How would you do a pulmonary embolectomy?

[polospy]

the title says it all! How would you do it?

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[JackADeli]

the title says it all! How would you do it?

I found the following with a google search, hope it helps:

http://ats.ctsnetjournals.org/cgi/content/full/77/3/819

http://www.ncbi.nlm.nih.gov/pubmed/11914247

http://ats.ctsnetjournals.org/cgi/content/full/79/4/1240

 

[Winged Scapula]

the title says it all! How would you do it?

Why does a pre-dent student want to know this?

I've never done one so can only read about how I would do it (and perhaps I will, thanks to JAD's links).

 

[Arzamus]

Why does a pre-dent student want to know this?

NOTES Embolectomy, obviously.

 

[Winged Scapula]

NOTES Embolectomy, obviously.

Ah yes, through the back molars obviously.

 

[DO_Surgeon]

the title says it all! How would you do it?

I will let you know. The CT fellow and I are sitting waiting for the OR to get ready. We have a guy in the ER with massive bilateral PE's with RV strain starting to show signs of decompensation. He is pretty giddy about this...says its his favorite operation.

 

[JackADeli]

...The CT fellow and I are sitting waiting for the OR to get ready. We have a guy in the ER with massive bilateral PE's with RV strain starting to show signs of decompensation. ...

Can't IR do this catheter based??? During my GSurgery residency, this was often dealt with in the acute setting in the IR/Cath lab. The one time it (bypass/on pump and washout)was done on a.... young, pro-athletic male.... didn't do so well.

JAD

 

[DO_Surgeon]

Can't IR do this catheter based??? During my GSurgery residency, this was often dealt with in the acute setting in the IR/Cath lab. The one time it (bypass/on pump and washout)was done on a.... young, pro-athletic male.... didn't do so well.

JAD

I think that at most places this is an IR thing. Here they are not all too aggressive and felt he was decompenstating rather quickly. Have to admit, it wasn't as hard or as technical as I thought it would be. Open the chest, two cannulas, open the PA, grab, suck, then close. I think the total pump time was something like 30 minutes. The guy is doing reasonable well this morning, but I have to agree with you...he have been better off with a puncture in the groin.

 

[JackADeli]

I think that at most places this is an IR thing. ...I have to agree with you...he have been better off with a puncture in the groin.

so, when does he get the filter (i.e. IR and groin stick anyways)???

 

[DO_Surgeon]

so, when does he get the filter (i.e. IR and groin stick anyways)???

Got his filter on the OR table last night around 2:00 AM after we closed the chest. No signs of hematoma, despite the fact he got a theraputic dose of fragmin in the ER before the decision was made for the OR and our 30,000 units of heparin. Granted he got protamine, but I am not all too sure we did this guy any favors by sawing open his chest. Intraop we noticed the guy had a small PFO, so there was a discussion about fixing it or not. We left it alone. I guess we will see if that was a right decision when he fails to wake up and get extubated.

The fellow made the argument if you wait for these guys to crash and code with RV failure, you are too late...ball game over. You want to catch them early. This guy had some RV strain, but I think he would have probably done fine with thrombolytics or even standard anticoagulation??

 

[JackADeli]

Got his filter on the OR table last night around 2:00 AM after we closed the chest. No signs of hematoma, despite the fact he got a theraputic dose of fragmin in the ER before the decision was made for the OR and our 30,000 units of heparin. Granted he got protamine, but I am not all too sure we did this guy any favors by sawing open his chest. Intraop we noticed the guy had a small PFO, so there was a discussion about fixing it or not. We left it alone. I guess we will see if that was a right decision when he fails to wake up and get extubated.

The fellow made the argument if you wait for these guys to crash and code with RV failure, you are too late...ball game over. You want to catch them early. This guy had some RV strain, but I think he would have probably done fine with thrombolytics or even standard anticoagulation??

yeh, just reading it.... based on my GSurgery residency experience.... I gots to agree with you (disagree with fellow). Guy got fragmin, so obviously not anticoag contra-indicated..... got endovasc procedure (i.e. filter) so not contraindicated... PFO left in place.... was he rt to lt shunting to any significant degree??? Was his tricuspid having incompetence 2nd to right heart failure???? Catching them "early" is more of an argument for IR/Cath lab intervention....

