Minimally Invasive Surgical Pulmonary Embolectomy

Abstract

Objective

Surgical pulmonary embolectomy has gained increasing popularity over the past decade with multiple series reporting excellent outcomes in the treatment of submassive pulmonary embolism. However, a significant barrier to the broader adoption of surgical pulmonary embolectomy remains the large incision and long recovery after a full sternotomy. We report the safety and efficacy of using a minimally invasive approach to surgical pulmonary embolectomy.

Methods

All consecutive patients undergoing surgical pulmonary embolectomy for a submassive pulmonary embolism (2015–2017) were reviewed. Patients were stratified as conventional or minimally invasive. The minimally invasive approach included a 5- to 7-cm skin incision with upper hemisternotomy to the third intercostal space. The primary outcomes were in-hospital and 90-day survival.

Results

Thirty patients (conventional = 20, minimally invasive = 10) were identified. Operative time was similar between the two groups, but cardiopulmonary bypass time was significantly longer in the minimally invasive group (58 vs 94 minutes, P = 0.04). While ventilator time and intensive care unit length of stay were similar between groups, hospital length of stay was 4.5 days shorter in the minimally invasive group, and there was a trend toward less blood product use. In-hospital and 90-day survival was 100%. Within the minimally invasive cohort, median right ventricular dysfunction at discharge was none-mild and no patient experienced postoperative renal failure, deep sternal wound infection, sepsis, or stroke.

Conclusions

Minimally invasive surgical pulmonary embolectomy appears to be a feasible approach in the treatment of patients with a submassive pulmonary embolism. A larger, prospective analysis comparing this modality with conventional surgical pulmonary embolectomy may be warranted.

Keywords

Minimally invasive surgery Surgical pulmonary embolectomy Hemisternotomy Pulmonary embolism

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References

Heit

J.A.

, Silverstein

M.D.

, Mohr

D.N.

The epidemiology of venous thromboembolism in the community. Thromb Haemost. 2001; 86: 452–463.

Kucher

, Rossi

, De Rosa

, Goldhaber

S.Z.

Massive pulmonary embolism. Circulation. 2006; 113: 577–582.

Office of the Surgeon General (US); National Heart, Lung, and Blood Institute. The Surgeon General's call to action to prevent deep vein thrombosis and pulmonary embolism. Section I: deep vein thrombosis and pulmonary embolism as major public health problems. Rockville, MD: Office of the Surgeon General (US); 2008: 9–18.

Neely

R.C.

, Byrne

J.G.

, Gosev

Surgical embolectomy for acute massive and submassive pulmonary embolism in a series of 115 patients. Ann Thorac Surg. 2015; 100: 1245–1251.

Keeling

W.B.

, Leshnower

B.G.

, Lasajanak

Midterm benefits of surgical pulmonary embolectomy for acute pulmonary embolus on right ventricular function. J Thorac Cardiovasc Surg. 2016; 152: 872–878.

Keeling

W.B.

, Sundt

, Leacche

Outcomes after surgical pulmonary embolectomy for acute pulmonary embolus: a multi-institutional study. Ann Thorac Surg. 2016; 102: 1498–1502.

Leacche

, Unic

, Goldhaber

S.Z.

Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg. 2005; 129: 1018–1023.

Pasrija

, Kronfli

, Rouse

Outcomes after surgical pulmonary embolectomy for acute submassive and massive pulmonary embolism: a single center experience. J Thorac Cardiovasc Surg. 2017; In press.

Bova

, Sanchez

, Prandoni

Identification of intermediate-risk patients with acute symptomatic pulmonary embolism. Eur Respir J. 2014; 44: 694–703.

10.

Fernandez

, Bova

, Sanchez

Validation of a model for identification of patients at intermediate to high risk for complications associated with acute symptomatic pulmonary embolism. Chest. 2015; 148: 211–218.

11.

Cohn

L.H.

, Adams

D.H.

, Couper

G.S.

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg. 1997; 226: 421–426.

12.

Cohn

L.H.

, Adams

D.H.

, Couper

G.S.

, Bichell

D.P.

Minimally invasive aortic valve replacement. Semin Thorac Cardiovasc Surg. 1997; 9: 331–336.

13.

Mihaljevic

, Gillinov

M.A.

, Cosgrove

D.M.

Minimally invasive aortic valve replacement. Multimed Man Cardiothorac Surg. 2006; 2006: mmcts 2005 001131.

14.

Tarzia

, Buratto

, Gallo

Implantation of the Heartware HVAD: from full sternotomy to less invasive techniques. Ann Cardiothorac Surg. 2014; 3: 535–537.

15.

Lentini

, Specchia

, Nicolardi

Surgery of the ascending aorta with or without combined procedures through an upper ministernotomy: outcomes of a series of more than 100 patients. Ann Thorac Cardiovasc Surg. 2016; 22: 44–48.

16.

Dogan

, Dzemali

, Wimmer-Greinecker

Minimally invasive versus conventional aortic valve replacement: a prospective randomized trial. J Heart Valve Dis. 2003; 12: 76–80.

17.

Piazza

, Hohlfelder

, Jaff

M.R.

A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II Study. JACC Cardiovasc Interv. 2015; 8: 1382–1392.