Department of Pulmonary/Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, California.
Division of Pulmonary/Critical Care Medicine, Department of Venous Thromboembolism and Pulmonary Vascular Disease Research, Clinical Research Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, California.
Semin Respir Crit Care Med. 2017 Feb;38(1):66-72. doi: 10.1055/s-0036-1597559. Epub 2017 Feb 16.
Massive pulmonary embolism (PE) refers to large emboli that cause hemodynamic instability, right ventricular failure, and circulatory collapse. According to the 2016 ACCP Antithrombotic Guidelines, therapy for massive PE should include systemic thrombolytic therapy in conjunction with anticoagulation and supportive care. However, in patients with a contraindication to systemic thrombolytics or in those who fail the above interventions, extracorporeal membrane oxygenation (ECMO) and/or surgical embolectomy may be used to improve oxygenation, achieve hemodynamic stability, and successfully treat massive PE. Randomized controlled human trials evaluating ECMO in this context have not been done, and its role has not been well-defined. The European Society of Cardiology 2014 acute PE guidelines briefly mention that ECMO can be used for massive PE as a method for hemodynamic support and as an adjunct to surgical embolectomy. The 2016 CHEST Antithrombotic Therapy for venous thromboembolism Disease guidelines do not mention ECMO in the management of massive PE. However, multiple case reports and small series cited benefit with ECMO for massive PE. Further, ECMO may facilitate stabilization for surgical embolectomy. Unfortunately, ECMO requires full anticoagulation to maintain the functionality of the system; hence, significant bleeding complicates its use in 35% of patients. Contraindications to ECMO include high bleeding risk, recent surgery or hemorrhagic stroke, poor baseline functional status, advanced age, neurologic dysfunction, morbid obesity, unrecoverable condition, renal failure, and prolonged cardiopulmonary resuscitation without adequate perfusion of end organs. In this review, we discuss management of massive PE, with an emphasis on the potential role for ECMO and/or surgical embolectomy.
大面积肺栓塞（PE）是指引起血流动力学不稳定、右心衰竭和循环衰竭的大栓子。根据 2016 年 ACCP 抗血栓治疗指南，大面积 PE 的治疗应包括全身溶栓治疗结合抗凝和支持治疗。然而，对于有全身溶栓禁忌证的患者或上述干预措施失败的患者，体外膜肺氧合（ECMO）和/或外科取栓术可用于改善氧合、实现血流动力学稳定，并成功治疗大面积 PE。尚未进行评估 ECMO 在这种情况下的随机对照人体试验，其作用尚未明确。欧洲心脏病学会 2014 年急性 PE 指南简要提到，ECMO 可用于大面积 PE，作为血流动力学支持的一种方法，并作为外科取栓术的辅助手段。2016 年 CHEST 静脉血栓栓塞症抗血栓治疗指南在大面积 PE 的管理中未提及 ECMO。然而，多项病例报告和小系列研究表明 ECMO 对大面积 PE 有益。此外，ECMO 可促进外科取栓术的稳定。不幸的是，ECMO 需要充分抗凝以维持系统的功能；因此，在 35%的患者中，大量出血使 ECMO 的使用复杂化。ECMO 的禁忌证包括高出血风险、近期手术或出血性中风、基础功能状态差、年龄较大、神经功能障碍、病态肥胖、无法恢复的病情、肾衰竭和心肺复苏时间延长而终末器官灌注不足。在这篇综述中，我们讨论了大面积 PE 的管理，重点讨论了 ECMO 和/或外科取栓术的潜在作用。
