From the Guidelines
Pulmonary embolectomy is indicated in patients with high-risk pulmonary embolism (PE) who have contraindications to thrombolysis or have failed thrombolysis, as recommended by the 2019 ESC guidelines 1. The procedure involves surgical removal of the clot (surgical embolectomy) or catheter-directed techniques to mechanically disrupt and remove the thrombus (catheter-directed embolectomy). Key considerations for embolectomy include:
- High-risk PE with hemodynamic instability, defined as persistent hypotension with systolic blood pressure <90 mmHg or a drop of ≥40 mmHg from baseline despite anticoagulation
- Contraindications to thrombolysis, such as active bleeding or recent surgery
- Failed thrombolysis, defined as lack of improvement in hemodynamic status after thrombolytic therapy
- Availability of surgical expertise and resources The rationale for embolectomy is to rapidly restore pulmonary blood flow, reduce right ventricular strain, improve hemodynamics, and potentially prevent death in critically ill patients. Prior to considering embolectomy, patients should receive anticoagulation therapy (typically unfractionated heparin) unless absolutely contraindicated, and a multidisciplinary team should evaluate the risk-benefit ratio for each individual patient, as suggested by the 2019 ESC guidelines 1 and supported by earlier guidelines 1.
From the Research
Indications for Pulmonary Embolectomy
The indications for pulmonary embolectomy in patients with pulmonary embolism (PE) include:
- Patients with contraindications to thrombolysis 2, 3
- Patients who have failed thrombolysis or catheter therapy 2, 3
- Patients with unstable hemodynamics due to pulmonary thromboembolism 3
- Patients who are already on a veno-arterial extra-corporate membrane oxygenator for circulatory collapse or cardiopulmonary arrest 3
- Patients with acute massive pulmonary embolism, particularly those without life-limiting comorbidities 4
Patient Selection
Patient selection for pulmonary embolectomy is crucial, and the decision should be made on a case-by-case basis. Factors to consider include:
- The degree of pulmonary arterial occlusion 3
- The presence of hemodynamic instability 3, 5
- The risk of potential hemorrhagic complications with thrombolytic therapy 3
- The patient's overall clinical condition and presence of comorbidities 4
Outcomes
The outcomes of pulmonary embolectomy are generally favorable, with reported in-hospital mortality rates of less than 10% 3. Prompt removal of emboli can reduce the right ventricular load and lead to quick recovery of cardiopulmonary function in the early postoperative period 3. However, the outcome for patients who require cardiopulmonary resuscitation for longer than 30 minutes is poor, highlighting the importance of early triage and intervention 3.