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Selection of Patients for Pulmonary Embolectomy Herbert L. Fred and Ethan A. Natelson Dis Chest 1969;56;139-142 DOI 10.1378/chest.56.2.139 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/56/2/139 CHEST is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright 1969 by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0096-0217 Downloaded from chestjournal.chestpubs.org by guest on July 29, 2010 1969, by the American College of Chest Physicians CRITICAL REVIEW Selection of Patients for Pulmonary Embolectomy* Herbert L. Fred, M.D., F.C.C.P.'* and Ethan A. Natelson, M.D.t A point of view in opposition to thut proposed by Drs. Fred and Natelson is presented in the editorial by Dr. Sasahara and colleagues on page 89. Editor D e s p i t e a renewed and expanding interest in pulmonary embolectomy, criteria for selection of patients remain controversial.'-5 Indeed, the wide divergence of opinion is difficult to reconcile. One author states, "All but minor emboli should now be treated by pulmonary embolect~my."O~thers believe, "The successful completion of emergency angiography virtually precludes the need for embole~tomy."W~ e examine here commonly cited indications for pulmonary embolectomy and demonstrate the need for flexibility in their application. We separate potential candidates for pulmonary embolectomy into one of three types, depending upon duration of symptoms after the embolic episode. Type I consists of patients in whom death ensues rapidly. In this group, classification often must be retrospective. About 50 to 75 percent of patients with massive, fatal pulmonary thromboembolism die within the first h o ~ r . S~o,m~e become agonal so quickly that their only hope for survival would seem to be immediate pulmonary arteriotomy performed without angiographic confirmation of the diagnosis or use of cardiopulmonary bypass. Four of 42 patients so treated left the hospital without cerebral damage.1 ' ~ r o mthe Department of Internal Medicine, Baylor College of Medicine, and Ben Taub General Hospital. Houston, Texas. **Director of Medical Education, St. lose h Hospital, Houston; formerlv Associate Professor of ~ e f i c i n e B, aylor College of Medicine and Director, Medical Inpatient Service, Ben Taub General Hospital, Houston. fResident Physician, Ben Taub General Hospital. Type I1 patients survive the immediate thromboembolic insult, thereby providing the physician with time to establish a precise diagnosis and to institute a planned therapeutic approach. The bulk of medical literature on pulmonary embolectomy concerns patients of this type. Patients in the Type I11 category have chronic obstruction of their major pulmonary arteries. Only a few of them have undergone embole~tomy.~~-'" Indications for the procedure in this group are especially difficult to define. Nevertheless, the operation has alleviated the chief manifestation of dyspnea on exertion,'"'?eturned the angiographic appearance of the pulmonary arterial tree to normal," and reduced the degree of pulmonary arterial hypertension.12 Our comments hereafter pertain to indications for pulmonary embolectomy in the Type I1 patient. Currently, angiography is indispensable for establishing the presence of surgically accessible pulmonary thromboemboli in this g r o ~ p . ' C~l-in~ic~al findings alone are decepti~e~"~"nd have led to unnecessary pulmonary arteriotomy with disastrous consequences.18 The angiographic demonstration of massive pulmonary thromboembolism (occlusion of greater than 50 percent of the pulmonary arterial tree) is not necessarily an indication for embolectomy. Angiograms performed serially have demonstrated spontaneous resolution of large pulmonary thromb o e r n b ~ l i . ~M~or-e~over, we have observed angiographic evidence of massive pulmonary thromboembolism in acutely ill patients who have survived without embolectomy. Systemic arterial hypotension unresponsive to vasopressor therapy is the most frequently cited and probably the most reliable indication for pulmonary embolect~my.~.~B~u-t" how long should one administer vasopressors before deciding upon such operative management? Some investigators Downloaded from chestjournal.chestpubs.org by guest on July 29, 2010 1969, by the American College of Chest Physicians FRED AND NATELSON suggest that 2P8 to 3P1minutes constitute an adequate trial; however, patients with systemic arterial pressures recorded as low as 5010 mm Hg7 have received vasopressors for at least an hour and have survived without embolectomy. In some patients pulmonury embolectomy should be done ideally before the onset of systemic arterial hypotension. Support for this contention comes from observations made at Ben Taub General Hospital on nine critically ill patients treated by embolectomy for acute, massive, pulmonary thromboembolism (Table 1).Of the four patients (Cases 2, 7, 8, 9) normotensive at the time of operation, three survived the procedure and are still living, six months to five years later. By contrast, only one (Case 1) of the five patients hypotensive at the time of embolectomy