Long-term experience with transvenous catheter pulmonary embolectomy.

PURPOSE

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.