Surgical Management of Acute Pulmonary Embolism

Karanpreet Dhaliwal, MD, Michael Mulligan, MD, Jay D. Pal, MD, PhD, Christopher Scott, MD, Neil Venardos, MD, Vicente Valero III, MD


Pulmonary embolism (PE) is a pervasive clinical condition with an incidence of approximately 70 per 100,000 people, and it is estimated to account for more than 300,000 deaths annually in the United States.[1],[2] Pulmonary embolism can be subdivided into submassive or massive based on clinical characteristics. Currently the American Heart Association (AHA) defines submassive PE as an acute PE with right ventricular dysfunction or myocardial necrosis but without systemic hypotension (systolic blood pressure is greater than 90 mm Hg).[3] About 80% of patients with acute PE present without systemic hypotension, and of this subset, about 25% to 55% will exhibit right ventricular dysfunction on echocardiogram. In contrast, patients are said to have a massive PE if they have associated sustained hypotension, cardiac arrest, or profound bradycardia with signs of shock per AHA definitions. [4],[5],[6],[3][7]

Most pulmonary emboli will resolve within 30 days with the use of systemic anticoagulation.[8] The therapeutic strategy for submassive and massive PE is divided into pharmacologic, which includes heparin and thrombolytics, and mechanical, which involve catheter and surgical embolectomy. Current standard of care is to manage patients with “non-massive” PE with anticoagulation therapy alone for at least 6 months. Most centers reserve surgical embolectomy (SE) for acute PE that has either failed catheter-based therapy, such as thrombolysis or mechanical extraction, or for those with contraindications to percutaneous intervention. Hence the role of the cardiothoracic surgeon in the care of these patients is limited to a relatively small subset of patients with acute pulmonary embolism. The complex decision-making involved in the care of these patients has driven many tertiary centers to build multidisciplinary acute PE teams comprised of critical care physicians, interventional radiologists, and a cardiothoracic surgeon to review complicated cases and develop a consensus care plan. These teams have shown improved outcomes after SE with appropriate patient selection.

The original surgical technique, described by Friedrich Trendelenburg in 1908, involved a left anterior thoracotomy through which the aorta and pulmonary artery were controlled with vessel loops. The main pulmonary artery was then opened while the great vessels were proximally occluded and the thrombus extracted. While the technique allowed removal of the pulmonary embolus, Trendelenburg was not able to accomplish this procedure in a surviving patient. Approximately 15 years later, Trendelenburg’s trainee, Martin Kirschner, performed the first successful pulmonary embolectomy using a variation of the original technique.

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Last updated: November 21, 2023