survived the operation. Baker and Wagnef14 have had a similar experience. In their nine cases of embolectomy for acute, massive, pulmonary thromboembolism, the three surviving patients were normotensive, whereas the six who died were hypotensive before induction of anesthesia. We cannot dismiss the possibility that the survivors among their patients and ours might have lived without embolectomy. Yet in our patients, the combined clinical, hemodynamic, and angiographic findings were sufficient to convince us that death was imrniment. Another point deserves emphasis. Two of our normotensive patients (Cases 7 and 8 ) showed significant clinical and angiographic worsening despite optimal heparin therapy for five and six days, respectively. One of these (Case 8 ) also underwent a second, preoperative hemodynamic study which demonstrated further rise in the already elevated right ventricular and pulmonary arterial pressures. We, like ~thers,~"elieve that such serial measurements, though not always possible or necessary, Table I-Hemodynamic and Angwgraphic Data in Nine Cases of Pulmonary Embolectomy Case Blood Pressure--rnm Hg Age Pulmonary (F), Sex systemic Right Ventricle Artery (mean) Estimated % Pulmonary Vasculature Occluded no angiogram 80/20 90/26 (44) 65 48/12 51/19 (27) 85 90 75/16 72/25 (34) 90 65 f30/15 65/29 (39) 60 70/6 65/17 (36) 60 39./1-4- 80 *Died 6 weeks postoperatively. Cause of death was not evident at autopsy. "Alive provide excellent evidence on which to base decisions for or against pulmonary embolectomy. Several investigators require the demonstration of either elevated right ventricular end-diastolic or increased "mean right ventricular p r e s s ~ r e " ~be~fo-r~e ~recommending embolectomy. A number of patients, however, with elevated right ventricular pressure have survived without embol e c t ~ m y .C~o*n~ve~rsely, the need for embokctomy may exist even when pressures in the pulmonary artery and right side of the heart are n o m l . We have observed two patients with acute, massive, fatal pulmonary thromboembolism in whom right ventricular and pulmonary arterial pressures were normal, but the brachial arterial pressure was 801 50 mm Hg. In retrospect, pulmonary embolectomy might have helped these patients. Some authors stress severe pulmonary arterial hypertension, with or without elevated right ventricular end-diastolic pressure, as an indication for pulmonary e m b o l e c t ~ m y . ~O~thers emphasize a mean pulmonary arterial pressure greater than 30 percent of mean systemic arterial pressure as a basis for such surgical i n t e r v e n t i ~ nN. ~e~vertheless, patients with massive pulmonary thromboembolism, severe pulmonary arterial hypertension, and/or systemic arterial hypotension have recovered without embolect~my.~~~~~~~~~~~~ The advent of fibrinolytic activators ultimately may affect the selection of patients for pulmonary embolectomy. At present, however, we believe that available information is insufficient to permit firm conclusions about indications for these agents in therapy for pulmonary thromboembolic disease. These drugs, with special reference to urokinase, undoubtedly facilitate dissolution of recently formed pulmonary t h r o r n b o e m b ~ l i ,b~u~t ~th~eir adrninistration has not brought about significant change in the mortality rate.46Furthermore, urokinase is not widely available and its use carries the ever present risk of hemorrhagic diathesis. SUMMARY 1. From a review of medical writings on pulmonary embolectomy and analysis of our own experience with such cases, we caution against strict adherence to a single criterion or set of criteria for the operation. 2. Systemic arterial hypotension unresponsive to vasopressor therapy is the most frequently cited and probably the most reliable indication for pulmonary embolectomy. In some patients, however, the procedure should be done ideally before the onset of systemic arterial hypotension, particularly when hemodynamic and angiographic studies demonstrate DIS. CHEST, VOL. 56, NO. 2, AUGUST 1969 Downloaded from chestjournal.chestpubs.org by guest on July 29, 2010 1969, by the American College of Chest Physicians SELECTION OF PATIENTS FOR PULMONARY EMBOLECTOMY progressive worsening despite optimal anticoagulant therapy. 3. Embolectomy may be necessary even when pressures in the pulmonary artery and right side of the heart are normal. 4. Angiography is indispensable for establishing the presence of surgically accessible pulmonary thromboemboli and should precede embolectomy in all but patients who rapidly become agonal. ACKNOWLEDGMENTS: Our associates in the sections of sur e , cardiology, and radiology, Ben Taub General Hosp i t 3 , Tindly made available some of the material presented. 1 FRED,H.L., AM, PETERSONK, .L.: Therapy of pulmonary thromboembolism: A growing predicament, Cardiou. Res. Cent. Bull., 6:2, 1967. 2 SAUTTER,R.D., EAIANUEL,D.A., AND WENZEL,F.J.: Treatment of acute massive pulmonary embolism: Medical or surgical? Ann. Thorac. 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AND DEXTER,L.: Diagnosis and manarze- ment of massive pulmonary embolism, Disease-a-Month, August 1967, p. 1. 