Medicine of the Future in America

Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism: Comment

Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism: CommentOur results are in accordance with those of a previous nonrandomized trial comparing thrombolysis and embolectomy in acute PE patients. The survival rate was 67% in the thrombolysis group compared with 77% in the surgical group. Until more recently, surgical embolectomy was confined to clinically desperate circumstances. More recent data, however, reported a high survival rate of 89% at 1 month, thus suggesting that surgical embo-lectomy might be counted as one of several therapeutic options in acute PE patients. This high survival rate observed in patients with submassive PE was attributed to improved surgical techniques, rapid diagnosis, and triage. The low in-hospital mortality rate observed in our study post-rescue surgical embolectomy confirms that surgery is a valuable therapeutic option, even in hemodynamically unstable patients who have undergone massive PE and are unresponsive to thrombolysis. so
Optimizing early pulmonary revascularization might be of importance since symptomatic chronic thromboembolic PH has been reported as a relatively common yet serious complication of PE, affecting approximately 4% of patients within 2 years after a first episode of symptomatic PE. In addition, the persistence of PH or RV dysfunction after thrombolytic therapy in patients with acute PE, is associated with increased long-term mortality and adverse outcomes.’ In this context, the better outcome observed in the surgical group could be explained by a more complete pulmonary revascularization, although pulmonary vascular obstruction was not reevaluated after surgery, nor after repeat thrombolysis. In both groups, patients who survived the acute phase could be considered simply as patients who experienced improvement in pulmonary revascularization and right heart function, since long-term outcomes were similar in the two treatment groups. The potential role for catheter embolectomy remains uncertain and has never been assessed in the setting of failed thrombolysis. In addition, this percutaneous approach may be associated with an increased bleeding risk in the context of previous recent fibrinolysis.

This entry was posted in Pulmonary function and tagged embolism, surgery, thrombolysis.
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