Acute PE is the third most common cause of cardiovascular death in the USA(1) 。 The symptom is often presented with poorly predictive such as dyspnea,chest pain, haemoptysis, syncope and arterial hypotension. Because of the clinical manesfestation being low characteristic and low sensitive, especially for those massive PE cases,patients would be deteriorated within short time rapidly, therefore rapid diangnosis is very important. In clinical practice, pulmonary artery computed tomography angiography (PACTA) was most common useful tool for making a rapid diagnosis and risk tratification. PACTA has sensibility of 83% and a specificity of 96%(27). By PACTA surgeons have very a visualazation of thrombosis clots location in the main pulmonary arteries and down to at least the segmental level. Acute PE was categorized as massive,submassive and nor-massive PTE. Massive PE(2) was defined as a PACTA finding of thrombosis clots in the man pulmonary artery or more than 2 lobar arteries. In our study,38 patients were diagnosied by PACTA of pulmonary artery,but 2 cases did not received CTA because of impossibility of receiving PACTA due to critical illness with cardiac arrest. In the case of patients with sever heamodynamic instability and inability to travel for PACTA, transthoracic echocardiagrapghy (TTE) should be considered a critical useful tool for making diagnosis. TTE provides not only location of thrombi clot but also assessment of right ventricle structure and function as well. In our study, all patient were diagnosed of PE by TTE.
For massive PE patients if hemodynamic unstable,the therapeutic window is very narrow, It was reported that about 10% of patients with symptomatic PE died within 1 hour of oneset,(12), There are several option of treatment for massive PE such as : systemic thrombolysis (ST ),catheter-directed thrombolysis or embolectomy and ST. (1)). According to traditional view,surgical embolectomy (SE) would not to be first choice but to be the last resort treatment when patients were contraindication to ST or CDL or ST failed to work even though patients were critical illness. SE was considered as very dangerous treatment for PE due to its high operative mortality with 27.2% to 59%(13). However, in 2005, Leacche M et al (4) firstly reported that pulmonary embolectomy mortality was only 6%, encouraged by the favorable result,the idea of extend indication for PE has evoluted to patient whose hemodynamaic are stable but intermediate and serve right ventricle dysfunction. The mortality of pulmonary embolectomy has gradually decreased. Lehnert P(14)reported 33cases of surgical treatment with 2 death,the mortality was 6%; Worku B(15) reported 20 cases surgical treatment for PE with only 1 case death,the mortality was 5%. Yalamanchili (16) reported with 8% mortality of surgical treatment, Edelman JJ (17)reported 37cases pulmonary embolectomy with 2 case death,the mortaliry was 5.4%.Aymard T(18) reported 28 cases pulmonary embolectomy with 2 cases death,mortality was only 3.6%. Cho(19)reported SE had lower cardiac mortality risk than thrombolysis in PE patients with heamodynamic stable. More and more good results of SE indicated SE should not only to be a rescue therapy for those patients who ST failed to work, but could be considered as to be first line treatment choice for PE. But there is still controversial about the outcome of SE. Jiye(20) reported 14.8% of surgical treatment mortality rate, Reza(21) recently reported 36 cases surgical treatment for massive PE with 10 death cases,the mortality was 27.8%. In our study,from 2007 to 2019,there were 41 cases of acute PE who received surgical embolectomy,of whom, 3 patients died postoperatively,the operative mortality rate was 7.32%, Consideration of 3 cases cardiac arrest preoperatively,the result was accepted,If cases of cardiac arrest was excluded,the operative mortality rate was 5.26 % (2/38), which is very favorable. In our study, there were only 2 patients accepted ST as first choice treatment but both of them failed to work and were transferred to surgical treatment. The other 39 cases of PE patients, SE were first-line treatment choice.,the mortality was low,only 2.56%(1/39).
Stein(22 ) performed a meta-analysis of 1300 patients in 46 reports and found a linear relationship between mortality and the prevalence of cardiac arrest before pulmonary embolectomy in each report.The most risk factor of surgical treatment is preoperative cardiac arrest which causing mortality up to 59%. Keeling (23)reported that the in-hospital mortality of patients with preoperative cardiopulmonary resuscitation (CPR) was significantly higher (9/28,32.8%) than in those without CPR (16/186,8.6%). Takahashi( 24) reported that 73% of patients who received CPR for longer than 30 minutes died after pulmonary embolectomy In our study,there were 3 patients who suffered from cardiac arrest before operation, 2 received surgical embolectomy as first line treatment even after continued CPR lasting more than 40 minutes, and got very good recovery without any brain damage. But the other one patient suffered from about 3mins CPR and then was treated with thrombolysis firstly,but failed and resorted to surgrical embolectomy. This patient died of surgical site bleeding lead to multiple organ function failure postoperatively. Even though there were reports of successful thrombolysis therapy for PE patient after long time CPR(25).In the light of our limited experience, it seemed to be more effectient to select surgical embolectomy as be the first choice treatment for PE patients with cardiac arrest. Aymard(8) did research for massive pulmonary embolism therapy between surgical embolectomy and thrombolytic therapy,and found that SE had lower mortality rate with 17.9% vs 23.1% in thrombolytic group. Compared with thrombolysis, surgical embolectomy would take less time in removal of clots in pulmonary artery and relieve afterlord of RV rapidly. Another reason is that postoperative bleeding also is a critical problem for those patients who failed in thrombolysis treatment.
Massive lung hemorrhage was severe operative related complication of SE which accounted for main cause of mortality in our study.There were 3 cases of massive lung hemorrhage postoperatively in the study. One patient died during operation because of uncontrolled great amount of bleeding in the lung. Another 2 patients were survival. Massive lung hemorrhage was often due to pulmonary arterial vasculature injured.During operation,in case of pulmonary massive hemorrhage, it is necessary to open pleural cavity,and locate the responsible pulmonary artery and repair rupture pulmonary artery with 6-0 polypropylene suture. In order to avoid damage to the infarcted smaller pulmonary artery,we modified surgical technique,when doing removal of thrombus clot in the distal pulmonary arterial branches,it is forbidden to perform extraction without visualization.It is hard to extract smaller clots deep in the distal pulmonary arterial branches, we used heparine saline to irrigate vigorously the pulmonary arterial branchs and aspirated till flesh red blood flew out from distal pulmonary arterial branch. Alternative option(14,26) was retrograde pulmonary venous perfusion with haparine saline, which was useful to removal very smaller clot in the distal pulmonary arterial branches.
Because all cases received anticoagulation therapy after discharge and lasted at least 2 years,there was no reoccurrent PE cases in the follow-up.However there was a case with cerebral intracranial bleeding at 1 year after SE.