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Pulmonary embolectomy
Pulmonary Embolectomy Arthur C. Beall, Jr, MD Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas
A
lthough Trendelenburg first suggested pulmonary embolectomy as early as 1908 [l],it remained for Kirschner, a pupil of Trendelenburg, to perform the first such operation associated with complete recovery in 1924 [2].In the ensuing years many attempts to duplicate this heroic surgical feat almost universally met with failure. As late as 1961 only 23 reports of long-term survival after pulmonary embolectomy could be found in the world medical literature. Successful pulmonary embolectomy using cardiopulmonary bypass first was reported in 1961 [3].Since that time numerous similar successes have been reported, and it has become apparent that cardiopulmonary bypass not only allows resuscitation of the moribund patient with acute massive pulmonary embolism, but also provides sufficient time to adequately remove embolic material from the pulmonary arterial tree. Nevertheless, many have questioned the usefulness of this procedure, citing extremely high operative mortality rates. Most of these objections to pulmonary embolectomy have been based on the fact that many operations were performed on patients who did not have massive pulmonary embolism. Others have assumed that the moribund patient with acute massive pulmonary embolism must live for at least
See also page 232. an hour after pulmonary angiography for pulmonary embolectomy to be feasible. This argument is antiquated and fails to appreciate modern technological advances, including portable cardiopulmonary bypass equipment and the availability of organized surgical teams. Still others have stated that pulmonary embolectomy never is indicated. Nevertheless, a substantial number of patients continue to die of pulmonary embolism each year. It seems that the negative literature regarding surgical intervention has promoted a nihilistic attitude and currently many physicians never even consider the possibility of pulmonary embolectomy for the moribund patient. Occasionally, the subject is brought up at mortality and morbidity conferences after the patient has died. The inescapable conclusion is that, however infrequent, the opportunity to salvage an otherwise helpless situation is missed. Only with a high index of suspicion and a prearranged plan of approach to the dying patient with acute, massive pulmonary embolism can a substantial number of these patients be salvaged. Address reprint requests to Dr Beall, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
0 1991 by The Society of Thoracic Surgeons
In this issue a 20-year experience with pulmonary embolectomy performed at one center in Paris is reported [4]. Ninety-six consecutive patients, of whom 92 had a definitive diagnosis by pulmonary angiography and 4 by perfusion lung scan, underwent pulmonary embolectomy with a salvage rate of 63%. The authors of this study conclude that most patients with pulmonary embolism can be treated by thrombolytic therapy and that pulmonary embolectomy only should be considered in hemodynamically compromised patients, in those in whom thrombolytic therapy is contraindicated, and in those so severely affected that the time required by an attempt at medical therapy is thought to be unacceptable. These conclusions are valid and are supported by their data and others. Most patients with pulmonary embolism can be treated medically with only the occasional patient requiring pulmonary embolectomy for survival. In this small group of moribund patients with massive pulmonary embolism, however, the most likely outcome would be death in virtually all without operation. Even after cardiac arrest the patient with massive pulmonary embolism often can be resuscitated by femoral vein to femoral artery cardiopulmonary bypass, thus providing oxygenated blood to such vital areas as the heart, brain, and kidneys [5]. With currently available portable pump oxygenators such a patient then can undergo pulmonary angiography for definitive diagnosis [6]. Finally, only those shown to have massive pulmonary embolism would be taken to the operating room for pulmonary embolectomy . With such an approach salvage rates for the few patients needing this procedure can be sizable. It is illogical to abandon a therapeutic modality that has the ability to correct a lethal mechanical problem in an otherwise salvageable patient.
References 1. Trendelenburg F. Ueber die operative Behandlung der Embolie der Lungenraterie. Arch Klin Chir 1908;86:686-700. 2. Kirschner M. Ein durch die Trendelenburgsche Operation Geheilter Fall Embolic der Art. Pulmonalis. Arch Klin Chir 1924;133:312-59. 3. Cooley DA, Beall AC Jr, Alexander JK. Acute massive pulmonary embolism. Successful surgical treatment using temporary cardiopulmonary bypass. JAMA 1961;177:28?-6. 4. Meyer G, Tamisier D, Sors H, et al. Pulmonary embolectomy: a Byear experience at one center. Ann Thorac Surg 1991;51:2324. 5. Beall AC Jr, Al-Atlar A, Mani P, Tuttle LLD Jr. Resuscitation after acute massive pulmonary embolism. J Thorac Cardiovasc Surg 1965;49:726-31. 6. Mattox KL, Feltman RW, Beall AC Jr, DeBakey ME. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Surg 1982;195:72&31.
