Severe pulmonary embolism: surgical aspects. Oliver Reuthebuch Clinic for Cardiac Surgery University Hospital Basel Switzerland
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1 Severe pulmonary embolism: surgical aspects Oliver Reuthebuch Clinic for Cardiac Surgery University Hospital Basel Switzerland
2 Severe pulmonary embolism Acute pulmonary embolism Chronic pulmonary thromboembolism
3 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
4 Acute pulmonary embolism: Surgical aspects 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
5 Acute pulmonary embolism: Surgical aspects Diagnostic: Chest x-ray Pulmonary angiography Multi-slice CT MRI Echocardiography Westermark sign
6 Acute pulmonary embolism: Surgical aspects Diagnostic: Chest x-ray Pulmonary angiography Multi-slice CT MRI Echocardiography
7 Acute pulmonary embolism: Surgical aspects Diagnostic: Chest x-ray Pulmonary angiography Multi-slice CT MRI Echocardiography
8 Acute pulmonary embolism: Surgical aspects Diagnostic: Chest x-ray Pulmonary angiography Multi-slice CT MRI Echocardiography
9 Acute pulmonary embolism: Surgical aspects Diagnostic: Chest x-ray Pulmonary angiography Multi-slice CT MRI Echocardiography Systolic D-shape sign Diastole Systole
10 Acute pulmonary embolism: Surgical aspects 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
11 Acute pulmonary embolism: Surgical aspects 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
12 Acute pulmonary embolism: Surgical aspects 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
13 Acute pulmonary embolism: surgical aspects Historical Considerations: Friedrich Trendelenburg ( ) Director of Department for Surgery, University Hospital Leipzig,
14 Acute pulmonary embolism: surgical aspects Historical Considerations:
15 Acute pulmonary embolism: surgical aspects Historical Considerations: 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
16 Acute pulmonary embolism: Surgical aspects 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
17 Acute pulmonary embolism: Surgical aspects Bicaval cannulation and inspection of cavities
18 Acute pulmonary embolism: Surgical aspects Extraction of huge clot
19 Acute pulmonary embolism: Surgical aspects
20 Acute pulmonary embolism: Surgical aspects
21 Acute pulmonary embolism: Surgical aspects Results 1: 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 Stein PD et al. Outcome of Pulmonary Embolectomy. Am J Cardio 2007;99:
22 Acute pulmonary embolism: Surgical aspects Stein PD et al. Outcome of Pulmonary Embolectomy. Am J Cardio 2007;99:
23 Acute pulmonary embolism: Surgical aspects Results 2: Meneveau N, et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006;129(4):
24 Acute pulmonary embolism: Surgical aspects 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
25 Chronic pulmonary embolism: Surgical aspects Chronic pulmonary embolism
26 Chronic pulmonary embolism: Surgical aspects 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
27 Chronic pulmonary embolism: Surgical aspects 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)
28 Chronic pulmonary embolism: Surgical aspects 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
29 Chronic pulmonary embolism: Surgical aspects Diagnostic: Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:
30 Chronic pulmonary embolism: Surgical aspects 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 Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:
31 Chronic pulmonary embolism: Surgical aspects Diagnostic: Peripheral Obstruction (not 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 Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:
32 Chronic pulmonary embolism: Surgical aspects Diagnosis: Kim NH et al. Chronic Thromboembolic Pulmonary Hypertension. JACC 2013;62(25):D92-D99
33 Chronic pulmonary embolism: Surgical aspects 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 support@ctisus.com
34 Chronic pulmonary embolism: Surgical aspects Surgery: Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic PH. Proc Am Thorac Soc 2006;3: Iversen S. Pulmonale Thrombeembolektomie und pulmonale Thrombendarterektomie. Springer Verlag
35 Chronic pulmonary embolism: Surgical aspects Surgery: Dartevelle P et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J 2004;23:
36 Chronic pulmonary embolism: Surgical aspects Surgery: Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic PH. Proc Am Thorac Soc 2006;3:
37 Chronic pulmonary embolism: Surgical aspects Surgery (angioscopic): Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic PH. Proc Am Thorac Soc 2006;3:
38 Chronic pulmonary embolism: Surgical aspects 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
39 Chronic pulmonary embolism: Surgical aspects 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)
40 Chronic pulmonary embolism: Surgical aspects Outcome (perioperative): Mayer E et al. Techniques and Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic PH. Proc Am Thorac Soc 2006;3:
41 Chronic pulmonary embolism: Surgical aspects Outcome (perioperative/longterm): UpToDate 2016: Chronic thrombembolic pulmonary hypertension: Surgical Treatment
42 Chronic pulmonary embolism: Surgical aspects Outcome (long-term): Freed DH et al. Survival after pulmonary thrombendarterctomy. JTCVS 2011;141:383
43 Chronic pulmonary embolism: Surgical aspects Outcome (long-term): Freed DH et al. Survival after pulmonary thrombendarterctomy. JTCVS 2011;141:383
44 Chronic pulmonary embolism: Surgical aspects Outcome (long-term): Cannon JE. Dynamik Risk stratification of Patient Long-Term Outcome. Circ 2016;133:1761
45 Chronic pulmonary embolism: Surgical aspects Outcome (long-term): Lang IM et al. Update on Chronic Thromboembolic Pulmonary Hypertension. Circ 2014.;130:
46 Chronic pulmonary embolism: Surgical aspects 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
47 Chronic pulmonary embolism: Surgical aspects Percutaneous Pulmonary Angioplasty Andreassen AK et al. Balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension. Heart 2013;99:
48 Chronic pulmonary embolism: Surgical aspects Representative angiographic and intravascular ultrasound (IVUS) images of balloon pulmonary angioplasty (BPA). Hiroki Mizoguchi et al. Circ Cardiovasc Interv. 2012;5:
49 Chronic pulmonary embolism: Surgical aspects Representative pulmonary angiograms before and after balloon pulmonary angioplasty (BPA). Hiroki Mizoguchi et al. Circ Cardiovasc Interv. 2012;5:
50 Chronic pulmonary embolism: Surgical aspects Correlation between the number of opened segments and the decrease in mean pulmonary arterial pressure. Hiroki Mizoguchi et al. Circ Cardiovasc Interv. 2012;5:
51 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
52 Acute and Chronic pulmonary embolism: Surgical aspects Thank you very much for your attention!
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