Greenfield L J, Proctor M C, Williams D M, Wakefield T W
Department of Surgery, University of Michigan Medical School, Ann Arbor.
J Vasc Surg. 1993 Sep;18(3):450-7; discussion 457-8.
Massive pulmonary embolism (PE), defined by systemic hypotension and need for inotropic support, has a high mortality rate. Transvenous catheter pulmonary embolectomy performed with the patient receiving local anesthetic provides an expeditious alternative to lytic therapy or open embolectomy on cardiopulmonary bypass.
The indication for embolectomy in this series of 46 patients was hypotension despite inotropic support in all but four patients (91%); the latter sustained major embolism and were respirator dependent. In the first 10 patients treated from 1970 to 1974, a metal cup attached to a straight catheter was used.
Hemodynamic improvement occurred in nine of 10 initial patients, but recurrent PE and a mortality rate of 50% prompted addition of a vena caval filter and directional control to the catheter. Subsequently 36 patients were treated with this combination from 1975 to 1992. Emboli were extracted in 76% (35 of 46) of the total series with a 30-day survival rate of 70% (32 of 46). Hemodynamic data showed an average reduction in mean pulmonary artery pressure of 8 mm Hg and a significant increase in mean cardiac output from 2.59 L/min to 4.47 L/min (p = 0.003) after embolectomy. Complications included wound hematoma (15%), pulmonary infarct (11%), recurrent deep venous thrombosis (6%), pleural effusion (4%), and myocardial infarction (4%).
Successful embolectomy was most likely for categories of major PE (4 of 4, 100%) and massive PE (27 of 33, 82%) and least likely for chronic PE (5 of 9, 56%) (p < 0.03). Successful embolectomy also predicted long-term survival (p < 0.01), which was 89 months for the series (range 1 to 237 months). Catheter pulmonary embolectomy by surgeon and radiologist is of maximal benefit for major or massive PE but less likely to benefit patients with chronic recurrent PE.
由系统性低血压和需要使用血管活性药物支持所定义的大面积肺栓塞（PE）死亡率很高。在患者接受局部麻醉的情况下进行经静脉导管肺栓子切除术，为溶栓治疗或体外循环下的开放性栓子切除术提供了一种快速的替代方法。
在这组46例患者中，除4例（91%）外，其余患者进行栓子切除术的指征均为尽管使用了血管活性药物支持仍存在低血压；这4例患者发生了严重栓塞且依赖呼吸机。在1970年至1974年治疗的前10例患者中，使用的是连接在直导管上的金属杯。
最初的10例患者中有9例血流动力学得到改善，但复发性肺栓塞和50%的死亡率促使在导管上增加了腔静脉滤器和方向控制装置。随后在1975年至1992年期间，36例患者接受了这种联合治疗。在整个系列中，76%（46例中的35例）的患者栓子被取出，30天生存率为70%（46例中的32例）。血流动力学数据显示，栓子切除术后平均肺动脉压平均降低8 mmHg，平均心输出量从2.59 L/分钟显著增加至4.47 L/分钟（p = 0.003）。并发症包括伤口血肿（15%）、肺梗死（11%）、复发性深静脉血栓形成（6%）、胸腔积液（4%）和心肌梗死（4%）。
成功的栓子切除术在大面积肺栓塞（4例中的4例，100%）和大块肺栓塞（33例中的27例，82%）类型中最有可能成功，而在慢性肺栓塞（9例中的5例，56%）中最不可能成功（p < 0.03）。成功的栓子切除术也预示着长期生存（p < 0.01），该系列患者的长期生存时间为89个月（范围为1至237个月）。由外科医生和放射科医生进行的导管肺栓子切除术对大面积或大块肺栓塞患者益处最大，但对慢性复发性肺栓塞患者益处较小。
