Surgical treatment of massive pulmonary embolism

Surgical treatment of massive pulmonary embolism (PE) is usually performed in cases of contraindications to fibrinolysis (trauma and/or recent surgery). Additional indications for the embolectomy are either clinical (shock low cardiac output, cardiac arrest) or angiographic (occlusion of more than 80% of pulmonary arterial bed). Due to the emergency setting, PE is often diagnosed only on a clinical basis (10-30% of the cases). Embolectomy is usually performed using cardio-pulmonary bypass (CPB). Trendelenburg procedure can be indicated in desperate situations. No general agreement exists concerning the role of interruption of the inferior vena cava (IVC), in order to prevent PE recurrence. Usually, interruption of the IVC is performed in cases of contraindications to anticoagulant therapy or in presence of recurrence despite anticoagulation. Operative mortality ranges from 40 to 70%; there are no differences between the two surgical techniques and the major risk factor for death is the preoperative clinical status (shock, and/or cardiac arrest). Anticoagulant therapy affords a low incidence of recurrence.