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Pulmonary embolectomy without cardiopulmonary bypass
Pulmonarv
Embolectomv
Cardiopulmonary Indications,
Diagnostic
without Bypass
Criteria,
and Case Report
RUDOLPH C. CAMISHION, M.D., LOUIS PIERUCCI, JR., M.D.,* NOEL H. FISHMAN, M.D., i WILLIAM FRAIMOW, M.D., AND ROY GREENING, M.D., Philadelphia, Pennsylvania
From the Departments of Surgery, Medicine, and Radiology, The Jefferson Medical College of Philadelphia, Philadelphia, Pennsylvania HE
METHOD
of performing pulmonary emhas progressed from the original technic of Trendelenburg [I] to that of making use of cardiopulmonary bypass [2,3]. Unquestionably, the latter procedure has enabled surgeons to remove pulmonary emboli much more safely than before, as witnessed by the fact that the successful operation for this condition is no longer a medical curiosity [4,5]. How-ever, with proper diagnostic technics, certain patients
T bolectomy
with pulmonary embolus can be operated upon with equal safety without bypass. The precise diagnostic maneuvers required to select patients for operation without extracorporeal circulation are outlined in this report. A successful case is presented.
FIG. 1. Electrocardiogram revealing no abnormalities
taken before pulmonary embolization occurred.
CASE REPORT
The patient, a sixty year old Negro woman, was admitted to the Jefferson Medical College Hospital on October 28, 1964. An adenocarcinoma of the sigmoid colon had been removed by sigmoidectomy at another hospital in 1959. An incisional hernia was repaired at Jefferson Medical College Hospital in 1961 at which time no residual cancer was found. In April 1964 a small firm mass was noted in the anterior abdominal wall. An incisional biopsy revealed metastatic adenocarcinoma with origin compatible with the colon. The patient was advised to have the lesion removed completely but she did not return for hospital admission until October.
The patient appeared to be a healthy, obese woman in no distress; her blood pressure was 130/80 mm. Hg. Physical examination revealed a heart of normal size and with a normal sinus rhythm and a pulse rate of 80 per minute. The second aortic sound was louder than the pulmonic second sound. Between the umbilicus and a long transverse scar on the lower abdomen a mass of 10 cm. in the anterior abdominal wall was palpable. The remainder of the physical examination was noncontributory. Pertinent laboratory findings included an electrocardiogram which revealed no abnormalities (Fig. I), an x-ray film of the chest showing slight increase in
* Trainee, National Heart Institute, NIH Grant HE-05339. t Fellow, American
Vol. III, May 1966
723
Cancer Society.
724
Camishion et al.
FIG. 2. Electrocardiogram taken shortly after pulmonary embolization occurred shows a shift of the axis to the right (Sr and aVL) and clockwise rotation. These findings are compatible with the diagnosis of acute pulmonary embolus. cardiac size with some left ventricular predominance and a barium enema examination which revealed no abnormalities except for some irritability of the transverse colon. On November 5 the tumor was excised en bloc with a full thickness of abdominal wall, a portion of the transverse colon, and a small segment of the ileum.
The defect in the abdominal wall was closed primarily. The patient tolerated the operation well. Approximately twenty-four hours postoperatively the patient suddenly became weak, dyspneic, and complained of precordial pain. At this time she was cold and clammy with a blood pressure of 80/60 mm. Hg and pulse rate of 120 per minute. On auscultation, both lung fields were clear and the heart sounds were active with an accentuated pulmonic second sound; a precordial diastolic gallop was heard. The abdomen was soft, peristalsis was absent, and there was no tenderness in the leg. An electrocardiogram taken immediately showed a shift of the electrical axis of the heart to the right which was suggestive of pulmonary embolization. (Fig. 2.) A roentgenogram of the chest taken at the bed side was interpreted as showing avascularity of the right lung field. (Fig. 3.) Venous angiocardiography performed a short time thereafter demonstrated a complete block of the right pulmonary artery. The left pulmonary arterial tree appeared normal. (Fig. 4.) The patient was given 15 mg. of levarterenol intravenously, 10 mg. of morphine sulfate intramuscularly, and nasal oxygen; blood pressure rose to 100/60 mm. Hg. There was no further improvement and the patient continued to require vasopressors to maintain an adequate blood pressure. Four hours after the onset of symptoms she was taken to the operating room. A disposable oxygenator primed with Ringer’s lactate solution was made ready because it was possible that a portion of the clot not visualized by angio-
FIG. 3. Plain film of the chest taken shortly after acute pulmonary embolization reveals absence of vascular markings in the right lung. This is apparent from the increased radiolucency on the right. FIG. 4. Preoperative venous angiocardiogram demonstrates the presence of a large embolus in the right pulmonary artery. The embolus obstructs nearly all pulmonary arterial flow to the right lung. The left pulmonary artery and its branches are well visualized and do not contain clot.
