Postgrad Med J: first published as 10.1136/pgmj.44.518.917 on 1 December 1968. Downloaded from Postgrad. med. J. (December 1968) 44, 917-922. CURRENT SURVEY The surgical treatment of acute massive pulmonary embolism H. P. GAUTAM M.S., F.R.C.S.(Eng.), F.R.C.S.(Edin.), F.I.C.S. Cardiothoracic Surgical Unit, Royal Infirmary, University of Manchester THE EFFECTIVE management of massive pul- second sound, sometimes a pulmonary diastolic monary embolism remains a challenge. The suc- murmur and, rarely, abdominal distention and cessful treatment rests primarily upon early epigastric tenderness due to hepatic congestion. operative intervention and survival without sur- If pulmonary infarction precedes or accompanies gery is extremely low. In the series of sixty-five the massive embolism, pleural pain, haemoptysis patients of Hampson, Milne & Small (1961) all and a pleural friction rub may also be present but nine died immediately. Donaldson et al. (1963) (Crane, 1966). reviewing 271 cases of massive pulmonary em- bolism, proved at autopsy, revealed that 30% Diagnostic studies lived for 30 min, 25% for 1 hr, 15% for 6 hr The chest X-ray usually remains normal but and only 9% lived for 12 hr. There is a race may, as suggested by Hanelin & Eyler (1951) be Protected by copyright. against time and the character of the circulatory of occasional value. However, Taplick, Haskin obstruction leaves little opportunity for effective & Steinberg (1964) described significant changes treatment. Unless, therefore, a fast decision is among two-thirds of the patients with acute made, only about one in five patients survives embolism. Increased prominence of the main pul- long enough for a proper diagnosis and surgical monary artery or one of its primary branches, treatment. unilateral elevation of the diaphragm (Daicoff, Although Trendelenburg first proposed pul- Rams & Moulder, 1966), increased radiolucency monary embolectomy in 1908, Kirschner in 1924 of the lung field due to loss of the peripheral performed the first successful operative pro- vascular markings on the side of the occlusion cedure. Thereafter within a 7-year period, and cardiac enlargement due to right ventricular Crafoord (1928), Meyer (1930) and Nystrom dilatation (Timmis, 1966) have been the sig- (1930) recorded eight successful cases. Steenberg nificant findings. Diameters of right and left et al. in 1958 reported the first successful em- pulmonary arteries greater than 17 and 16 mm, bolectomy in America. In the last few years respectively in adult males and 16 and 15 mm in many more successful embolectomies have been adult females are definitely abnormal radiological http://pmj.bmj.com/ performed at many centres (Beall & Cooley, features (Davis, 1964). 1965; Makey & Bliss, 1966; Cross & Mowlem, The electrocardiogram may be entirely nor- 1967; Barraclough & Braimbridge, 1967; Paneth, mal but often shows non-specific changes. Israel 1967; Sautter, 1967). Among the many factors & Goldstein (1957) reported evidence of acute in the recent increase in success, the most im- cor pulmonale in 70% of their cases. Right axis portant has been the use of cardiopulmonary by- deviation, prolonged P-R interval, and depressed pass, first employed successfully in this context ST segments in lead I and II and inverted T on September 24, 2021 by guest. by Sharp in 1962. waves in II and III are strongly suggestive of major pulmonary arterial obstruction. Other Clinical manifestations changes include RBBB, an S1Q3 pattern and in- The clinical picture suggests a major cardio- version of T waves in right precordial leads. vascular catastrophe. It consists of sudden pain- Pulmonary radioactive scintiscanning is uti- less dyspnoea, collapse, restlessness, apprehen- lized in diagnosis (Sabiston, 1964; Wagner, sion, pallor, mild cyanosis and sometimes chest Sabiston & McAfee, 1964; Sabiston & Wagner, pain. Significant physical findings are severe 1965). Macroaggregated human albumin tagged hypotension, tachycardia in most cases, poor with 1:'I is given intravenously and is immedi- circulation, distended neck veins, gallop rhythm ately followed by scanning of the chest. Per- with premature beats, an accentuated pulmonary fusion defects in the pulmonary embolism are Postgrad Med J: first published as 10.1136/pgmj.44.518.917 on 1 December 1968. Downloaded from 918 Current survey shown by the presence of cold areas in the multiple and finely fragmented embolism. In the normal pattern of the pulmonary silhouette. presence of cardiac failure and pulmonary Though its safe application in the ill patient and pathology causing increased pulmonary vascular the ease and speed with which it can be carried resistance, the basal segments often appear oli- out makes it an excellent investigation, this has gaemic and third- and fourth-order vessels its own limitation. The cold areas do not speci- appear pruned off or vascular filling is delayed. fically mean intraluminal pulmonary arterial ob- Therefore, while reading an angiogram non- struction but can also be seen in lesions that filling or pruning of small vessels should not be displace pulmonary