Patient now at risk of post-pump-run complications, sternal complications, groin complications, and etc..... If patient is young, his future coronary wil represent a "re-do" chest. your fellow got a pump case. It may have represented one of the few cases the attending allowed the fellow to actually do most of case....

Thought I would add..... Generally what I have seen is
a) 5000 heparin push, CTA to confirm diagnosis, followed by alteplase ~100 (adjust according to protocols/etc...) over 2hrs (faster if needed i.e. 30min protocol) followed by hep drip protocol
b) 5000 heparin push and then cath lab
c) if a & b fail, the on-pump... with ~fair salvage results.

Those that got "a" or "b" above were often sick and/or high O2 if not intubated and +/- on vasoactive drip support.....

I am by no means an expert on this, but it's what my colleagues in critical care and ED do.

JAD

 

[polospy]

Sorry, I am no means an expert at anything. The reason why I started this thread was because I've been shadowing a surgeon and he did a pulmonary embolectomy under fluoro. It was definitely one of the coolest procedures I've ever seen.

 

[JackADeli]

...I've been shadowing a surgeon and he did a pulmonary embolectomy under fluoro...

What type of surgeon are you shadowing, General surgeon? Cardiac surgeon? Vascular surgeon?

I am surprised that a surgeon did a catheter based pulmonary embolectomy. I suspect that is a fairly atypical scenario. I would suspect/expect such a procedure to be done by interventional cardiologist or interventional radiologist. Granted, I have seen surgeons do extremity embolectomies.... in the OR.

JAD

 

[ESU_MD]

I always thought the acute PE scenario was similar to the "fulminant c diff/toxic megacolon" scenario: how long do you optimize medical management before going for a high risk operation?

Its all about patient selection and judgement.

You have to be sick enough to need intervention (beyond a little heparin) to go to the cath lab, but not sick enough to need an operation. quite a fine line. not a ton of data to predict whos gonna go bad on you.
The trauma guys always say the CT scanner is the most dangerous place in the hospital, well- the cath lab is probably a close second. not a good place for an unstable patient.
massive PE is a bad problem and catheter based procedures arent perfected either. I suspect the "good" outcomes with catheters were in patients who would've done the same with just anticoagulation and filters.

I guess I would only offer surgical embolectomy to those who are unstable.
-intubated
-on alot of pressors
-RV struggling on echo
a short pump run itself isnt THAT dangerous, but if the RV is already gone the outcome will be poor no matter what. this indeed is salvage surgery and I dont think anyone offers it as a primary option.

BTW- I think you should fix he PFO, it adds no time to the operation and its very easy to place a filter via the R atrium

 

[dpmd]

This made me think of a trauma patient we had that started doing poorly during one of his takeback operations. There was concern about massive PE so they opened the chest and opened the pulmonary artery (didn't find a clot) and closed everything back up. I should tell you we are at a facility that doesn't have bypass capability or cardiac surgeons. I wasn't there for the case, but I heard it was exciting to say the least.

 

[JackADeli]

I always thought the acute PE scenario was similar to the "fulminant c diff/toxic megacolon" scenario...

You have to be sick enough to need intervention (beyond a little heparin) to go to the cath lab, but not sick enough to need an operation. I suspect the "good" outcomes with catheters were in patients who would've done the same with just anticoagulation and filters.

I guess I would only offer surgical embolectomy to those who are unstable.

Where I am, plenty of surgeons available.... but very rare operative therapy. The first step is usually IV alteplase..... The lytics are pretty fast acting. It can be infused over two hours or 30 minutes if patient response not quick enough. They seem to act far faster then it takes to get pump built, patient to OR and chest open. Thus, if you are looking at a patient in ED you can give it alteplase (if confident of diagnosis) or if diagnosis in question, 5k heparin, CTA and then alteplase.....

...a trauma patient we had ...doing poorly during one of his takeback operations. ...was concern about massive PE so they opened the chest and opened the pulmonary artery .... ...at a facility that doesn't have bypass capability or cardiac surgeons...

