Massive pulmonary embolism: embolectomy or thrombolysis?

The purpose of this paper is to evaluate the indications for surgical or thrombolytic treatment of massive pulmonary embolism. Analysis of the outcome of the disease depending on the indices of lung vascular damage volume and hemodynamics was performed. One hundred and thirty five patients with thromboembolism of truncus or main branches of the pulmonary artery were examined. Right cardiac catheterization, angiopulmonography and Tc-perfusion lung scanning were carried out. Predictive criteria of the lethal outcome (with 86% probability) were defined in patients without surgical treatment. These criteria included extensive volume of lung vascular damage (Miller angiographic index greater than or equal to 27, scannographic perfusion deficit greater than or equal to 60%) and significant hemodynamic disturbances (refractory systemic arterial hypotension or severe pulmonary arterial hypertension: right ventricular systolic pressure greater than or equal to 60 mmHg, right ventricular end-diastolic pressure greater than or equal to 15 mmHg, mean right ventricular pressure greater than or equal to 25 mmHg, and mean pulmonary arterial pressure greater than or equal to 35 mmHg). With these indices available these are indications for pulmonary artery embolectomy. With lower indices, but close to those estimated in the study, thrombolytic therapy is indicated.

Artery embolism of the upper limbs.

This report consists of an analysis of 256 consecutive patients with a total of 260 arterial emboli to the upper limbs treated in the Spasokukotsky Surgical Department of the Second Moscow Pirogov Medical Institute during the 35 year period from 1939 through 1974. Cardiac diseases were the causes of embolism in 92.58 percent of these patients. Mild ischemia of the limbs was revealed only in 33.82 percent of the patients. Severe ischemia accompanied by significant restriction or full absence of active movements in the joints of affected extremities was observed in 55.94 percent of the patients. Acute ischemia with a muscular edema and partial or total contracture was observed in 9.88 percent of the patients. Forty-seven patients were treated conservatively. Arteriectomy was performed in three patients. Embolectomy was carried out on 206 patients, 101 of whom were operated on by means of the approach outside the cubital fossa and 105 by means of the antecubital approach. The best results were obtained when embolectomy was performed with the use of the Fogarty catheter by means of the antecubital approach. This method achieved full restoration of circulation in 91.59 percent of our patients. The mortality rate was approximately equal in all groups of patients. The over-all hospital mortality rate was 21.1 percent. Recurrent embolism of cerebral and mesenteric arteries was the main cause of death. Fatal postischemic complications led to the death of two patients who were operated on with a total ischemic contracture of a limb. Autopsy revealed a pulmonary microembolism in one case and a myoglobinuric nephrosis in the other.