Eisenmann B, Thiranos J C, Petit H, Kieny R
Service de Chirurgie Cardiovasculaire, Hôpital Central, Hospices Civils de Strasbourg, France.
Herz. 1989 Jun;14(3):172-81.
Pulmonary embolism was first described by Laennec in 1819. After introduction of the Trendelenburg surgical technique, Kirschner, in 1925, performed the first successful embolectomy. In a review of the literature, in 42 patients, survival rate was 45% on use of a modified Trendelenburg method employing cross-clamping of the vena cava. The use of this intervention can still be considered justified if extracorporeal circulation is not available. Establishment of the indication and anatomical fundamentals The indication for surgical embolectomy is considered established in the presence of massive pulmonary arterial obstruction with pending death of the patient. The difficulty lies in identification of the patient with massive pulmonary embolism who will succumb and in defining the extent of pulmonary arterial obstruction which will lead to death. Limitation of the indication to only those patients in shock led to mortality rates up to 93%. Immediate death after pulmonary embolism is not the rule. Of 52 patients with massive pulmonary embolism, 50% survived more than two hours; in those with no preexistent cardiopulmonary disease up to eight hours. Surgical intervention can be considered accordingly. Anatomically, massive pulmonary embolism implies at least 60 to 70% obstruction of the pulmonary arterial bed. In 85 of 100 patients who died of pulmonary embolism, voluminous emboli were found in both pulmonary arteries. In the presence of preexistent cardiopulmonary disease, lesser degrees of obstruction can lead to a critical condition. In consideration of the indication as above, the following comments are considered appropriate: 1. Quantification of the obstruction: Pulmonary angiography remains the most appropriate diagnostic examination. The degree of obstruction can be quantified according to a number of indices. As of 60%-obstruction, surgical intervention can be considered. 2. Justification of embolectomy: The classical indication can be established in 2 to 6% of the patients based on treatment-refractory hypotension. In Table 1, the classical stages of massive pulmonary embolism are shown with the indication for embolectomy being considered as of stage IV but these characteristics are unreliable in everyday practice. If surgery is delayed until vasoactive drugs are no longer effective, an irreversible condition is frequently incurred in spite of operative removal of the obstruction. More favorable results can be achieved when the indication for surgery is based only on the degree of obstruction since, in this case, the condition of shock will not be prolonged and a hemodynamically-stable patient can be subjected to surgery. 3. Thrombolytic treatment
肺栓塞于1819年由雷奈克首次描述。在引入特伦德伦伯格手术技术后，1925年，基尔施纳进行了首例成功的栓子切除术。在一篇文献综述中，42例患者采用改良的特伦德伦伯格方法（即腔静脉交叉钳夹），生存率为45%。如果没有体外循环，这种干预措施的使用仍可认为是合理的。手术指征及解剖学基础 手术栓子切除术的指征在患者面临因大量肺动脉阻塞而濒死的情况下被认为是明确的。难点在于识别即将死亡的大量肺栓塞患者，以及确定会导致死亡的肺动脉阻塞程度。将指征仅局限于休克患者导致死亡率高达93%。肺栓塞后立即死亡并非普遍规律。52例大量肺栓塞患者中，50%存活超过两小时；无基础心肺疾病的患者存活时间可达八小时。因此可考虑进行手术干预。从解剖学角度来看，大量肺栓塞意味着至少60%至70%的肺动脉床被阻塞。在100例死于肺栓塞的患者中，85例在双侧肺动脉中发现大量栓子。在存在基础心肺疾病的情况下，较轻程度的阻塞也可导致危急状况。考虑到上述指征，以下观点被认为是恰当的：1. 阻塞程度的量化：肺血管造影仍是最合适的诊断检查。阻塞程度可根据多个指标进行量化。阻塞达到60%时，可考虑手术干预。2. 栓子切除术的合理性：基于难治性低血压，经典指征可在2%至6%的患者中确立。表1展示了大量肺栓塞的经典阶段，栓子切除术的指征被认为始于IV期，但这些特征在日常实践中并不可靠。如果手术延迟到血管活性药物不再有效时进行，尽管手术清除了阻塞，仍常常会出现不可逆的情况。当手术指征仅基于阻塞程度时，可取得更有利的结果，因为在这种情况下，休克状态不会延长，血流动力学稳定的患者可接受手术。3. 溶栓治疗
