Authors: Stavros V Konstantinides, Guy Meyer, Cecilia Becattini...

Topics: Acute Disease; Anticoagulants; Cardiology; Disease Management; Embolectomy; Europe; Humans; Pulmonary Embolism; Pulmonary Medicine; Societies, Medical; Thrombolytic Therapy

PubMed: 31504429
DOI: 10.1093/eurheartj/ehz405

Review

Authors: Carlos R Martinez Licha, Chelsea M McCurdy, Sarina Masso Maldonado...

PURPOSE

Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. While non-surgical approaches have supplanted surgery as primary treatment, surgical pulmonary embolectomy (SPE) remains a vital option for select patients. We review the current management of acute PE, with a focus on surgical therapy.

METHODS

A PubMed search was performed to identify literature regarding PE and treatment. Results were filtered to include the most comprehensive publications over the past decade.

RESULTS

PE is stratified based on presenting hemodynamic status or degree of mechanical pulmonary arterial occlusion. Although systemic or catheter-guided fibrinolysis is the preferred first-line treatment for the majority of cases, patients who are not candidates should be considered for SPE. Studies demonstrate no mortality benefit of thrombolysis over surgery. Systemic anticoagulation is a mainstay of treatment regardless of intervention approach. Following surgical embolectomy, direct oral anticoagulants (DOACs) have been shown to reduce recurrence of thromboembolism.

CONCLUSIONS

Acute PE presents with varying degrees of clinical stability. Patients should be evaluated in the context of various available treatment options including medical, catheter-based, and surgical interventions. SPE is a safe and appropriate treatment option for appropriate patients.

Topics: Acute Disease; Anticoagulants; Embolectomy; Hemodynamics; Humans; Pulmonary Embolism; Recurrence; Risk Factors; Thrombolytic Therapy; Treatment Outcome

PubMed: 31588070
DOI: 10.5761/atcs.ra.19-00158

2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric...

Authors: Nazzareno Galiè, Marc Humbert, Jean-Luc Vachiery...

Topics: Adult; Algorithms; Antihypertensive Agents; Arrhythmias, Cardiac; Balloon Embolectomy; Biomarkers; Cardiac Catheterization; Child; Combined Modality Therapy; Connective Tissue Diseases; Cross Infection; Drug Interactions; Echocardiography; Elective Surgical Procedures; Electrocardiography; Exercise Test; Exercise Therapy; Female; Genetic Counseling; Genetic Testing; HIV Infections; Health Status; Heart Defects, Congenital; Hemangioma; Hemoptysis; Humans; Hypertension, Portal; Hypertension, Pulmonary; Lung Transplantation; Magnetic Resonance Angiography; Multimodal Imaging; Patient Compliance; Pregnancy; Pregnancy Complications, Cardiovascular; Referral and Consultation; Respiratory Function Tests; Risk Assessment; Risk Factors; Social Support; Terminal Care; Therapies, Investigational; Thromboembolism; Tomography, X-Ray Computed; Travel Medicine; Treatment Outcome; Ventricular Dysfunction, Right

PubMed: 26320113
DOI: 10.1093/eurheartj/ehv317

Review

Authors: Gregory Piazza

Intermediate-risk (submassive) pulmonary embolism (PE) describes normotensive patients with evidence of right ventricular compromise, whereas high-risk (massive) PE comprises those who have experienced hemodynamic decompensation with hypotension, cardiogenic shock, or cardiac arrest. Together, these 2 syndromes represent the most clinically challenging manifestations of the PE spectrum. Prompt therapeutic anticoagulation remains the cornerstone of therapy for both intermediate- and high-risk PE. Patients with intermediate-risk PE who subsequently deteriorate despite anticoagulation and those with high-risk PE require additional advanced therapies, typically focused on pulmonary artery reperfusion. Strategies for reperfusion therapy include systemic fibrinolysis, surgical pulmonary embolectomy, and a growing number of options for catheter-based therapy. Multidisciplinary PE response teams can aid in selection of appropriate management strategies, especially where gaps in evidence exist and guideline recommendations are sparse.

Topics: Clinical Decision-Making; Disease Management; Embolectomy; Fibrinolytic Agents; Humans; Pulmonary Embolism; Risk Assessment; Risk Factors; Thrombolytic Therapy; Treatment Outcome

PubMed: 33121720
DOI: 10.1016/j.jacc.2020.05.028

Review

Authors: Catherine Ross, Riten Kumar, Marie-Claude Pelland-Marcotte...

Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.

Topics: Acute Disease; Child; Embolectomy; Humans; Pulmonary Embolism; Risk Factors; Thrombolytic Therapy; Treatment Outcome

PubMed: 34587483
DOI: 10.1016/j.chest.2021.09.019

Authors: Stavros V Konstantinides, Adam Torbicki, Giancarlo Agnelli...

