Schmidt Götz, Edinger Fabian, Koch Christian, Wolff Matthias, Biehl Christoph, Hörbelt Rüdiger, Sander Michael
Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.
Department of Trauma, Hand and Reconstructive Surgery, Justus Liebig University of Giessen, Rudolf-Buchheim-Strasse 7, 35392, Giessen, Germany.
Perioper Med (Lond). 2021 Oct 18;10(1):35. doi: 10.1186/s13741-021-00205-4.
Treatment of high-risk pulmonary embolism (PE) in perioperative patients remains challenging. Systemic thrombolysis is associated with a high risk of major bleedings and intracranial haemorrhage. High mortality rates are reported for open pulmonary embolectomy. Therefore, postoperative surgical patients may benefit substantially from catheter-directed ultrasound-accelerated thrombolysis (USAT).
We report two cases of high-risk perioperative PE. Both patients developed severe haemodynamic instability leading to cardiac arrest. After the implantation of a veno-arterial extracorporeal membrane oxygenation (ECMO), they were both successfully treated with USAT. Adequate improvement of right ventricular function was achieved; thus, ECMO could be successfully weaned after 3 and 4 days, respectively. Both patients showed favourable outcomes and could be discharged to rehabilitation.
Current guidelines on treatment of PE offer no specific therapies for perioperative patients with high-risk PE. However, systemic thrombolysis is often excluded due to the perioperative setting and the risk of major bleeding. Catheter-directed thrombolysis was shown to utilise less thrombolytic agent while obtaining comparable thrombolytic effects. The risk for major bleeding (including intracranial haemorrhage) is also significantly lowered. Until further trials determining the value of adopted treatment strategies of high-risk PE in perioperative patients are available, USAT should be considered in similar cases.
围手术期高危肺栓塞（PE）患者的治疗仍然具有挑战性。全身溶栓治疗与大出血和颅内出血的高风险相关。开放性肺栓子切除术的死亡率较高。因此，术后手术患者可能从导管导向超声加速溶栓（USAT）中显著获益。
我们报告两例围手术期高危PE病例。两名患者均出现严重血流动力学不稳定，导致心脏骤停。在植入静脉-动脉体外膜肺氧合（ECMO）后，他们均成功接受了USAT治疗。右心室功能得到充分改善；因此，ECMO分别在3天和4天后成功撤机。两名患者均预后良好，可出院接受康复治疗。
目前关于PE治疗的指南没有为围手术期高危PE患者提供具体治疗方法。然而，由于围手术期情况和大出血风险，全身溶栓治疗通常被排除。导管导向溶栓显示在获得相当溶栓效果的同时使用较少的溶栓剂。大出血（包括颅内出血）风险也显著降低。在有进一步试验确定围手术期高危PE患者采用的治疗策略的价值之前，类似病例应考虑使用USAT。
