Steinhorn Rachel, Dalia Adam A, Bittner Edward A, Chang Marvin G
Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine, United States.
Respir Med Case Rep. 2021 Nov 10;34:101551. doi: 10.1016/j.rmcr.2021.101551. eCollection 2021.
Surgical pulmonary embolectomy is a procedure that is often used to rescue patients with massive pulmonary embolism (PE) and circulatory collapse that have failed or may not be ideal candidates for other systemic and endovascular treatment modalities. This procedure typically involves a sternotomy and the use of cardiopulmonary bypass (CPB), which requires full systemic anticoagulation. Here, we report the case of a surgical pulmonary embolectomy performed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) rather than CPB to minimize systemic anticoagulation. The patient had suffered a cardiac arrest due to a saddle PE and required VA-ECMO which was complicated by a concomitant intracranial hemorrhage. The patient tolerated the surgical pulmonary embolectomy performed on VA-ECMO without procedure-related complications, and the ECMO support did not substantially complicate the technical performance of the procedure. In contrast to surgical pulmonary embolectomy performed on CPB, greater attention must be paid to volume status when performing the procedure on VA-ECMO since there is no blood reservoir. This case suggests cardiopulmonary support on ECMO as a viable strategy for surgical embolectomy in patients with unstable PEs in whom thrombolysis or full systemic anticoagulation are contraindicated.
外科肺动脉血栓切除术是一种常用于抢救患有大面积肺栓塞（PE）且出现循环衰竭、其他全身和血管内治疗方式无效或不适合的患者的手术。该手术通常需要进行胸骨切开术并使用体外循环（CPB），这需要全身充分抗凝。在此，我们报告一例在静脉-动脉体外膜肺氧合（VA-ECMO）而非CPB上进行外科肺动脉血栓切除术以尽量减少全身抗凝的病例。该患者因鞍状PE发生心脏骤停，需要VA-ECMO支持，同时并发颅内出血。患者耐受了在VA-ECMO上进行的外科肺动脉血栓切除术，未出现与手术相关的并发症，且ECMO支持并未使手术的技术操作显著复杂化。与在CPB上进行的外科肺动脉血栓切除术不同，在VA-ECMO上进行该手术时必须更加关注容量状态，因为没有血库。该病例表明，对于不稳定PE且溶栓或全身充分抗凝禁忌的患者，以ECMO进行心肺支持是外科血栓切除术的一种可行策略。
