What are the indications for surgical embolectomy (removal of a blood clot)?

Indications for Surgical Embolectomy

Surgical embolectomy is indicated for patients with acute limb ischemia who have contraindications to thrombolysis, failed thrombolytic therapy, or shock that is likely to cause death before thrombolysis can take effect, provided surgical expertise and resources are available. 1

Pulmonary Embolism Indications

High-Risk (Massive) Pulmonary Embolism

• Surgical embolectomy is indicated for patients with high-risk PE (with hypotension/shock) who have contraindications to thrombolysis 1
• Surgical embolectomy should be considered when thrombolytic therapy has failed to improve hemodynamics in high-risk PE 1
• Surgical embolectomy is appropriate when shock is likely to cause death before thrombolysis can take effect (within hours) 1

Intermediate-Risk Pulmonary Embolism

• Surgical embolectomy may be considered for selected patients with intermediate-high-risk PE (without hypotension but with RV dysfunction and myocardial necrosis), particularly if thrombolysis is contraindicated 1
• Surgical embolectomy is not recommended for patients with low-risk PE or submassive PE with only minor RV dysfunction and no clinical worsening 1

Special Circumstances

• Surgical embolectomy has been successfully performed in patients with right heart thrombi straddling the interatrial septum through a patent foramen ovale 1
• Surgical embolectomy should be avoided in patients who have received prolonged CPR 1

Acute Limb Ischemia Indications

Embolic Occlusions

• Isolated suprainguinal emboli should be removed surgically as a consensus recommendation 1
• Surgical embolectomy is indicated for viable limbs with acute limb ischemia, even in patients presenting late (6-72 hours) in the absence of tissue necrosis 2, 3
• Surgical embolectomy is appropriate for patients with profound limb paralysis and proximal emboli 4

Failed Endovascular Approaches

• Surgical approaches should be reserved for patients in whom thrombolysis or endovascular thrombectomy has failed 1
• Surgical embolectomy is indicated when an unacceptable delay due to attempted endovascular techniques would jeopardize limb viability 1

Non-viable Limbs

• Surgical embolectomy is indicated for non-viable limbs 1
• Even in stage 3 ischemia (profound sensory loss and muscle weakness), patients should be given a chance for limb salvage through surgical embolectomy 3

Technical Considerations

Pulmonary Embolectomy

• Pulmonary embolectomy is technically a relatively simple operation 1
• Following rapid transfer to the operating room and induction of anesthesia and median sternotomy, normothermic cardiopulmonary bypass should be instituted 1
• Aortic cross-clamping and cardioplegic cardiac arrest should be avoided 1
• With bilateral PA incisions, clots can be removed from both pulmonary arteries down to the segmental level under direct vision 1

Limb Embolectomy

• Successful limb salvage can be achieved by revascularization of at least one ankle artery by surgical thromboembolectomy with concomitant anticoagulation therapy 5
• Below-knee popliteal approach is an effective method for lower limb embolectomy 5
• Hybrid procedures combining surgical embolectomy with endovascular techniques may improve outcomes in acute lower limb ischemia 6

Contraindications and Cautions

• Pre-operative thrombolysis increases the risk of bleeding but is not an absolute contraindication to surgical embolectomy 1
• Surgical embolectomy should be avoided in patients who have received prolonged CPR 1
• The site of surgical care does not significantly affect operative outcomes; patients need not be transferred to a specialized cardiothoracic center if on-site embolectomy using extracorporeal circulation is possible 1

Outcomes and Prognosis

• With a rapid multidisciplinary approach and individualized indications for embolectomy before hemodynamic collapse, perioperative mortality rates of 6% or less have been reported for pulmonary embolectomy 1
• For acute limb ischemia, overall limb salvage rates of 85.7% have been reported even in patients presenting late (6-72 hours) 2
• Primary anticoagulation therapy alone or with a secondary embolectomy can be effective across the spectrum of ischemia severity despite significant delays beyond guideline recommendations 4