Surgical Embolectomy: Surgical embolectomy was performed within 72 h of the initial thrombolysis. After median sternotomy and pericardiotomy, patients were heparinized and cannulated for cardiopulmonary bypass. The arterial cannula was placed in the ascending aorta with either a bicaval or a single venous cannula placed through the right atrium. The procedure was performed under normothermia without cardiac arrest and with vacuum-assisted venous drainage. The clot was extracted through a longitudinal arteriotomy in the main pulmonary artery, under direct vision using forceps. In all patients, an inferior vena caval filter was inserted perioperatively prior to sternal closure.
Repeat Thrombolysis: Repeat thrombolysis was started at least 24 h after initial thrombolysis and consisted of the administration of streptokinase in patients previously treated with alteplase, while patients who received streptokinase initially were subsequently treated with alteplase. Streptokinase was administered as an infusion of 1.5 million IU over 2 h. Alteplase was infused at a dose of 100 mg over 2 h. Both thrombolytics were only administered once fibrinogen level rose above 1 g/L. so
Postintervention Treatment: Therapy with IV unfractionated heparin was started immediately after surgery or at the end of thrombolytic infusion, was maintained at a dose of 1,000 IU/h, and was adapted thereafter to achieve an activated partial thromboplastin time ratio of two to three times the control value. Oral anticoagulant therapy was introduced within 3 to 5 days and was continued for at least 6 months, but was adjusted to maintain the international normalized ratio between 2 and 3. The clinical end point of the in-hospital course was a combined end point including recurrent PE, bleeding complications, or PE-related death, which was defined as death from recurrent PE or cardiogenic shock. Major bleeding complications were prospectively defined as any bleeding event that required blood transfusion, surgical control, and discontinuation of thrombolytic or anticoagulant treatment; hemorrhagic stroke confirmed by CT scan or autopsy; or any bleeding causing death or defined as a fall of 15% in hematocrit.