Pulmonary Embolectomy
without Cardiopulmonary
cardiography extended into the main pulmonary artery. The heart was exposed through a median sternotomy incision. Upon opening the pericardium it was noted that the right ventricle and the main pulmonarv artery were distended. Careful palpation of the main pulmonary artery did not disclose an intraluminal thrombus, whereas an embolus could be felt on palpation of the intrapericardial portion of the right pulmonary artery. A cotton tape was placed round the right pulmonary artery at this location. The right mediastinal pleura was opened widely. A second tape was placed about the arterial branches to the upper lobe and the intermediate pulmonary artery. A longitudinal incision was then made in the extrapericardial right pulmonary artery and an embolus that completely occluded the lumen was found. When the clotwas pulledfrom the proximal artery a gush of dark blood followed. The intrapericardial tape was then tightened. The other end of the clot was removed from the more distal pulmonary artery, but no back bleeding occurred. The lobes of the right lung were then compressed methodically from the periphery toward the hilum; clots were thus extruded from the segmental branches into the main artery from which they were removed. Retrograde flow of bright red blood followed extraction of these clots from each segmental branch. (Fig. 5.) In this way the entire right lung was freed of thrombi after which the tourniquets about the distal branches of the pulVol. 111, May 1966
Bypass
Y-20
monary artery were tightened. ,The artery was then washed clear of any remaining thrombi with an isotonic sodium chloride solution containing 50 units of heparin per liter of saline and the arteriotomy closed with a running suture of No. 5-O black silk. Upon release of the tourniquets, excellent pulsation was observed in the pulmonary artery and its branches, The right pleural space was drained by an intercostal tube and the sternotomy incision was closed. The inferior vena cava was then ligated through an anterolateral incision in the right flank. At completion of the operation the blood pressure was 130/80 mm. Hg and the pulse rate was 100 per minute. ,4 tracheostomy was performed becauseof the patient’s poor pulmonary ventilation. A cuffed tracheostomy tube was inserted and respirations were assisted with a ventilator for the first three postoperative days. She recovered without further incident until the twelfth postoperative day when acute thrombophlebitis of the right leg developed. This was controlled by elevation of the leg, warm compresses, and elastic bandages. Pain and edema subsided slowly within the next five days. A venous angiocardiogram performed fifteen days postoperatively revealed a normal pulmonary arterial and venous tree. (Fig. 6.) The patient was discharged feeling well one month after operation. She has been studied at biweekly intervals since then. She is asymptomatic and the phlebitis of the right leg has
Camishion completely subsided. The patient continues to wear
compression bandages on both lower extremities as a prophylactic measure. COMMENTS
Pulmonary embolism may be sudden and massive, resulting in the immediate death of the patient, or it may be so slight as to assure a nonfatal outcome from the onset. Between these extremes are the large, but not immediately fatal emboli that can be removed successfully by surgical means. Donaldson and associates at the Massachusetts General Hospital have estimated that approximately 20 per cent of patients with a massive pulmonary embolus willlive long enough to be candidates for pulmonary embolectomy [6]. According to Gorham the embolus will be confined to one side in approximately 15 per cent of patients. However, patients under fifty years of age rarely die of unilateral embolus unless they have pre-existing cardiac or pulmonary disease [7]. A large pulmonary embolus usually causes a sudden rise in pulmonary pressure proximal to the embolus. The elevated pressure, particularly in patients with a unilateral embolus, is probably due to an interplay of mechanical, chemical [8], and reflex factors [9]. The end result is an increase in the workload of the right ventricle and if sufficiently great, the right ventricle