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.