tissue (tumour, bulla, cyst), given undue emphasis unless previous pulmonary lesions featuring consolidation (pneumonia, and cardiac pathology have been ruled out atelectasis) and situations slowing blood-flow as (Crane, 1966). Though a venous angiography in congestive cardiac failure and pulmonary employing a peripheral vein may be a success, hypertension (Crane, 1966). Therefore a recent pulmonary arterial angiography gives better de- chest film preferably free of opacities is vital to lineation. While catheterizing the right heart for a lung-scan interpretation. pulmonary arterial angiography, care should be Pulmonary angiography is the only certain taken not to advance far into the pulmonary method which affords a definite diagnosis. It is artery as it may dislodge and fragment the em- safe, pulmonary arterial and right ventricular bolus. For the same reason injection of contrast pressures may be registered at the same time, medium into the outflow tract of the right ven- and the severity of pulmonary arterial obstruc- tricle is preferable than into the pulmonary tion is most accurately assessed. The positive artery. In the presence of a failing circulation, angiogram will show a filling defect due to intra- angiography can be performed during a peri- luminal thrombus or clear 'cut-off' due to im- pheral partial cardio-pulmonary by-pass. A suc- pacted thrombus (Fig. 1). It is negative in small cessful angiogram can even be obtained when the Protected by copyright. http://pmj.bmj.com/ on September 24, 2021 by guest. FIG. 1. Selective pulmonary angiogram performed prior to a successful embolectomy, showing catheter in the right ventricle and clear 'cut-off' of the left lower lobe artery due to an impacted embolus. Postgrad Med J: first published as 10.1136/pgmj.44.518.917 on 1 December 1968. Downloaded from Current survey 919 circulation can only be maintained by external ing the establishment of peripheral bypass in cardiac compression (Gautam, 1968). The basic massive pulmonary embolism. Patients may be indication for angiography is to establish the put on peripheral bypass in the ward using a diagnosis in those cases, considered for surgery. portable pump oxygenator (Paneth, 1964; Not only is the diagnosis made certain but the Beall & Cooley, 1965). The peripheral bypass also side of the occlusion is known and if it is uni- averts severe circulatory collapse and hypoxic lateral, as it is in 15% (Gorham, 1961), surgery myocardial damage (Vosschulte, 1958) secondary can be carried out through unilateral thoraco- to induction of anaesthesia prior to the establish- tomy even without the help of bypass (Bradley, ment of total bypass for pulmonary embolectomy Bennett & Lyons, 1964; Frater et al., 1966). (Sharp, 1962). Sudden death from pulmonary embolism Indications for embolectomy should be treated by external cardiac compres- Obviously embolectomy is reserved for one sion, for in some cases, the compression will who would die without it. But to decide which break up the thrombus and move it on and so will live without it is also a difficult problem. allow some pulmonary blood-flow. If the circula- As more successful procedures have been carried tion is restored and the patient responds, then out, indications for embolectomy are now being this is continued until the establishment of sup- made more clear. Initially the patient is hep- portive peripheral bypass. arinized, digitalized, and is given oxygen. If General anaesthesia is administered and the the hypotension is significant, a vasopressor is chest is opened by transverse or median sterno- used. Isoprenaline, because of its antispasmodic tomy. If the peripheral bypass has not been action on the bronchial tree, is known to give a established beforehand simultaneous exposure of better result. Reflex bronchospasm due to em- the femoral artery is performed. Before any can- bolism is relieved by heparin which is believed nulation, heparin (300 units/kg body weight) Protected by copyright. to antagonize the serotonin-like action of pul- is administered. The superior and inferior venae monary embolism on the bronchial tree. Hep- cavae and femoral artery are cannulated and a arinization also stops the distal propagation of the total bypass begun (Fig. 2). Though it is quite thrombus. possible to perform the operation using dextrose A weakening pulse, falling blood pressure de- solution to prime the pump oxygenator (Dewall spite continuous pressor support, rising respir- atory rate in spite of oxygen, increasing distension of neck veins, more pronounced gallop rhythm, increased right ventricular heave and accentuation of the pulmonary second sound, definite angiographic proof of the embolism and a raised pulmonary artery pressure the mean of which is greater than 30% of the mean systolic systemic arterial pressure (Diacoff, Rams & Moulder, 1966), are the indications for the sur- http://pmj.bmj.com/ gical approach to the problem. Technique The prompt establishment of a cardio- pulmonary bypass is specific temporary therapy for the essential circulatory derangement of mas- sive pulmonary embolism (Gibbon, 1937).