MODIFIED SURGICAL CONCEPT FOR FULMINANT PULMONARY-EMBOLISM

Surgical intervention in fulminant pulmonary embolism (PE) is still as sociated with an overall 30% fatal outcome which increases to about 60 % when cardiopulmonary resuscitation (CPR) is necessary. Despite unfav orable conditions like hemodynamic instability, failed lysis or CPR, t he surgical strategy might have a certain impact on the patient's outc ome since 30-40% of the surgical mortality is related to persistent ri ght heart failure and early thromboembolic recurrence. From 1/88 to 8/ 94 a total of 25 patients (15 females, 10 men, mean age 57 [25-78]) ye ars underwent emergency pulmonary embolectomy with the use of the hear t-lung machine. Seventeen patients were operated upon between 1988 and 1992, A standard approach by central pulmonary artery incision with e xtraction of adjacent pulmonary emboli using forceps, suction of Fogar ty catheters was used. Six of these patients (35%) died, with four out of six operated upon under CPR. Since 1993 we have used a modified su rgical strategy in eight patients. Five patients (63%) were operated o n after or under CPR. In these cases, left and right pulmonary arterie s were incised peripherally and all segmental arteries were desobliter ated selectively using small suction devices. Thereafter the right atr ium was opened and inspected. After removal of the inferior caval vein cannula all inferior body blood was taken with cardiotomy suction whi le both legs and the abdomen were massaged centripetally to mobilize a dditional fresh thrombotic material. In three cases up to 50 cm long t hrombi could be delivered. All patients have survived to date with two patients receiving a LGM caval filter placed percutaneously after bil ateral postoperative phlebography had revealed ongoing thrombotic dise ase. We conclude that selective desobliteration of every segmental pul monary artery in combination with simultaneous clearance of major body veins from additional thrombotic material will probably lower surgica l mortality in these critically ill patients.