32 JUST-VIERAJ,.O., NORWOODT, ., AND YEAGEFIC, .H.: Importanw of shock and cvanosis in pulmonary embo]ism Ann. Surg., 165:528, 1967. 33 STIRLINGG, .R.. MORRISK, .N., MCLEANK, .H., MIRAMS, J.A., RUBINSTEIND, ., AND WAGNERG, .R.: Surgical as- pects of pulmonary embolism, Med. ]. Acrst., 1:571, 1968. 34 BAKERR, R.. AND WAGNERH, .N., JR.: Pi~lmonaryem- bolectomy in the treatment of massive pulmonary embolism. Surg., Gynec., Obstet., 122:513, 1966. 35 HIRSH, J., HALE, G.S.. MCDONALDI,.G., MCCARTHY, DIS. CHEST, VOL. 56, NO. 2, AUGUST 1969 Downloaded from chestjournal.chestpubs.org by guest on July 29, 2010 1969, by the American College of Chest Physicians R.A., AND Rn,A.: Streptokinase therapy in acute major pulmonary embolism: Effectiveness and problems, Brit. Med., J.,4:729, 1968. 36 STANSELH, .C., JR., HIJME,M., AND GLENNW, .W.L.: Pulmonary embolectomy: Results in ten patients, New Eng. J . Med., 276:717, 1967. 37 DEL GUERCIOL.R.M., COHN,J.D., FEINS,N.R., CooMARASWAMRY.P,., AND MANTLEL, .: Pulmonary em- bolism shock: Physiologic basis of a bedside screening test, J.A.M.A., 196:751, 1966. 38 DEL GUERCIOL, .R.M., COOMARASWAMR.YP.,, FEINS, N.R., AND STATE,D.: Bedside hemodynamic diagnosis of acute pulmonary embolism, Surg. Forum, 15:192, 1964. 39 ALEXANDERJ.,K., LEWIS,J.M., AXELRAD,M.A., LOCKHART, R.W., AND FRED, H.L.: Cardiorespiratory function in patients with acute pulmonary thromboembolism demonstrated angiographically, Clin. Res., 13:346, 1965. 40 DNCOFF,G.R., RAMS,J.J., AND MOULDERP,.V.: Pul- FRED AND NATELSON monary embolectomy, Surg. Clin. N. Amer., 46:27, 1966. 41 EMANUELD, .A.. SAUTTERR, .D., AND WENZEL,F.J.: Conservative treatment of massive pulmonary embolism, J.A.M.A.,197:924, 1966. 42 S a s u , A.A., CANNILLAJ.,E., BELKO,J.S., MORSE, R.L., AND CRISS,A.J.: Urokinase therapy in clinical pulmonary embolism: A new thrombolytic agent, New Eng. 1. Med., 277:1168, 1967. 43 SAUTTER,.D., EMANUELD,.A., FLETCHER, F.W., WENZEL,F.J., AND MATSONJ,.I.: Urokinase for the treatment of acute pulmonary thromboembolism, J.A.M.A., 202: 215, 1967. 44 Tow, D.E., WAGNERH, .N., JR., AND HOLMES,R.A.: Urokinase in pulmonary embolism, New Eng. J . Med., 277:1161, 1967. 45 THOMASD,.P.. AND GUREWICHV,.: Management of pulmonary embolism, New Eng. l . Med., 278:338, 1988. Reprint requests: Dr. Fred, St. loseph Hospital, Houston 77002 TRIUMPH OF SCIENCE The city of Leyden, The Netherlands, had just heroically withstood the onslaught by its Spanish besiegers. T o reward the burghers for their gallant stand, William the Silent asked them to choose between two gifts: freedom from taxes for ten years, or the establishment of a university. Intellectual interests prevailed. Leyden University opened the next year and its fame spread around the world. Leyden's rising fame as a medical school rested on two pillars, anatomical research and clinical instruction. Francis de la Boe Sylvius introduced bedside demonstration in Leyden in . .1658. This was the most im ortant innovation. Sylvius himself described it: I have f'ed my students . daily to visit the sick at the public hospital. There I have Rput the syrn toms of disease before their eyes; have let them hear t e complaints of the patients . . . and have asked them their opinion in each case . . . Then I have given my judgment on every point. Bettmann, 0.L.: A Pictorial H i s t m y of Medicine, C . C Thomas, Springfield, (Third printing) 1962 AN EARLY PATHFINDER IN CARDIOLOGY Raymond Vieussens (1641-1715), who graduated at Montpellier and, in 1671, became physician to the Hospital of St. Eloys, is worthy of remembering by posterity. During the first ten years of his service he dissected 500 bodies. His investigations were published in his Narrographia Universalis, a work which gained for its author immediate fame, election as a member of the Academy of Sciences of Paris and as a Fellow of the Royal Society of London. His last book, Trait6 Nouoeau de la Structure et des Causes ah Mwement Nature1 du Coeur, published in 1715, the year of his death, is a classic in the history of cardiology. It contains the first accurate detailed illustration of the coronary vessels, the first illustration of mitral stenosis, and the first recognizable description of the characteristic pulse of aortic insufficiency, which was full, bounding, and "struck the tips of my fingers like a cord which had been tightly stretched and violently agitated." Major, R. H.: A History of Medicine, C . C Thomas, Springfield, 1954 DIS. CHEST, VOL. 56, NO. 2, AUGUST 1969 Downloaded from chestjournal.chestpubs.org by guest on July 29, 2010 1969, by the American College of Chest Physicians Selection of Patients for Pulmonary Embolectomy Herbert L. Fred and Ethan A. Natelson Dis Chest 1969;56; 139-142 DOI 10.1378/chest.56.2.139 This information is current as of July 29, 2010 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/56/2/139 Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions. Downloaded from chestjournal.chestpubs.org by guest on July 29, 2010 1969, by the American College of Chest Physicians