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Ann Thorac Surg 1998;66:982-983
© 1998 The Society of Thoracic Surgeons

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Correspondence

Angioscopic pulmonary embolectomy and ecmo

^a Department of Cardiovascular Surgery, Jichi Medical School, Yakushiji 3311-1, Minami-Kawachi, Kawachi, Tochigi 329-04, Japan

To the Editor

We have read with interest the article by Ohteki and associates [1]. They reported a favorable outcome in 3 pulmonary embolectomy patients in whom extracorporeal membrane oxygenation (ECMO) was used. Extracorporeal membrane oxygenation allows for successful emergency pulmonary embolectomy after immediate resuscitation and stabilizing of cardiopulmonary function. However, concomitant irreversible cardiac arrest still causes an excessively high mortality rate in spite of recent advances in operative techniques. One reason for this is deterioration of vital organs caused by insufficient end-organ perfusion before and after surgical intervention, and the other is right heart failure caused by incomplete clot extraction in peripheral pulmonary artery branches or massive endobronchial hemorrhage due to mechanical arterial wall injury associated with the "blind" technique. We totally agree with Ohteki and associates’ opinion that ECMO is effective for resuscitation and improving end-organ perfusion. To complete clot extraction without arterial wall injury, we performed pulmonary embolectomy using fiberoptic angioscopy and visualized the pulmonary branches. Resustitation by ECMO and subsequent embolectomy under angioscopy has been used to achieve a favorable outcome in our institution.

According to this strategy, we treated 2 acute pulmonary embolism patients with cardiopulmonary arrest. One was a 28-year-old woman who suffered a cardiac arrest refractory to conventional treatment just after arriving at our emergency room. Extracorporeal membrane oxygenation (Capiox Emergent Bypass System; Terumo Inc, Tokyo, Japan) was promptly introduced. While hemodynamic stability was maintained with ECMO, the patient was moved to the operating room. We entered her through a median sternotomy. The operation was performed under circulatory arrest with deep hypothermia using standard cardiopulmonary bypass with aortic and bicaval cannulation. Thrombi were extracted through a main pulmonary arteriotomy using a fiberoptic choledochoscope (Olympus CHF P20, Tokyo, Japan). Cold normal saline solution was flushed through the working channel, allowing clear visualization of secondary and tertiary pulmonary artery branches. Under direct visual control a 4F Fogarty balloon catheter was passed down the working channel beyond the clot. The balloon was inflated, and the thrombus was removed completed. (Fig 1). The patient was weaned from cardiopulmonary bypass with ECMO and was supported for 75 hours postoperatively. She was discharged on day 14 after the operation in good condition.

View larger version (129K): [in this window] [in a new window]   Fig 1. A thrombus occluding the segmental branches of the right upper lobe. This thrombus was removed under direct visual control with a Fogarty catheter.

The first intraoperative pulmonary angioscopy using the choledochoscope was reported in 1986 by Beckman and associates [3], who reported pulmonary angioscopy to be a valuable adjunct to the pulmonary embolectomy. In 1989, Morshuis and associates [4] reported intraoperative pulmonary angioscopy for the evaluation of a pulmonary embolectomy. Although this method has not been used widely, our experience indicates the efficacy of embolectomy with the choledochoscope, which is available in most surgical suites. Percutaneous ECMO was recently introduced for extracorporeal life support for the patient with sudden cardiopulmonary catastrophe, and it has facilitated excellent outcomes. We believe this combined therapeutic strategy is beneficial to reduce the operative mortality rate of acute pulmonary embolism with cardiopulmonary collapse.

References

1. Ohteki H., Norita H., Sakai M., Narita Y. Emergency pulmonary embolectomy with percutaneous cardiopulmonary bypass. Ann Thorac Surg 1997;63:1584-1586.[Abstract/Free Full Text]
2. Murata S., Adachi H., Ino T., Yamaguchi A., Kamio H., Okada M. An emergent surgical case of acute massive pulmonary embolism supported by antithrombotic percutaneous cardiopulmonary support system. J Jpn Assoc Thorac Surg 1997;45:1159-1164.
3. Beckman D., Solmos B., Herod G., Siderys H. Intraoperative pulmonary angioscopy using the flexible fiberoptic choledochoscope. Ann Thorac Surg 1986;41:563-564.[Abstract]
4. Morshuis W.J., Jansen E.W., Vincent J.G., Heystraten F.J., Lacquet L.K. Intraoperative fiberoptic angioscopy to evaluate the completeness of pulmonary embolectomy. J Cardiovasc Surg 1989;30:630-634.[Medline]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Seiichiro Murata Takashi Ino Katsuo Fuse Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kawahito, K. Articles by Fuse, K. Search for Related Content PubMed PubMed Citation Articles by Kawahito, K. Articles by Fuse, K.