This scenario makes NO sense. Take a look at Netter to understand why it makes no sense (and why bypass with systemic heparinization is required for open operative embolectomy). Take look at excerpt below....

Surgical technique
After median sternotomy and pericardiotomy, the patients were heparinized and cannulated for cardiopulmonary bypass. The arterial cannula was placed in the ascending aorta with either bicaval or a single venous cannula placed through the right atrium. Cardiopulmonary bypass was instituted ...had a cross clamp ...with a mean cardiopulmonary bypass time of 66 minutes (41 to 113 minutes). In the other 8 ...performed without cross clamp and a mean cardiopulmonary bypass time of 35 minutes (19 to 65 minutes). Clot was extracted under direct vision using forceps through a longitudinal incision made in the main pulmonary artery. A second incision was made in the right pulmonary artery between the aorta and the superior vena cava (SVC) in 12 patients to facilitate clot removal....

 

[nonbilious]

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[ESU_MD]

The first step is usually IV alteplase..... The lytics are pretty fast acting. It can be infused over two hours or 30 minutes if patient response not quick enough.

JAD, I dont have alot of experience with using thrombolytics in PE. It seems like you just give them systemically? I have setup a few pts for catheter directed lysis for limb ischemia with mixed results though.

 

[ESU_MD]

This made me think of a trauma patient we had that started doing poorly during one of his takeback operations. There was concern about massive PE so they opened the chest and opened the pulmonary artery (didn't find a clot) and closed everything back up. I should tell you we are at a facility that doesn't have bypass capability or cardiac surgeons. I wasn't there for the case, but I heard it was exciting to say the least.

did this patient survive??

i guess they used bicaval inflow occlusion technique which combined with some cooling may allow for a few minutes to open the PA, suck some clot AND sew it back up. Wouldnt reccomend trying this... unless you are Denton Cooley.

 

[DO_Surgeon]

JAD, I dont have alot of experience with using thrombolytics in PE. It seems like you just give them systemically? I have setup a few pts for catheter directed lysis for limb ischemia with mixed results though.

I researched this last year...there is no benefit of giving tPA through a PA catheter. Just given systemically. Usually given over 2 hours, but as mentioned you can speed this up abit if need to. Keep in mind there has not been a study to show that tPA has any survival benefit. Patients may benefit short and long term as far as lung issues, Pulm HTN, etc. but no evidence patients live longer.

 

[JackADeli]

did this patient survive??

i guess they used bicaval inflow occlusion technique which combined with some cooling may allow for a few minutes to open the PA, suck some clot AND sew it back up. Wouldnt reccomend trying this...

This patient scenario sounds like urban legend. It is definately the answer to give if you enjoy your time with the grey haired men in the hotel and want to come back another year.

Basically, the scenario reported....
A trauma patient undergoing takeback. Presumably abdominal trauma???
So, some intra-op instability occurs. The "trauma surgeon" decides it must be a massive PE.
As there are NO perfusionists, NO pumps, NO qualified heart surgeons... He/she procedes to split the sternum. Now what???
Heart beating, incise PA and blindly suck with blood in your face? I guess four cell savers must have been running to collect the outflow of the RVOT. I guess in TBerg to avoid air emboli to lungs??? Was any systemic heparin given?

Of course, no clot was found. I am not sure he/she would have found any clot in the swimming pool of blood. The operative technique described in all my readings talks about on pump with "direct vision" extraction.

Ultimately, this scenario is, IMHO, MALPRACTICE. I am no heart surgery expert. But, this was a cowboy maneuver if it happened at all. You would be hard pressed convincing anyone that it was the correct thing to do. I can not imagine any heart surgeon backing this [reported] play.

On the stand.... are you a heart surgeon? how was the diagnosis made? So, you didn't find any clot in the lungs? etc....

...I dont have alot of experience with using thrombolytics in PE. It seems like you just give them systemically?...

What the EM and MICU do is intravenous via infusion pump. Alteplase is over 2 hours. However, plenty of reports of giving half dose over first 10 minutes followed by remainder over next 20 minutes. Then according to protocol, a heparin drip will be started. Supportive care given throughout. Some places may use catheter directed... usually more for extraction then purely lysis.