Topics: Administration, Oral; Algorithms; Anticoagulants; Biomarkers; Chronic Disease; Clinical Laboratory Techniques; Diagnostic Imaging; Embolectomy; Endovascular Procedures; Female; Fibrin Fibrinogen Degradation Products; Fibrinolytic Agents; Heart Failure; Home Care Services; Humans; Hypertension, Pulmonary; Long-Term Care; Neoplasms; Pregnancy; Pregnancy Complications, Cardiovascular; Prognosis; Pulmonary Embolism; Risk Factors; Vasoconstrictor Agents; Vasodilator Agents; Vitamin K

PubMed: 25173341
DOI: 10.1093/eurheartj/ehu283

Authors: Edo Bedzra, Daniel A Aldea, Gabriel S Aldea...

Topics: Embolectomy; Humans; Pulmonary Embolism

PubMed: 30098803
DOI: 10.1016/j.jtcvs.2018.06.032

Review

Authors: Parth Rali, Viral Gandhi, Khalid Malik...

Pulmonary embolism covers a wide spectrum of presentation from an asymptomatic individual to a life-threatening medical emergency. It is of paramount importance to appropriately risk stratify patients with pulmonary embolism, particularly with those who present without hypotension. Right ventricular dysfunction can evolve after a patient has received a diagnosis of pulmonary embolism, necessitating aggressive measures rather than simple anticoagulation. In this review, we discuss definition, risk stratification, pathogenesis, diagnostic approach, and management, with particular focus on massive pulmonary embolism.

Topics: Anticoagulants; Biomarkers; Embolectomy; Humans; Pulmonary Embolism; Risk Assessment; Thrombolytic Therapy; Ventricular Dysfunction, Right

PubMed: 26919674
DOI: 10.1097/CNQ.0000000000000106

Review

Authors: Christopher D Theroux, Jason M Aliotta, Christopher J Mullin...

Acute pulmonary embolism (PE) causes significant morbidity and mortality, particularly for patients with subsequent right ventricular (RV) dysfunction. Once diagnosed, risk stratification is imperative for therapeutic decision making and centers on evaluation of RV function. Treatment includes supportive care, systemic anticoagulation, and consideration of reperfusion therapy. In addition to systemic anticoagulation, patients with high-risk PE should receive reperfusion therapy, typically with systemic thrombolysis. The role of reperfusion therapies, which include catheter-based interventions, systemic thrombolysis, and surgical embolectomy, are controversial in the management of intermediate risk PE. Catheter directed thrombolysis (CDT) can be considered in certain intermediate risk patients although prospective, comparative data for its use are lacking. Surgical or catheter embolectomy are viable treatment options for high-risk patients in whom reperfusion therapy is warranted but who have absolute contraindications to thrombolysis. Further research is needed to better elucidate which patients with PE would most benefit from advanced reperfusion therapies.

Topics: Clinical Decision-Making; Embolectomy; Evidence-Based Practice; Fibrinolytic Agents; Humans; Patient Selection; Pulmonary Embolism; Randomized Controlled Trials as Topic; Risk Factors; Severity of Illness Index; Thrombolytic Therapy; Treatment Outcome

PubMed: 31795534
DOI: No ID Found

Authors: A Mahmood, R Hardy, A Garnham...

BACKGROUND

microtibial embolectomy is an important technique in cases of limb threatening acute arterial occlusion affecting native crural and pedal vessels. It is particularly useful when thrombolysis is contraindicated or ineffective as in "trash foot".

METHODS

in order to evaluate the efficacy of this technique, a retrospective case note review was carried out for patients undergoing microtibial embolectomy from 1990 to 1999. Data collected included the causes and degree of ischaemia, additional procedures required, vessel patency, limb salvage and complications encountered.

RESULTS

twenty-two limbs underwent exploration of the crural/pedal vessels with ankle level arteriotomies under local anaesthetic in 12 cases, general anaesthetic in nine and epidural in one. The causes of ischaemia were cardiac emboli (8), "trash foot" (7), emboli from aortic and popliteal aneurysms (3) and thrombotic occlusion of crural vessels (4). The vessel patency rate was 69% and limb salvage rate 62% (13/21) up to 5-years follow-up. Six of the seven cases with "trash foot" were salvaged while one required an amputation at 3-months post-operatively. The 30-day mortality was 22% (5/22).

CONCLUSIONS

microtibial embolectomy is effective in acute occlusion of the crural/pedal arteries including cases of "trash foot", offering limb salvage to a worthwhile proportion of cases.

Topics: Aged; Aged, 80 and over; Embolectomy; Female; Foot; Humans; Ischemia; Lower Extremity; Male; Middle Aged; Retrospective Studies; Thromboembolism; Tibial Arteries; Treatment Outcome

PubMed: 12525809
DOI: 10.1053/ejvs.2002.1768