Severe pulmonary embolism - Unispital Basel · Obstruction of pulmonary arteries by single or recurrent pulmonary emboli without complete resolution 5-year survival is pressure dependent

Severe pulmonary embolism:

surgical aspects

Oliver Reuthebuch

Clinic for Cardiac Surgery

University Hospital Basel

Switzerland

Severe pulmonary embolism

Acute pulmonary embolism

Chronic pulmonary thromboembolism

Acute pulmonary embolism: Surgical aspects

Lethality of >30%

2/3 of deaths within first 60 min

Most common cause of death without clinical diagnosis

Very unspecific clinical symptoms

• Dyspnoea

• Tachycardia

• Chest pain

• Hypotension

Unspecific laboratory parameters

• Elevation of D-dimer (90% of cases)

• Elevation of Troponin and pro-BNP

• Hypoxaemia


Causes for acute pulmonary embolism:

• Thrombus formation in venous system (90%)

Virchow Triad

Vessel wall lesion

Stasis

Hypercoagulability

• Fat- and bone particles

• Amnion fluid

• Tissue- and tumor cells

• Bacteria

• Parasites

• Foreign bodies


Diagnostic:

• Chest x-ray

• Pulmonary angiography

• Multi-slice CT

• MRI

• Echocardiography

Westermark sign


Diagnostic:

• Chest x-ray


• Multi-slice CT

• MRI



Diagnostic:

• Chest x-ray


• Multi-slice CT

• MRI



Diagnostic:

• Chest x-ray


• Multi-slice CT

• MRI



Diagnostic:

• Chest x-ray


• Multi-slice CT

• MRI


Diastole

Systole

Systolic D-shape sign


Treatment options:

Hemodynamically stable patient Hemodynamically unstable patient

Anticoagulation

IVC Filter

Thrombolytic therapy

Embolectomy

Ultrasound-assisted

Rheolytic embolectomy

Rotational embolectomy

Suction embolectomy

Thrombus fragmentation

Surgical embolectomy


Indication for Surgery:

5.8. In patients with acute PE associated with hypotension, we suggest surgical

pulmonary embolectomy over no such intervention if they have

(i) contraindications to thrombolysis

(ii) failed thrombolysis or catheter-assisted embolectomy

(iii) shock that is likely to cause death before thrombolysis can take effect

provided surgical expertise and resources are available (Grade 2C).

Antithrombotic therapy for VTE Diseases: Chest 2012;141(2) (Suppl.):e419S-e494S


Indication for Surgery:

Addendum to the guidelines:

Diagnosis of additional intracardial (floating) thromboembolisms

Patent foramen ovale

Antithrombotic therapy for VTE Diseases: Chest 2012;141(2) (Suppl.):e419S-e494S

Acute pulmonary embolism: surgical aspects

Historical Considerations:

Friedrich Trendelenburg (1844-1924)

Director of Department for Surgery, University Hospital Leipzig, 1895-1911





John Gibbon:

Experienced the death of a young lady due to pulmonary embolism

Initiation of a 23 years research program for ECC

(Artificial maintenance of circulation during experimental occlusion of pulmonary artery,

Arch Surg 1937:34)

1953 first clinical use of ECC

1961 first PE with ECC by D. Cooley


Surgical procedure:

Median sternotomy

Bicaval cannulation

Normothermic

Fibrillating heart vs. arrested heart

Incision of pulmonary trunk

Additional incisions if applicable

Grasping of emboli

Ventilation of lungs or manual pulmonary

massage to mobilize emboli

Closure with 5/0, 6/0

RA-incision: inspection of cavities

Control CT or Doppler of venous system

Heparin and consecutive Marcoumar for 6 months


Bicaval cannulation and inspection of cavities


Extraction of huge clot




Stein PD et al. Outcome of Pulmonary Embolectomy. Am J Cardio 2007;99:421-423

41 series reviewed

Data between 1961 and 2005

Mortality ranged between 6% and 64%, average mortality of 30%

• between 1961 and 1984: average mortality 32%

• between 1985 and 2006: average mortality 20%

Indication for surgery

• 74% hemodynamic instability

• 32% cardiac arrest

• 19% contraindication to thrombolytic therapy

Results 1:


Stein PD et al. Outcome of Pulmonary Embolectomy. Am J Cardio 2007;99:421-423


Results 2:

Meneveau N, et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006;129(4):1043-50


Conclusion 1:

Surgery is indicated

in hemodynamically unstable patients

In the presence of huge emboli in cardiac cavities

In the presence of anatomical abnormalities

High mortality (salvage treatment)

Advisable in the subset of recurrent embolism

Chronic pulmonary embolism: Surgical aspects

Chronic pulmonary embolism


Nature of chronic thromboembolic pulmonary hypertension (CTEPH)

Obstruction of pulmonary arteries by single or recurrent pulmonary emboli

without complete resolution

5-year survival is pressure dependent (mPAP)

>50mmHg 10%

>30mmHg 30%

<30mmHg 90%

Endothelialized residues obliterate or significantly narrow pulmonary arteries

Incidence of 0.57% to 3.8% in survivors of acute pulmonary embolism (PE)

