Letters Pulmonary embolism

Surgical embolectomy is underused

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1955 (Published 02 April 2013) Cite this as: BMJ 2013;346:f1955
  1. Ed W K Peng, specialty registrar in cardiothoracic surgery1,
  2. John Simpson, professor in respiratory medicine1,
  3. Logan Thirugnanasothy, specialty registrar in respiratory medicine1,
  4. Patrick Kesteven, consultant haematologist1,
  5. John H Dark, professor in cardiothoracic surgery and cardiopulmonary transplant1
  1. 1Freeman Hospital, Newcastle upon Tyne NE3 2XZ, UK
  1. epeng{at}nhs.ne

Pulmonary embolism remains a major healthcare burden and some patients still die from this preventable disease, perhaps because of limited knowledge about available treatments for massive pulmonary embolism.1

Systemic thrombolysis has been the mainstay for massive pulmonary embolism. Other options include transcatheter clot removal and locally directed thrombolysis, but their application is limited by availability of local expertise and absence of long term outcome data. Surgery, barely considered by many clinicians or in Takach Lapner and Kearon’s review, is another option.1 2 Long term survival and functional outcome after surgical embolectomy are encouraging.3

Surgery has clearcut indications in massive pulmonary embolism, including patients in whom thrombolysis is contraindicated, those with a large right atrial or ventricular clot, and those with a clot lying across an interatrial foramen. However, perhaps the most important indication is in patients who do not respond to thrombolysis. Many perceive surgery to be impossible in this setting. Although the ensuing coagulopathy can be a problem, requiring skilled haematological input to reverse it, many of these patients will die without intervention. If operated on before cardiac arrest, current mortality is just over 10%.2 Evidence also suggests that surgery gives a better outcome than repeat thrombolysis.4 Finally, the review also overlooked the potential of stabilisation with extracorporeal membrane oxygenation for acute unstable massive pulmonary embolism.5

To reduce mortality in patients with acute massive pulmonary embolism, frontline clinicians need greater awareness of the potential benefits of surgery and direct lines of communication with surgeons familiar with the procedure.2

Notes

Cite this as: BMJ 2013;346:f1955

Footnotes

  • Competing interests: None declared.

References