Letter to the Director
Surgical embolectomy as salvage treatment after percutaneous thrombectomy in high-risk pulmonary embolism in postsurgical patients
Embolectomía quirúrgica como tratamiento de rescate tras trombectomía percutánea en embolismo pulmonar de alto riesgo en pacientes postquirúrgicos
M. Garví López
Servicio de Anestesiología y Reanimación, Hospital General Universitario de Albacete, Albacete, Spain
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"apellidos" => "Echevarría Moreno" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935621002462" "doi" => "10.1016/j.redar.2021.09.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621002462?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192923000203?idApp=UINPBA00004N" "url" => "/23411929/0000007000000002/v1_202303141745/S2341192923000203/v1_202303141745/en/main.assets" ] "en" => array:15 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Director</span>" "titulo" => "Surgical embolectomy as salvage treatment after percutaneous thrombectomy in high-risk pulmonary embolism in postsurgical patients" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "116" "paginaFinal" => "117" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "M. Garví López" "autores" => array:1 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Garví López" "email" => array:1 [ 0 => "marietagarvi@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital General Universitario de Albacete, Albacete, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Embolectomía quirúrgica como tratamiento de rescate tras trombectomía percutánea en embolismo pulmonar de alto riesgo en pacientes postquirúrgicos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1195 "Ancho" => 2167 "Tamanyo" => 263105 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0145" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Axial thoracic angio-CT scan showing repletion defects (red arrow) in relation to end-split PTE between main pulmonary arteries. (B) Intraoperative image of 2 large thrombi.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute massive pulmonary thromboembolism (PTE) remains a major cause of mortality requiring appropriate treatment. Although thrombolysis and endovascular techniques have displaced surgical embolectomy as the first line option, this could be a vital alternative in selected patients with high-risk PTE and contraindications to thrombolysis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a patient with no relevant medical history except for an adaptive disorder being followed up by psychiatry, who consulted the emergency department for dyspnoea and abdominal pain of several days' evolution, and underwent computed axial tomography (CT) of the chest and abdomen, which revealed moderate bilateral pleural effusion and ascites with an ovarian-dependent mass. Examination revealed oxygen saturation (SatO<span class="elsevierStyleInf">2</span>) of 90% (with inspiratory oxygen fraction FiO<span class="elsevierStyleInf">2</span> of 21%) and crackles. The patient was admitted to the ward for treatment with oxygen and diuretics, with clinical improvement, resulting in the gynaecology department scheduling her for surgery. In the preoperative study, a 47-year-old woman (67<span class="elsevierStyleHsp" style=""></span>kg, 156<span class="elsevierStyleHsp" style=""></span>cm and BMI: 27.5<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>) with physical status II according to the American Society of Anesthesiologists (ASA) was assessed and a chest X-ray and echocardiogram were requested, which were normal. A laparotomy was performed under general anaesthesia for bilateral adnexectomy and simple hysterectomy plus complete pelvic peritonectomy, surgery that was performed without incident. According to protocol, low molecular weight heparin 40<span class="elsevierStyleHsp" style=""></span>mg was administered subcutaneously 8<span class="elsevierStyleHsp" style=""></span>h after the operation, as prophylaxis for venous embolism. On the first postoperative day, the patient began with dyspnoea and a tendency to hypotension. Suspecting PTE, thoracic CT angiography was requested and reported repletion defects due to end-stopped PTE between both main pulmonary arteries (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). D-dimer was 4−300<span class="elsevierStyleHsp" style=""></span>ng/ml, troponin was 2500<span class="elsevierStyleHsp" style=""></span>ng/ml, blood pressure was 80/50<span class="elsevierStyleHsp" style=""></span>mmHg, SatO<span class="elsevierStyleInf">2</span> 93% with FiO<span class="elsevierStyleInf">2</span> 60% and oligoanuria. The patient required haemodynamic support with noradrenaline at a maximum dose of 0.3<span class="elsevierStyleHsp" style=""></span>μg/kg/min and dobutamine at 10<span class="elsevierStyleHsp" style=""></span>μg/kg/min.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Echocardiography reported dysfunctioning right ventricle with severe tricuspid regurgitation. Anticoagulant treatment with heparin was started and the haemodynamics and cardiac surgery services were consulted. Since systemic thrombolysis was contraindicated, mechanical thrombectomy and local thrombolysis with 2.5<span class="elsevierStyleHsp" style=""></span>mg of recombinant tissue plasminogen activator (rtPA) was performed but proved ineffective. The patient was re-evaluated by the cardiac surgery department and an embolectomy was performed 24<span class="elsevierStyleHsp" style=""></span>h later, in which 2 large thrombi were removed from both pulmonary arteries (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). During the intraoperative period she required circulatory support with a venoarterial extracorporeal membrane oxygenation (ECMO) system for 48<span class="elsevierStyleHsp" style=""></span>h. After its removal, she remained haemodynamically stable and was extubated on the second postoperative day with the need for non-invasive mechanical ventilation for 3 days. On the twelfth day she was discharged to the ward. Pathological anatomy revealed endometrial adenocarcinoma with peritoneal carcinomatosis and bilateral ovarian involvement (stage IIIC).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Venous embolism causes 10% of early mortality in surgical patients with cancer. Our case presented a high risk of thrombosis given that it involved complex gynaecological oncological surgery with a surgical time of over 2<span class="elsevierStyleHsp" style=""></span>h in a hospitalised patient.