Cardiology Department, University Hospital Jean Minjoz, Besancon, France.
Curr Opin Cardiol. 2010 Nov;25(6):560-7. doi: 10.1097/HCO.0b013e32833f02c5.
Acute pulmonary embolism remains associated with high morbidity and mortality rates despite currently available therapeutic options. This review outlines the most recent changes in this field and summarizes the main indications for thrombolytic therapy and surgical or catheter-based embolectomy in patients with high-risk pulmonary embolism.
There have been no major advances in therapy for high-risk pulmonary embolism over the past few years. The main change concerns risk stratification, which now classifies patients as high risk versus intermediate or low risk, replacing the former terminology of acute massive, submassive or nonmassive pulmonary embolism. Risk stratification is now oriented toward evaluation of the risk of early pulmonary embolism-related death. Thrombolysis is the mainstay of therapy in high-risk pulmonary embolism. Surgical embolectomy has become more frequent, due to the reduction in mortality risk associated with this technique. However, it remains limited to patients unsuitable for thrombolysis. Catheter-based embolectomy is reserved for situations in which neither thrombolysis nor surgical embolectomy is possible.
Thrombolytic treatment should be first-line therapy in patients with high-risk pulmonary embolism presenting with cardiogenic shock and/or persistent arterial hypotension, with very few absolute contraindications. Both surgical and catheter pulmonary embolectomy are valuable therapeutic options in patients in whom thrombolysis is absolutely contraindicated or has failed.
尽管目前有多种治疗方法，但急性肺栓塞仍与高发病率和死亡率相关。本文概述了该领域的最新进展，并总结了高危肺栓塞患者溶栓治疗及手术或导管取栓术的主要适应证。
近年来，高危肺栓塞的治疗方法没有重大进展。主要的变化是危险分层，现在将患者分为高危、中危或低危，取代了之前急性大块、次大块或非大块肺栓塞的分类术语。危险分层现在侧重于评估早期与肺栓塞相关的死亡风险。溶栓是高危肺栓塞治疗的主要方法。由于与该技术相关的死亡率降低，手术取栓术更为常见。然而，它仍然限于不适合溶栓的患者。导管取栓术适用于溶栓和手术取栓术均不可行的情况。
对于出现心源性休克和/或持续动脉低血压的高危肺栓塞患者，溶栓治疗应作为一线治疗方法，只有极少数绝对禁忌证。对于溶栓绝对禁忌或溶栓失败的患者，手术和导管肺血栓切除术都是有价值的治疗选择。
