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| __NOTOC__
| | #Redirect [[Pulmonary embolism embolectomy]] |
| {{Pulmonary embolism}}
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| {{CMG}}
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| ==Overview==
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| In [[thoracic surgery]], a '''pulmonary thrombectomy''', is an [[emergency procedure]] that removes [[blood clot|clotted]] [[blood]] ([[thrombus]]) from the [[pulmonary artery|pulmonary arteries]]. Embolectomy can be done via a catheter or surgically.
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| ==Indications==
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| *Pulmonary embolism patient (formed from venous embolisms). Embolectomy is used for patients with persisting shock despite supportive care and who have an absolute contraindication for thrombolytic therapy.
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| *Arterial embolisms in acute limb ischemia.<ref name="pmid19298929">{{cite journal |author=Rutherford RB |title=Clinical staging of acute limb ischemia as the basis for choice of revascularization method: when and how to intervene |journal=Semin Vasc Surg |volume=22 |issue=1 |pages=5–9 |year=2009 |month=March |pmid=19298929 |doi=10.1053/j.semvascsurg.2008.12.003 |url=http://linkinghub.elsevier.com/retrieve/pii/S0895-7967(08)00074-4 |accessdate=2011-12-14}}</ref>
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| *Other ischemias due to embolism ([[mesenteric ischemia]] and [[stroke]]).<ref name="pmid18695052">{{cite journal |author=Stead LG, Gilmore RM, Bellolio MF, Rabinstein AA, Decker WW |title=Percutaneous clot removal devices in acute ischemic stroke: a systematic review and meta-analysis |journal=Arch. Neurol. |volume=65 |issue=8 |pages=1024–30 |year=2008 |month=August |pmid=18695052 |doi=10.1001/archneur.65.8.1024 |url=http://archneur.ama-assn.org/cgi/pmidlookup?view=long&pmid=18695052 |accessdate=2011-12-14}}</ref>
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| Transcatheter procedures can be performed as an alternative to [[thrombolysis]] when
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| *[[Thrombolysis]] is contraindicated.
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| *When emergency surgical thrombectomy is unavailable or contraindicated.
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| *When thrombolysis has failed to improve the patient's hemodynamics in the acute setting.
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| ==Therapeutic Goal==
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| The goals of catheter-based therapy include
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| *Rapidly reduce [[pulmonary artery pressure]], [[RV strain]], and [[pulmonary vascular resistance]] ([[PVR]]).
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| *Improve hemodynamics.
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| *Facilitate right ventricular recovery.
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| ==Types==
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| *'''Percutaneous thrombectomy:''' It is a treatment option for patients having contraindications to fibrinilytics or who are at institutions where surgical embelectomy is not available. It is broadly divided into three types:
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| ** Rheolytic thrombectomy
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| ** Thrombus fragmentation
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| ** Rotational thrombectomy
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| *'''Surgical thrombectomy'''
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| ==Rheolytic thrombectomy==
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| Pressurized saline is passed through a catheter's distal tip, which breaks-down the emboli. The saline and clot fragments are then sucked back into an exhaust lumen of the catheter and disposed off.<ref name="pmid9355883">{{cite journal| author=Koning R, Cribier A, Gerber L, Eltchaninoff H, Tron C, Gupta V et al.| title=A new treatment for severe pulmonary embolism: percutaneous rheolytic thrombectomy. | journal=Circulation | year= 1997 | volume= 96 | issue= 8 | pages= 2498-500 | pmid=9355883 | doi= | pmc= | url= }} </ref>
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| Insertion of a large catheter increases the risk of bleeding which pose as the major disadvantage.
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| ==Rotational thrombectomy==
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| As the name suggest, a rotational device is used to fragment the thrombus. In this, cardiac catheters are used, which does not require venotomy at the puncture site. The fragments are continuously aspirated.
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| '''Major complications:'''
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| Perforation: Mechanical thrombectomy should be limited to the main and lobar pulmonary arterial branches, because the risk of perforation increases, when vessels smaller than 6 mm in diameter are operated.
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| '''Minor complications:'''
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| *Puncture or dissection of cardiopulmonary structures.
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| *[[Pulmonary hemorrhage]].
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| *[[Pericardial tamponade]].
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| *Distal Thrombus embolization.
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| ==Thrombus fragmentation==
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| Thrombus fragmentation has been performed with balloon angioplasty, a pigtail rotational catheter, or a more advanced fragmentation device, the Amplataze catheter, which uses an impeller to homogenize the thrombus.
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| ==Surgical thrombectomy==
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| This procedure is typically limited to large medical centers (as it requires experienced surgeon and cardiopulmonary bypass).
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| '''Indications'''
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| *Hypotensive patients in which thrombolysis is contraindicated.
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| *Embolus trapped within patent foramen ovale, right atrium or the right ventricle, as evident on Echocardiography.
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| '''Benefits'''
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| *Among patients failing initial thrombolysis, surgical embolectomy was found to have fewer death rates and fewer major bleedings.<ref name="pmid16608956">{{cite journal| author=Meneveau N, Séronde MF, Blonde MC, Legalery P, Didier-Petit K, Briand F et al.| title=Management of unsuccessful thrombolysis in acute massive pulmonary embolism. | journal=Chest | year= 2006 | volume= 129 | issue= 4 | pages= 1043-50 | pmid=16608956 | doi=10.1378/chest.129.4.1043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16608956 }} </ref>
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| '''Special Considerations'''
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| *A study had shown the presence of extrapulmonary thrombus in 13 out of 50 patients undergoing surgical embolectomy, thus emphasizing the need of [[transesophageal echocardiography]] (TEE).<ref name="pmid15337008">{{cite journal| author=Rosenberger P, Shernan SK, Mihaljevic T, Eltzschig HK| title=Transesophageal echocardiography for detecting extrapulmonary thrombi during pulmonary embolectomy. | journal=Ann Thorac Surg | year= 2004 | volume= 78 | issue= 3 | pages= 862-6; discussion 866 | pmid=15337008 | doi=10.1016/j.athoracsur.2004.02.069 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15337008 }} </ref> TEE should be performed before or during the procedure to look for extrapulmonary thrombus. Extrapulmonary thrombus are thrombus present in [[right atrium]], [[right ventricle]], or [[inferior vena cava]].
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| ==Relation to PTE==
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| Pulmonary thrombectomies and [[pulmonary thromboendarterectomy|pulmonary thromboendarterectomies]] (PTEs) are both operations that remove thrombus. Aside from this similarity they differ in many ways.
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| *PTEs are done non-emergently whilst pulmonary thrombectomies are typically done as an emergency procedure.
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| *PTEs typically are done using hypothermia and full cardiac arrest.
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| *PTEs are done for chronic pulmonary embolism, thrombectomies for severe acute pulmonary embolism.
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| *PTEs are generally considered a very effective treatment, surgical thrombectomies are an area of some controversy and their effectiveness a matter of some debate in the medical community.
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| ==Related Chapters==
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| *[[Pulmonary embolism surgery|Pulmonary embolism Surgical Therapy]]
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| *[[Pulmonary embolism]]
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| *[[Heart-lung machine]]
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| *[[Pulmonary embolism ACC/AHA guidelines surgical embolectomy|ACC/AHA Guidelines Surgical Embolectomy]]
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| ==References==
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| {{Reflist|2}}
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| [[Category:Thoracic surgery]]
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| [[Category:Surgical procedures]]
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