fails and cardiac output is diminished. The use of extracorporeal circulation to perform embolectomy virtually assures the technical success of the operation. However, a patient is occasionally encountered such as the one herein described and one reported by Bradley, Bennett, and Lyons [IO], in whom the embolus is on one side only and extracorporeal circulation is not needed for its removal and would only add to the complexity of the operation. However, in order for this latter procedure to be safely performed, precise localization of the embolus is required. Use of the usual diagnostic maneuvers to establish the presence of massive embolus is well illustrated in our case. The electrocardiogram showed the typical right axis shift of the heart which occurs in this disease. The physical findings of an increased pulmonic second sound and a diastolic gallop indicated that pressure in the main pulmonary artery was elevated and that right ventricular failure was imminent. A plain chest film taken at the bedside showed decreased pulmonary vascular markings in the right lung. The venous angiocardiogram con-
et al. firmed the diagnosis of pulmonary embolization; it further revealed that the embolus was lodged in the right pulmonary artery and that the left pulmonary arterial tree was not obstructed. Many patients, especially those who have an embolus in only one artery, are in sufficiently good condition that preoperative angiography is an invaluable diagnostic procedure. In a moribund patient it may be possible to obtain these studies preoperatively by instituting partial cardiopulmonary bypass. If pulmonary angiography is not available preoperatively, but the diagnosis of pulmonary embolization is otherwise secure, it is unwise to attempt embolectomy without the aid of cardiopulmonary bypass. If the embolus is lodged in the main pulmonary artery, the prolonged occlusion of the pulmonary circulation required to milk the distal vessels free of clot is dangerous. No matter how the clot is extracted, the operation should be completed by ligating the inferior vena cava. SUMMARY
AND CONCLUSIONS
Successful removal of an embolus in the right pulmonary artery without use of cardiopulmonary bypass is described. This is a safe procedure when an embolus is confined to either the right or left pulmonary artery. The contributions of electrocardiography, plain films of the chest, and venous angiocardiography in making the diagnosis and localizing the embolus are outlined. REFERENCES
1. TRENDELENBURG,F. I. Operative interference in embolism of pulmonary artery. Ann. Surg., 48:
772, 1908. 2. COOLEY,D. A., BEALL,A. C., JR., and ALEXANDER,
3.
4.
5.
6.
J. K. Acute massive pulmonary embolism: successful surgical treatment using temporary cardiopulmonary bypass. J.A.M.A., 177: 283, 1961. SHARP, E. H. Pulmonary embolectomy: successful removal of massive pulmonary embolus with support of cardiopulmonary bypass: case report. Ann. Surg., 156: 1, 1962. VOSSSCHULTE, K., STILLER,H., and EISENREICH,F. Emergency embolectomy by the transternal approach in acute pulmonary embolism. Surgery, 58: 317, 1965. WARREN, R. The current status of pulmonary embolectomy. In: Pulmonary Embolic Disease. Edited by Sasahara, A. A. and Stein, M. New York, 1965. Grune and Stratton. DONALDSON, G. A., WILLIAMS, C., SCANNELL, J. G., and SHAW, R. S. Reappraisal of the applica-
AmericanJournal of Surwy
Pulmonary
Embolectomy
without
tioll of the twntlel~mburg operatiotl to massive fatal ~nil-roli~~n .\‘rx Englnnd J. dlcd., 28: 171.
1SG~. 7. GURHAM. L \V. Stutly of pulmonary crnbolisrn. .Ir(-h. /nl. .\I&.. 108: 8, 189, and 418, 1961. X. CUMKOE. J. II.. \-OS LINGEN, B., STRWJD, R. C.. and RONC‘ORONI, A. Reflex and direct cardiopulmonary effects of 5.OH-tryptamine (serotonin I, I w. .I. i’kysiol., 173: 379, lY53.
vol. 111, May 1966
Cardiopulmonary
Bypass
797
9. LBI.A~D, 0. S., JR. and SASAIIAKA. .I. A. HWNdynamic Observations in Patients with I’ulmonary Thromboembolism. In: Pulmonary Embolic Disease. Edited by Sasaharn. A. A. and Stein, M. New York, 1965. Grunt and Stratton. 10. BRADLEY, M. N., BESNETT, A. L.. and Luoss. C. Successful unilateral pulmonary cmbolrctomy without c,ardiopulmonary bypass: report of a case. *Vew England J. Afed.. 271: i13. 1964.
