheral emboli. Figure 16. Pulmonary scan; left anterior oblique projection taken January on 12, 1970. Figure 1 C. Pulmonary scan; right anterior oblique projection taken on January 12, 1970.
pulmonary embolism: a mechanical obstruction and a reflex phenomenon. Neither one alone is sufficient to explain the changes observed in all cases, but the cardiovascular surgeon can make a strong point for the irreversible changes secondary to marked dilation and stretching of the myocardium when the ventricles are placed between an obstruction of the outflow tract on one side and a competent mitral or tricuspid valve on the other. The resulting myocardial ischemia, if prolonged and severe, soon reaches a point at which recovery is impossible. Nonoperative Approach. A nonoperative approach to extensive pulmonary embolization is based mainly
618
on two assumptions as follows: (1) the cardiovascular and respiratory systems can withstand and compensate for the severe limitation; (2) a resolution of the embolus occurs fast enough to result in spontaneous recovery. The case of patient FL illustrates both possibilities. She was hospitalized in severe shock and recovered after conservative management. This patient had undergone cholecystectomy followed three weeks later by abdominal exploration for intestinal obstruction. One week after exploration she had the sudden onset of severe right-sided chest pain and she became dyspneic and hypotensive. Figures 1, 2. and 3 show the findings on pulmonary scan and angio-
The American Journal of Surgery
Massive Pulmonary
Figure 2A. Pulmonary angiogram 1970 showing marked improvement.
taken
on January
Embolism
21,
Figure 28. Pulmonary scan taken on January 21, 1970; tett anterior oblique projection showing some improvement. Figure 2C. Pulmonary scan taken on January 21, 1970; right anterior oblique projection showing some improvement.
grams. She was initially treated with intravenous heparin followed by oral Coumadin@. Considerable work has been carried out and is in progress to evaluate the results of nonoperative treatment of extensive pulmonary embolism. The intravenous administration of heparin, streptokinase, and urokinase is being evaluated [46-491. A cooperative study conducted in the United States shows encouraging early results with streptokinase of a 9 per cent mortality and 19 per cent recurrent emboli [46]. A marked hemodynamic and pulmonary improvement in the patients treated has been reported. The majority of the nonoperative patients studied, however,
Volume
125,
May
1973
represent a highly selected group of patients who had achieved a satisfactory level of hemodynamic and respiratory compensation and had no associated severe complications. This eliminates the patients usually referred to surgery, that is, those not improved by any initial supportive therapy. In addition, in patients with chronic pulmonary hypertension secondary to obstruction of the pulmonary tree by organizing emboli, it is not proved that the use of enzymes will relieve the obstruction. The results of surgery, on the other hand, have been gratifying [8]. Operative Approach. With the introduction of cardiopulmonary bypass in the surgical management of
619
Turnier et al
Figure 3A. Pulmonary angiogram taken on April 4, 1970 showing almost complete disappearance of the obstructions in the distal pulmonary branches. Figure 36. Left anterior oblique projection April 4, 1970 showing marked improvement.
taken
on
Figure 3C. Pulmonary scan taken on April 4, 1970; right anterior oblique projection showing marked improvement.
massive pulmonary embolism by Cooley, Beall, and Alexander [50] and Sharp [51] in 1961, a revolutionary approach to surgical treatment began. Immediate decompression of the right heart and an improvement in oxygenation are made possible by cardiopulmonary bypass. Surgical removal of the clots eliminates the obstruction. Cooley and Beall [52-541 subsequently outlined a mode of approach to the management of massive pulmonary embolism which is used widely. The patients selected are in refractory shock, and ideally a partial cardiopulmonary bypass by groin cannulation is initiated prior to thoracotomy. In an attempt to evaluate the possible deleterious effects of prolonged hypotension, cardiac arrest, or
620
both in the outcome of patients operated on, we selected from the cases published since 1967 (Table VII) a group of patients who were reported to have hypotension before operation, Similarly, we isolated a group of patients who had cardiac arrest before of survival was slightly surgery. The percentage lower in patients with hypotension and significantly lower in those with cardiac arrest, when compared with the over-all survival during that same period. As expected, the outcome was poorer in those operated on without assisted circulation. The Trendelenburg procedure, as described either in 1908 [55] or later in its different modifications, such as selective clamping of the main pulmonary artery
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Massive Pulmonary Embolism
[56], compounds the hemodynamic embarrassment before bringing relief by removal of the clot. The results, as shown in Table VI, are uniformly poor. The technic of inflow occlusion, with [57] or without [6] hypothermia, offers a better alternative since the overload of an already distended right ventricle is stopped. The Trendelenburg procedure and the latter methods. have in common an added loss of blood volume and a severe limitation of the time that can be afforded for completion of the procedure. The unilateral clamping of the right or left pulmonary artery, when involved alone, has good results in a carefully selected group. (Table VI.) The surgical approach to massive pulmonary embolization without assisted circulation currently has more than just historic interest, since in many parts of the world the facilities for cardiopulmonary bypass are either nonexistent or not readily available. A small group of patients not responding to conservative management can be benefited by such procedures. Also of interest is the method described by Greenfield at t.he annual meeting of the American Association of Thoracic Surgery in May 1971 in which a transvenous aspiration of clots in the pulmonary artery is performed through a double lumen catheter. In the three successful cases presented, there was immediate hemodynamic improvement although extended periods of pulmonary assistance were required. The over-all results of pulmonary embolectomy with cardiopulmonary bypass represent the effect of the bypass itself as well as the insult of operation in these critically ill patients. Most surgeons reported marked improvement in the patients’ clinical condition after the beginning of partial bypass. The improved performance of some current oxygenators allows safer use for prolonged periods [58-601. This strongly favors the development of a method of extended partial bypass for patients with massive pulmonary emboli in intractable shock, during which a large enough portion of the occluding clots can be lysed. As shown by the results of nonoperative management, this treatment is often sufficient to return the patient to his own cardiovascular and respiratory system, thus avoiding the burden of a thoracotomy. Summary and Conclusion
A review is presented of our total experience with pulmonary embolism. It includes 149 cases confirmed by autopsy, 310 cases diagnosed by clinical means and managed conservatively, and 8 cases in which operation was performed. In addition, a review of the world literature on the results of surgical management is presented.
“_I.....s
4?C
US”
,07R
The emphasis is placed on the following factors: (1) the probable importance of cases of microscopic emboli; (2) the mean age of occurrence and the associated conditions as a major factor influencing prognosis; (3) the high incidence (65 per cent) of embolization as a main contribution to the cause of death; (4) the feasibility of establishing cardiopulmonary bypass in 58 per cent of patients in severe distress from extensive pulmonary embolism; (5) an accumulated survival rate since 1967 of 71 per cent with cardiopulmonary bypass and 61 per cent without support; (6) the better results in cases of surgically treated unilateral embolization than in cases of bilateral embolization whether or not cardiopulmonary bypass was used; (7) the adverse effect of hypotension or cardiac arrest prior to surgery on prognosis. In view of the frequent failure during surgery to extract the clots lodged in the distal pulmonary branches, the likelihood that some of the clots will undergo spontaneous lysis, the effectiveness of some lytic enzymes used intravenously, and the safety of prolonged partial cardiopulmonary bypass, it is proposed that cases of massive pulmonary embolism with shock could be managed without thoracotomy by using prolonged partial cardiopulmonary bypass with or without lytic enzymes.
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