Incidence of >10% in patients with recurrent PE

Incidence of 0.1% for surgical treatment in all patients with PE

First PEA in 1957, since then >3000 cases

Bilateral procedure

Total removal of thromboembolic material


Pathophysiology

Chronic thromboembolic lesions in vessel wall

change into fibrous and elastic fibers and finally

become endothelialized

Development of a precapillary vasculopathy in

over-perfused vessels

• reactive, Eisenmenger-like reaction

• vasoconstriction of small vessels

• hypertrophy of media

• final sclerosis

Mixed form of mechanical obstruction of lobar-, segmental and sub-segmental

arteries (surgically accessible) in conjunction with irreversible vasculopathy

(no surgical access)


Indication:

New York Heart Association (NYHA) functional class III or IV

Preoperative pulmonary vascular resistance (PVR) of greater

than 300 dyn · s · cm-5

Surgically accessible thrombus in the main lobar or segmental

pulmonary arteries

No severe co-morbidities

• obstructive or restrictive chronic lung disease

• Advanced secondary arteriopathy


Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:508-518

Diagnostic:



A1: Tech-99m-aerosol ventilation scan; B1: perfusion scan; C1: high-resolution CT scan;

D1: spiral CT angiography; E1/F1 and G1/H1: pulmonary angiography in a.-p. and lateral aspect

Diagnostic: Central Obstruction (amenable for surgery)



A1: Tech-99m-aerosol ventilation scan; B1: perfusion scan; C1: high-resolution CT scan;

D1: spiral CT angiography; E1/F1 and G1/H1: pulmonary angiography in a.-p. and lateral aspect

Diagnostic: Peripheral Obstruction (not amenable for surgery)


Kim NH et al. Chronic Thromboembolic Pulmonary Hypertension. JACC 2013;62(25):D92-D99

Diagnosis:


Surgery:

Median sternotomy

Total circulatory arrest (18°-20°)

• visibility diminished due to back-bleeding as result of

systemic-to-pulmonary artery circulation

Arrest less < 20min per side

[email protected]


Surgery:

Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic

Thromboembolic PH. Proc Am Thorac Soc 2006;3:589-593

Iversen S. Pulmonale Thrombeembolektomie und pulmonale

Thrombendarterektomie. Springer Verlag


Surgery:

Dartevelle P et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J 2004;23:637-648


Surgery:

Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic PH. Proc Am Thorac Soc 2006;3:589-593


Surgery (angioscopic):



Surgery:

Reperfusion of appr. 15min during closure of arteriotomy

De-airing of cardiac chambers

Unclamping of aorta

Rewarming to 37°

• additional procedures:

• aorto-coronary bypass

• valve surgery

• combined procedures


Postoperative management:

Persistent PAH (mean >25mmHg)

• inadequate endarterectomy in 10% patients

• significant vasculopathy

Reperfusion edema

• incidence of 10-15%

• adequate ventilation (tidal volume < 8ml/kg, I:E 3:1, PiP <18cmH2O)

• fluid restriction

• avoidance of inotropes

• ECMO

Rupture of arteriotomy

Nosocomial pneumonia

Hemoptysis

Intrapulmonary bleeding (0.5-1%)

Rethrombosis (rare)


Outcome (perioperative):



Outcome (perioperative/longterm):

UpToDate 2016: Chronic thrombembolic pulmonary hypertension: Surgical Treatment


Outcome (long-term):

Freed DH et al. Survival after pulmonary thrombendarterctomy. JTCVS 2011;141:383



Freed DH et al. Survival after pulmonary thrombendarterctomy. JTCVS 2011;141:383



Cannon JE. Dynamik Risk stratification of Patient Long-Term Outcome. Circ 2016;133:1761





Percutaneous Pulmonary Angioplasty

First publication in 2001 (Feinstein)

Reestablishing of method in 2012 (Japan)

• data published of >127 patients

Multiple procedures

• smaller balloons

• average 4.8 sessions needed

• vessel rupture

• reperfusion lung injury

Increasing interest

Amenable for peripheral PE


Percutaneous Pulmonary Angioplasty

Andreassen AK et al. Balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension. Heart 2013;99:1415-1420


Representative angiographic and intravascular ultrasound (IVUS) images of

balloon pulmonary angioplasty (BPA).

Hiroki Mizoguchi et al. Circ Cardiovasc Interv. 2012;5:748-755


Representative pulmonary angiograms before and after balloon pulmonary

angioplasty (BPA).



Correlation between the number of opened segments and the decrease in

mean pulmonary arterial pressure.


Acute and Chronic pulmonary embolism: Surgical aspects

Conclusion

Surgery for acute pulmonary embolism is last treatment option

• Contraindication/failed thrombolysis

• Shock

PEA in chronicTEPH is standard and recommended treatment

ECMO should be a standard of care in PEA centers

Role of percutaneous pulmonary angioplasty needs further evaluation

and so far can`t replace PEA

CTEPH team assess operability before other treatments are considered

Acute and Chronic pulmonary embolism: Surgical aspects

Thank you very much for your attention!

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Severe pulmonary embolism - Unispital Basel · Obstruction of pulmonary arteries by single or recurrent pulmonary emboli without complete resolution 5-year survival is pressure dependent