Embolectomv
Cardiopulmonary Indications,
Diagnostic
without Bypass
Criteria,
and Case Report
RUDOLPH C. CAMISHION, M.D., LOUIS PIERUCCI, JR., M.D.,* NOEL H. FISHMAN, M.D., i WILLIAM FRAIMOW, M.D., AND ROY GREENING, M.D., Philadelphia, Pennsylvania
From the Departments of Surgery, Medicine, and Radiology, The Jefferson Medical College of Philadelphia, Philadelphia, Pennsylvania HE
METHOD
of performing pulmonary emhas progressed from the original technic of Trendelenburg [I] to that of making use of cardiopulmonary bypass [2,3]. Unquestionably, the latter procedure has enabled surgeons to remove pulmonary emboli much more safely than before, as witnessed by the fact that the successful operation for this condition is no longer a medical curiosity [4,5]. How-ever, with proper diagnostic technics, certain patients
T bolectomy
with pulmonary embolus can be operated upon with equal safety without bypass. The precise diagnostic maneuvers required to select patients for operation without extracorporeal circulation are outlined in this report. A successful case is presented.
FIG. 1. Electrocardiogram revealing no abnormalities
taken before pulmonary embolization occurred.
CASE REPORT
The patient, a sixty year old Negro woman, was admitted to the Jefferson Medical College Hospital on October 28, 1964. An adenocarcinoma of the sigmoid colon had been removed by sigmoidectomy at another hospital in 1959. An incisional hernia was repaired at Jefferson Medical College Hospital in 1961 at which time no residual cancer was found. In April 1964 a small firm mass was noted in the anterior abdominal wall. An incisional biopsy revealed metastatic adenocarcinoma with origin compatible with the colon. The patient was advised to have the lesion removed completely but she did not return for hospital admission until October.
The patient appeared to be a healthy, obese woman in no distress; her blood pressure was 130/80 mm. Hg. Physical examination revealed a heart of normal size and with a normal sinus rhythm and a pulse rate of 80 per minute. The second aortic sound was louder than the pulmonic second sound. Between the umbilicus and a long transverse scar on the lower abdomen a mass of 10 cm. in the anterior abdominal wall was palpable. The remainder of the physical examination was noncontributory. Pertinent laboratory findings included an electrocardiogram which revealed no abnormalities (Fig. I), an x-ray film of the chest showing slight increase in
* Trainee, National Heart Institute, NIH Grant HE-05339. t Fellow, American
Vol. III, May 1966
723
Cancer Society.
724
Camishion et al.
FIG. 2. Electrocardiogram taken shortly after pulmonary embolization occurred shows a shift of the axis to the right (Sr and aVL) and clockwise rotation. These findings are compatible with the diagnosis of acute pulmonary embolus. cardiac size with some left ventricular predominance and a barium enema examination which revealed no abnormalities except for some irritability of the transverse colon. On November 5 the tumor was excised en bloc with a full thickness of abdominal wall, a portion of the transverse colon, and a small segment of the ileum.
The defect in the abdominal wall was closed primarily. The patient tolerated the operation well. Approximately twenty-four hours postoperatively the patient suddenly became weak, dyspneic, and complained of precordial pain. At this time she was cold and clammy with a blood pressure of 80/60 mm. Hg and pulse rate of 120 per minute. On auscultation, both lung fields were clear and the heart sounds were active with an accentuated pulmonic second sound; a precordial diastolic gallop was heard. The abdomen was soft, peristalsis was absent, and there was no tenderness in the leg. An electrocardiogram taken immediately showed a shift of the electrical axis of the heart to the right which was suggestive of pulmonary embolization. (Fig. 2.) A roentgenogram of the chest taken at the bed side was interpreted as showing avascularity of the right lung field. (Fig. 3.) Venous angiocardiography performed a short time thereafter demonstrated a complete block of the right pulmonary artery. The left pulmonary arterial tree appeared normal. (Fig. 4.) The patient was given 15 mg. of levarterenol intravenously, 10 mg. of morphine sulfate intramuscularly, and nasal oxygen; blood pressure rose to 100/60 mm. Hg. There was no further improvement and the patient continued to require vasopressors to maintain an adequate blood pressure. Four hours after the onset of symptoms she was taken to the operating room. A disposable oxygenator primed with Ringer’s lactate solution was made ready because it was possible that a portion of the clot not visualized by angio-
FIG. 3. Plain film of the chest taken shortly after acute pulmonary embolization reveals absence of vascular markings in the right lung. This is apparent from the increased radiolucency on the right. FIG. 4. Preoperative venous angiocardiogram demonstrates the presence of a large embolus in the right pulmonary artery. The embolus obstructs nearly all pulmonary arterial flow to the right lung. The left pulmonary artery and its branches are well visualized and do not contain clot.
