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Annals of Thoracic and Cardiovascular... Apr 2020Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. While non-surgical approaches have supplanted... (Review)
Review
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 -
European Heart Journal Jan 2020
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 -
European Heart Journal Jan 2016
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...
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 -
Journal of the American College of... Nov 2020Intermediate-risk (submassive) pulmonary embolism (PE) describes normotensive patients with evidence of right ventricular compromise, whereas high-risk (massive) PE... (Review)
Review
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 -
Chest Mar 2022Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe... (Review)
Review
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 -
European Heart Journal Nov 2014
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 -
The Journal of Thoracic and... Dec 2018
Topics: Embolectomy; Humans; Pulmonary Embolism
PubMed: 30098803
DOI: 10.1016/j.jtcvs.2018.06.032 -
Rhode Island Medical Journal (2013) Dec 2019Acute pulmonary embolism (PE) causes significant morbidity and mortality, particularly for patients with subsequent right ventricular (RV) dysfunction. Once diagnosed,... (Review)
Review
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 -
Journal of the American College of... Aug 2020
Topics: Acute Disease; Embolectomy; Extracorporeal Membrane Oxygenation; Humans; Pulmonary Embolism; Ventricular Function, Right
PubMed: 32819464
DOI: 10.1016/j.jacc.2020.07.016 -
Thrombosis Research Aug 2021Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability... (Review)
Review
Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability and circulatory failure through a large thrombotic pulmonary obstruction. The very challenging management of these dramatic situations comprises the need to quickly select a therapy of pulmonary reperfusion or hemodynamic replacement, while taking into account both maternal and fetal risks. In this review, we discuss the role of risk stratification in pregnancy-associated PE and the available evidence to support the use of thrombolysis, catheter-directed thrombectomy/thrombolysis, surgical embolectomy and extracorporeal membrane oxygenation. Despite the lack of comparative studies and solid evidence, most reported cases of high-risk pregnancy-associated PE have been treated with thrombolysis, with high maternal and fetal survivals, and thrombolysis is suggested by guidelines in life-threatening PE. For women in the peripartum and early post-partum period, non-fibrinolytic treatments may be preferred as a first-line treatment, if available, because of the particularly high bleeding risk. In all cases, pregnancy-associated high-risk PE requires a multidisciplinary approach involving PE response teams and obstetricians.
Topics: Embolectomy; Extracorporeal Membrane Oxygenation; Female; Fibrinolytic Agents; Humans; Pregnancy; Pulmonary Embolism; Thrombectomy; Thrombolytic Therapy; Treatment Outcome
PubMed: 34146979
DOI: 10.1016/j.thromres.2021.05.019