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Stratification of the severity of PTE is necessary to determine therapeutic management; it is based on symptoms and signs of haemodynamic instability indicating high risk of early death (in hospital or within the first 30 days).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The treatment approach has 3 components: cardiopulmonary support, anticoagulation and pulmonary artery reperfusion. More than 70% receive reperfusion therapy with thrombolysis being the most commonly used and has been shown to reduce mortality. However, it carries a 20% risk of bleeding.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our patient, thrombolysis was contraindicated due to the recent postoperative period, so catheter therapy or surgery was considered. Percutaneous treatment offers patients at high risk of bleeding the option of endovascular intervention with low-dose or no rtPA. Regarding embolectomy, although it requires systemic heparinisation, cardiopulmonary bypass has a short duration and is safe for bleeding.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Regarding the use of ECMO in these cases, it is recommended to delay the start of heparin to 12−48<span class="elsevierStyleHsp" style=""></span>h postoperatively and not to start it when there is bleeding, as long as high flows are maintained (><span class="elsevierStyleHsp" style=""></span>2–2.5<span class="elsevierStyleHsp" style=""></span>l/min) to avoid the formation of clots in the system. To prevent thrombosis of both the system and the cardiac cavities, unfractionated heparin is the most commonly used anticoagulant and its control through activated clotting time (ACT) (160–180) and activated partial thromboplastin time (aPTT) (1.5–2 times baseline) is the recommended guideline. Due to recent surgery, individualised and continuous monitoring should be performed, adjusting anticoagulation to the patient's specific circumstances at any given time. In the case of severe life-threatening haemorrhage, anticoagulation should be discontinued and blood products should be transfused according to a transfusion protocol.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The European Society of Cardiology guidelines recommend surgery for high-risk patients in whom thrombolysis is contraindicated (class I recommendation), and endovascular treatment should also be considered in these cases (class IIa recommendation).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Both embolectomy and percutaneous therapies have good mortality outcomes, however, PTE surgery is associated with higher mortality because it is performed in more critically ill patients with a higher incidence of cardiac arrest.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In this case, due to the availability and experience of endovascular treatment in our centre, this therapy was chosen. However, surgery was considered in case of failure due to the morphological characteristics of the thrombus occupying both pulmonary arteries.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The results of embolectomy have improved over the last 30 years. Due to advances in surgical technique, it can be considered as a first-line alternative to thrombolysis.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2,5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">We conclude that the decision algorithm is complex and should be based on protocols as well as multidisciplinary teams, taking into account hospital experience and resources.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5</span></a> Surgical embolectomy is a safe and appropriate treatment for selected cases with centrally located thrombi,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and should therefore be present as the first treatment option for high-risk PTE in post-surgical patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author received no specific aid from the public sector, comercial sector or not-for-profit entities.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1195 "Ancho" => 2167 "Tamanyo" => 263105 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0145" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Axial thoracic angio-CT scan showing repletion defects (red arrow) in relation to end-split PTE between main pulmonary arteries. (B) Intraoperative image of 2 large thrombi.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.V. Konstantinides" 1 => "G. Meyer" 2 => "C. Becattini" 3 => "H. Bueno" 4 => "G.J. Geersing" 5 => "V.P. Harjola" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehz405" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2020" "volumen" => "41" "paginaInicial" => "543" "paginaFinal" => "603" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/31504429" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current management of acute pulmonary embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.R. Martinez Licha" 1 => "C.M. McCurdy" 2 => "S. Masso Maldonado" 3 => "L.S. 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Cegarra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2020.12.011" "Revista" => array:5 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2021" "volumen" => "68" "paginaInicial" => "443" "paginaFinal" => "471" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical pulmonary embolectomy outcomes for acute pulmonary embolism" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.H. Choi" 1 => "T.J. O’Malley" 2 => "E. Maynes" 3 => "M. Weber" 4 => "N.D. D’Antonio" 5 => "M. Mellado" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2020.01.075" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2020" "volumen" => "110" "paginaInicial" => "1072" "paginaFinal" => "1080" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32151576" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000007000000002/v1_202303141745/S234119292300029X/v1_202303141745/en/main.assets" "Apartado" => array:4 [ "identificador" => "66474" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000007000000002/v1_202303141745/S234119292300029X/v1_202303141745/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234119292300029X?idApp=UINPBA00004N" ]