Pulmonary Embolectomy
without Cardiopulmonary
cardiography extended into the main pulmonary artery. The heart was exposed through a median sternotomy incision. Upon opening the pericardium it was noted that the right ventricle and the main pulmonarv artery were distended. Careful palpation of the main pulmonary artery did not disclose an intraluminal thrombus, whereas an embolus could be felt on palpation of the intrapericardial portion of the right pulmonary artery. A cotton tape was placed round the right pulmonary artery at this location. The right mediastinal pleura was opened widely. A second tape was placed about the arterial branches to the upper lobe and the intermediate pulmonary artery. A longitudinal incision was then made in the extrapericardial right pulmonary artery and an embolus that completely occluded the lumen was found. When the clotwas pulledfrom the proximal artery a gush of dark blood followed. The intrapericardial tape was then tightened. The other end of the clot was removed from the more distal pulmonary artery, but no back bleeding occurred. The lobes of the right lung were then compressed methodically from the periphery toward the hilum; clots were thus extruded from the segmental branches into the main artery from which they were removed. Retrograde flow of bright red blood followed extraction of these clots from each segmental branch. (Fig. 5.) In this way the entire right lung was freed of thrombi after which the tourniquets about the distal branches of the pulVol. 111, May 1966
Bypass
Y-20
monary artery were tightened. ,The artery was then washed clear of any remaining thrombi with an isotonic sodium chloride solution containing 50 units of heparin per liter of saline and the arteriotomy closed with a running suture of No. 5-O black silk. Upon release of the tourniquets, excellent pulsation was observed in the pulmonary artery and its branches, The right pleural space was drained by an intercostal tube and the sternotomy incision was closed. The inferior vena cava was then ligated through an anterolateral incision in the right flank. At completion of the operation the blood pressure was 130/80 mm. Hg and the pulse rate was 100 per minute. ,4 tracheostomy was performed becauseof the patient’s poor pulmonary ventilation. A cuffed tracheostomy tube was inserted and respirations were assisted with a ventilator for the first three postoperative days. She recovered without further incident until the twelfth postoperative day when acute thrombophlebitis of the right leg developed. This was controlled by elevation of the leg, warm compresses, and elastic bandages. Pain and edema subsided slowly within the next five days. A venous angiocardiogram performed fifteen days postoperatively revealed a normal pulmonary arterial and venous tree. (Fig. 6.) The patient was discharged feeling well one month after operation. She has been studied at biweekly intervals since then. She is asymptomatic and the phlebitis of the right leg has
Camishion completely subsided. The patient continues to wear
compression bandages on both lower extremities as a prophylactic measure. COMMENTS
Pulmonary embolism may be sudden and massive, resulting in the immediate death of the patient, or it may be so slight as to assure a nonfatal outcome from the onset. Between these extremes are the large, but not immediately fatal emboli that can be removed successfully by surgical means. Donaldson and associates at the Massachusetts General Hospital have estimated that approximately 20 per cent of patients with a massive pulmonary embolus willlive long enough to be candidates for pulmonary embolectomy [6]. According to Gorham the embolus will be confined to one side in approximately 15 per cent of patients. However, patients under fifty years of age rarely die of unilateral embolus unless they have pre-existing cardiac or pulmonary disease [7]. A large pulmonary embolus usually causes a sudden rise in pulmonary pressure proximal to the embolus. The elevated pressure, particularly in patients with a unilateral embolus, is probably due to an interplay of mechanical, chemical [8], and reflex factors [9]. The end result is an increase in the workload of the right ventricle and if sufficiently great, the right