Surgical Thrombectomy for PE: Is it Making a Comeback

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1 Surgical Thrombectomy for PE: Is it Making a Comeback Prashanth Vallabhajosyula, MD MS The University of Pennsylvania Health System Philadelphia, PA

2 Case - 84 year old female presents with submassive right PE with near complete obstruction of RPA

3 Operative Technique - Median sternotomy - Ascending aorta arterial cannulation - Selective SVC/ Right atrial cannulation - Aortic cross clamp not necessary Wikipedia

4 Operative Technique : en bloc removal of clot Wikipedia

5 Background Pulmonary embolism (PE) carries 7% in-hospital mortality in allcomers, with 31% mortality in patients with hemodynamic instability Surgical pulmonary embolectomy is one of the many treatment options available for patients with PE Massive PE: hypotension, cardiogenic shock, cardiac arrest, respiratory failure Submassive PE: RV dysfunction, elevated cardiac markers, without severe hypotension these patients are also at risk for adverse outcomes and early mortality ADVANCED THERAPIES, INCLUDING PULMONARY EMBOLECTOMY HAVE A ROLE IN TREATING MASSIVE AND SUBMASSIVE PE

6 Background Advanced therapies include systemic thrombolysis/ fibrinolysis, catheter based drug delivery, Angiovac endovascular device, and pulmonary embolectomy Systemic fibrinolysis is associated with 1.7% absolute mortality reduction, but 6% bleeding risk, especially intracranial hemorrhage (1.5%) This, along with contraindications for fibrinolysis, has driven ongoing interest in alternative therapies described above Over the past decade, improvements in surgical care, increasing experience with techniques has recently created a renewed interest in expanding the role of surgical embolectomy

7 History First successful case was performed in Germany in 1924 by Martin Kirschner Cardiopulmonary bypass was incorporated in 1960s Surgical mortality in mid to later 1900s was >30%, with restriction of surgical intervention only in patients with refractory shock This led to belief that the risk of surgical embolectomy was prohibitive, and therefore there was little to no utility for this procedure either patients were too sick for surgery, or too healthy for surgery PULMONARY EMBOLECTOMY WAS ABANDONED IN MANY HOSPITALS

8 Role for pulmonary embolectomy In 1990s, few centers reported improved outcomes with improved surgical techniques Gulba et al (Lancet, 1995) showed 77% survival in pulmonary embolectomy patients with shock, compared to 67% for fibrinolysis Takahashi et al (Ann Thorac Surg, 2013) reported 5 year survival of 87.5% in 24 patients with circulatory collapse, along with the benefit of decreased PAP from 66.9 to 28.5 mm Hg Kadner et al (J Thorac Cardiovasc Surg, 2008) showed 8% mortality with pulmonary embolectomy, even in patients presenting with cardiogenic shock THIS HAS LED TO THE INCREASED USE OF PULMONARY EMBOLECTOMY AS FIRST LINE THERAPY RATHER THAN RESCUE THERAPY FOR MASSIVE PE

9 Submassive PE Some groups have advocated for role for pulmonary embolectomy in treating submassive PE, given the improved outcomes seen with massive PE especially in cases with contraindications for fibrinolysis Aklog et al (Circulation, 2002) reported 89% 1 month survival in 29 patients with submassive PE with moderate to severe RV dysfunction Leacche et al (J Thorac Cardiovasc Surg, 2005) published outcomes in 47 patients 6% operative mortality and 86% 1-year survival Greelish et al (J Thorac Cardiovasc Surg, 2011) compared 107 patients undergoing medical therapy (88 patients) versus pulmonary embolectomy (15 patients) mortality was 29% with embolectomy versus 43% with medical therapy at 30 days, even though surgical cohort had much higher hypotension (47% vs. 8%)

10 Submassive PE Aymard et al (Eur J Cardiothorac Surg, 2013) showed improved outcomes in patients with pulmonary embolectomy (28 patients) compared to thrombolytic therapy (52 patients) - mortality 3.6% versus 13.5%; bleeding 3.6% versus 26.5% Neely et al (Ann Thorac Surg, 2015) reported outcomes in 115 patients undergoing pulmonary embolectomy 6.6% mortality 55 patients in this group had submassive PE that was treated surgically because of contraindications to fibrinolysis, failure of catheter based techniques, or severe RV dysfunction mortality in this subgroup was 3.6% OVERALL, RECENT SURGICAL MORTALITY HAS RANGED FROM 3.6% TO 13%

11 AHA/ ACCP/ ESC guidelines Massive PE with contraindication for fibrinolytic therapy Massive or submassive PE with failed systemic or catheter based therapy Pulmonary embolectomy has better outcomes than repeat fibrinolysis Clot-in-transit in RA or RV along with PE has mortality rate of 29%, and these patients should be considered for pulmonary embolectomy Large PFO patients have worse outcomes than those without, and should be considered Submassive PE with moderate to severe RV dysfunction may benefit from surgery due to the immediate pulmonary hemodynamic effects

12 Thank you