JAD

 

[dpmd]

This patient scenario sounds like urban legend.
Basically, the scenario reported....
A trauma patient undergoing takeback. Presumably abdominal trauma???
So, some intra-op instability occurs. The "trauma surgeon" decides it must be a massive PE.
As there are NO perfusionists, NO pumps, NO qualified heart surgeons... He/she procedes to split the sternum. Now what???
Heart beating, incise PA and blindly suck with blood in your face? I guess four cell savers must have been running to collect the outflow of the RVOT. I guess in TBerg to avoid air emboli to lungs??? Was any systemic heparin given?

Of course, no clot was found. I am not sure he/she would have found any clot in the swimming pool of blood. The operative technique described in all my readings talks about on pump with "direct vision" extraction.

Ultimately, this scenario is, IMHO, MALPRACTICE. I am no heart surgery expert. But, this was a cowboy maneuver if it happened at all. You would be hard pressed convincing anyone that it was the correct thing to do. I can not imagine any heart surgeon backing this [reported] play.

On the stand.... are you a heart surgeon? how was the diagnosis made? So, you didn't find any clot in the lungs? etc....

JAD

Interesting response. Pulmonary embolectomy with inflow occlusion has been well described. Certainly if you have the option of bypass and a specialist you should take advantage of it. I assure you this is not a made up patient. It was a very unusual and difficult situation, but patient was fortunate to have an attending who had performed the procedure in the past (and trust me, he wasn't thrilled at having to do it again).

Given a patient in the OR with abrubt onset of hypotension resistant to treatment, hypoxia, and a drop in end tidal CO2 would you not suspect PE, especially if all looks ok in the belly, and he had risk factor for PE like pelvic fxs. If you are at a facility that does not have cardiac surgeons, or any bypass capability, and the pt is about to arrest what would you do? Do your own angio or transesophageal echo to try to confirm, then order up the thrombolytics and potentially be doing CPR until the clot dissolves or jou decide to call it? Call in one of the cardio surgeons from in town and have him bring his equipment and people while you try to keep the pt alive? Or would you try a less desirable procedure based on the fact that death is the most likely outcome without it.

Bottom line pt survived, not all will with or without bypass.

Just out of curiosity, would you also be unwilling to believe that we take care of GSW's to the heart without cardiac surgeons too?

 

[JackADeli]

...Pulmonary embolectomy with inflow occlusion has been well described. Certainly if you have the option of bypass and a specialist you should take advantage of it...

A great deal of things have been reported in the past. A great deal of surgeons have "gotten away with it" in the past.... That does not mean it is appropriate. I could point you to the massive spike in trauma thorocotomies... and subsequent dip when true outcomes/conditions examined beyond just anectdotal experience of individual surgeons.

...Given a patient in the OR with abrubt onset of hypotension resistant to treatment, hypoxia, and a drop in end tidal CO2 would you not suspect PE, especially if all looks ok in the belly, and he had risk factor for PE like pelvic fxs. If you are at a facility that does not have cardiac surgeons, or any bypass capability, and the pt is about to arrest what would you do?...

The problem is that your patient did NOT have a PE. Thus, great risk at no benefit to the patient. That is why suspicion (without confirmation) of PE alone will not even get a CT surgeon to crack open the chest....

..would you try a less desirable procedure based on the fact that death is the most likely outcome without it.

Bottom line pt survived, not all will with or without bypass...

And if patient didn't survive (and no PE)? or patient developed mediasternitis (and no PE)? The patient survived but underwent an unnecessary, highly morbid, dangerous procedure.... because of a error in diagnosis.

I am not trying to get into a urination match. I appreciate what you are saying. The problem is I see too much of folks doing "something" because it is beter then "doing nothing" and/or the patient would die if nothing was done..... yet, your patient received absolutely NO benefit from the doing something and lived.... I do not think it was a defendable act. That is just my opinion.

As for penetrating wound to heart..... Yes, open sternum and whip stitch. If you can not do whip stitch (or appropriate variant), and requires bypass, that means patient has non-survivable injury for the facilities/timing/conditions... In that scenario, you have a diagnosis. That is quite different then the scenario of you having a misdiagnosis and innadequate equipment.

JAD