ventricle fails and cardiac output is diminished. The use of extracorporeal circulation to perform embolectomy virtually assures the technical success of the operation. However, a patient is occasionally encountered such as the one herein described and one reported by Bradley, Bennett, and Lyons [IO], in whom the embolus is on one side only and extracorporeal circulation is not needed for its removal and would only add to the complexity of the operation. However, in order for this latter procedure to be safely performed, precise localization of the embolus is required. Use of the usual diagnostic maneuvers to establish the presence of massive embolus is well illustrated in our case. The electrocardiogram showed the typical right axis shift of the heart which occurs in this disease. The physical findings of an increased pulmonic second sound and a diastolic gallop indicated that pressure in the main pulmonary artery was elevated and that right ventricular failure was imminent. A plain chest film taken at the bedside showed decreased pulmonary vascular markings in the right lung. The venous angiocardiogram con-
et al. firmed the diagnosis of pulmonary embolization; it further revealed that the embolus was lodged in the right pulmonary artery and that the left pulmonary arterial tree was not obstructed. Many patients, especially those who have an embolus in only one artery, are in sufficiently good condition that preoperative angiography is an invaluable diagnostic procedure. In a moribund patient it may be possible to obtain these studies preoperatively by instituting partial cardiopulmonary bypass. If pulmonary angiography is not available preoperatively, but the diagnosis of pulmonary embolization is otherwise secure, it is unwise to attempt embolectomy without the aid of cardiopulmonary bypass. If the embolus is lodged in the main pulmonary artery, the prolonged occlusion of the pulmonary circulation required to milk the distal vessels free of clot is dangerous. No matter how the clot is extracted, the operation should be completed by ligating the inferior vena cava. SUMMARY
AND CONCLUSIONS
Successful removal of an embolus in the right pulmonary artery without use of cardiopulmonary bypass is described. This is a safe procedure when an embolus is confined to either the right or left pulmonary artery. The contributions of electrocardiography, plain films of the chest, and venous angiocardiography in making the diagnosis and localizing the embolus are outlined. REFERENCES
1. TRENDELENBURG,F. I. Operative interference in embolism of pulmonary artery. Ann. Surg., 48:
772, 1908. 2. COOLEY,D. A., BEALL,A. C., JR., and ALEXANDER,
3.
4.
5.
6.
J. K. Acute massive pulmonary embolism: successful surgical treatment using temporary cardiopulmonary bypass. J.A.M.A., 177: 283, 1961. SHARP, E. H. Pulmonary embolectomy: successful removal of massive pulmonary embolus with support of cardiopulmonary bypass: case report. Ann. Surg., 156: 1, 1962. VOSSSCHULTE, K., STILLER,H., and EISENREICH,F. Emergency embolectomy by the transternal approach in acute pulmonary embolism. Surgery, 58: 317, 1965. WARREN, R. The current status of pulmonary embolectomy. In: Pulmonary Embolic Disease. Edited by Sasahara, A. A. and Stein, M. New York, 1965. Grune and Stratton. DONALDSON, G. A., WILLIAMS, C., SCANNELL, J. G., and SHAW, R. S. Reappraisal of the applica-
AmericanJournal of Surwy
Pulmonary
Embolectomy
without
tioll of the twntlel~mburg operatiotl to massive fatal ~nil-roli~~n .\‘rx Englnnd J. dlcd., 28: 171.
1SG~. 7. GURHAM. L \V. Stutly of pulmonary crnbolisrn. .Ir(-h. /nl. .\I&.. 108: 8, 189, and 418, 1961. X. CUMKOE. J. II.. \-OS LINGEN, B., STRWJD, R. C.. and RONC‘ORONI, A. Reflex and direct cardiopulmonary effects of 5.OH-tryptamine (serotonin I, I w. .I. i’kysiol., 173: 379, lY53.
vol. 111, May 1966
Cardiopulmonary
Bypass
797
9. LBI.A~D, 0. S., JR. and SASAIIAKA. .I. A. HWNdynamic Observations in Patients with I’ulmonary Thromboembolism. In: Pulmonary Embolic Disease. Edited by Sasaharn. A. A. and Stein, M. New York, 1965. Grunt and Stratton. 10. BRADLEY, M. N., BESNETT, A. L.. and Luoss. C. Successful unilateral pulmonary cmbolrctomy without c,ardiopulmonary bypass: report of a case. *Vew England J. Afed.. 271: i13. 1964.