Ann Thorac Surg 1991;51:179
0003-4975/91/$3.50
A
lthough Trendelenburg first suggested pulmonary embolectomy as early as 1908 [l],it remained for Kirschner, a pupil of Trendelenburg, to perform the first such operation associated with complete recovery in 1924 [2].In the ensuing years many attempts to duplicate this heroic surgical feat almost universally met with failure. As late as 1961 only 23 reports of long-term survival after pulmonary embolectomy could be found in the world medical literature. Successful pulmonary embolectomy using cardiopulmonary bypass first was reported in 1961 [3].Since that time numerous similar successes have been reported, and it has become apparent that cardiopulmonary bypass not only allows resuscitation of the moribund patient with acute massive pulmonary embolism, but also provides sufficient time to adequately remove embolic material from the pulmonary arterial tree. Nevertheless, many have questioned the usefulness of this procedure, citing extremely high operative mortality rates. Most of these objections to pulmonary embolectomy have been based on the fact that many operations were performed on patients who did not have massive pulmonary embolism. Others have assumed that the moribund patient with acute massive pulmonary embolism must live for at least
See also page 232. an hour after pulmonary angiography for pulmonary embolectomy to be feasible. This argument is antiquated and fails to appreciate modern technological advances, including portable cardiopulmonary bypass equipment and the availability of organized surgical teams. Still others have stated that pulmonary embolectomy never is indicated. Nevertheless, a substantial number of patients continue to die of pulmonary embolism each year. It seems that the negative literature regarding surgical intervention has promoted a nihilistic attitude and currently many physicians never even consider the possibility of pulmonary embolectomy for the moribund patient. Occasionally, the subject is brought up at mortality and morbidity conferences after the patient has died. The inescapable conclusion is that, however infrequent, the opportunity to salvage an otherwise helpless situation is missed. Only with a high index of suspicion and a prearranged plan of approach to the dying patient with acute, massive pulmonary embolism can a substantial number of these patients be salvaged. Address reprint requests to Dr Beall, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
0 1991 by The Society of Thoracic Surgeons
In this issue a 20-year experience with pulmonary embolectomy performed at one center in Paris is reported [4]. Ninety-six consecutive patients, of whom 92 had a definitive diagnosis by pulmonary angiography and 4 by perfusion lung scan, underwent pulmonary embolectomy with a salvage rate of 63%. The authors of this study conclude that most patients with pulmonary embolism can be treated by thrombolytic therapy and that pulmonary embolectomy only should be considered in hemodynamically compromised patients, in those in whom thrombolytic therapy is contraindicated, and in those so severely affected that the time required by an attempt at medical therapy is thought to be unacceptable. These conclusions are valid and are supported by their data and others. Most patients with pulmonary embolism can be treated medically with only the occasional patient requiring pulmonary embolectomy for survival. In this small group of moribund patients with massive pulmonary embolism, however, the most likely outcome would be death in virtually all without operation. Even after cardiac arrest the patient with massive pulmonary embolism often can be resuscitated by femoral vein to femoral artery cardiopulmonary bypass, thus providing oxygenated blood to such vital areas as the heart, brain, and kidneys [5]. With currently available portable pump oxygenators such a patient then can undergo pulmonary angiography for definitive diagnosis [6]. Finally, only those shown to have massive pulmonary embolism would be taken to the operating room for pulmonary embolectomy . With such an approach salvage rates for the few patients needing this procedure can be sizable. It is illogical to abandon a therapeutic modality that has the ability to correct a lethal mechanical problem in an otherwise salvageable patient.
References 1. Trendelenburg F. Ueber die operative Behandlung der Embolie der Lungenraterie. Arch Klin Chir 1908;86:686-700. 2. Kirschner M. Ein durch die Trendelenburgsche Operation Geheilter Fall Embolic der Art. Pulmonalis. Arch Klin Chir 1924;133:312-59. 3. Cooley DA, Beall AC Jr, Alexander JK. Acute massive pulmonary embolism. Successful surgical treatment using temporary cardiopulmonary bypass. JAMA 1961;177:28?-6. 4. Meyer G, Tamisier D, Sors H, et al. Pulmonary embolectomy: a Byear experience at one center. Ann Thorac Surg 1991;51:2324. 5. Beall AC Jr, Al-Atlar A, Mani P, Tuttle LLD Jr. Resuscitation after acute massive pulmonary embolism. J Thorac Cardiovasc Surg 1965;49:726-31. 6. Mattox KL, Feltman RW, Beall AC Jr, DeBakey ME. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Surg 1982;195:72&31.
Ann Thorac Surg 1991;51:179
0003-4975/91/$3.50