Surgical approaches to thromboembolism.

Management of angiographically confirmed pulmonary thromboembolism in 313 patients has been based on a physiological classification system. Patients in shock (Class IV) are managed either by catheter embolectomy (26 patients) with 27 per cent mortality rate or by open embolectomy during active resuscitation (6 patients) with a 33 per cent mortality rate. High-risk patients with transient hypotension (Class III) are managed by anticoagulation and filter insertion. The most common indication for filter placement is a contra-indication to anticoagulation (37 per cent). Filter placement was infrarenal in 268 patients (86 per cent) and intentionally suprarenal in 19 patients (6 per cent). Misplacement has occurred into the iliac veins, renal veins and the heart but has not been seen since the guide wire technique for insertion was developed. The 30 day mortality for patients receiving filters was 14 per cent and due to other disorders. Only one death was suspected from recurrent embolism. One hundred and thirteen venacavagrams at intervals up to 99 months in 110 patients showed long-term patency in 97 per cent. Recurrent embolism was seen in five patients (2 per cent) but caused no deaths.