Pulmonary thromboendarterectomy with embolectomy: a report of two cases
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KeywordsPulmonary Embolism Pulmonary Hypertension Status Epilepticus Nosocomial Pneumonia Inferior Vena Cava Filter
Pulmonary Embolism (PE) continues to have a high mortality despite advances in diagnosis and therapy. We hereby present two patients with massive PE that underwent successful pulmonary thromboendarterectomy with embolectomy (PTE).
A 56-year-old white male presented with a 10-day history of progressive dyspnea. Massive PE was diagnosed and the patient was started on anticoagulation. An inferior vena cava filter was placed because of extensive internal iliac thrombosis. Finally, PTE was undertaken because of recurrent hemodynamic instability in spite of thrombolytic therapy. In the postoperative period, the patient developed hemoptysis followed by status epilepticus and the appearance of petechiae on the legs. Serologies confirmed antiphospholipid antibody syndrome, which was managed with corticosteroids and immunoglobulin because of the aggressive presentation. After a long inhospital stay with several infectious, renal and hematological (bleeding) complications, the patient was discharged with no ventilatory assistance.
A 46-year-old white, heavy smoker and obese male was admitted after a 3-day history of dyspnea. Initial examinations showed hypoxemia, a S1Q3 pattern on ECG, chronic pulmonary hypertension and right ventricular dysfunction on echocardiogram. A chest computed tomography confirmed massive PE in both pulmonary arteries with calcification over the thrombi, leading to the diagnosis of an acute episode complicating chronic PE. An inferior vena cava filter was placed because the patient was considered to have a high risk of death after recurrent PE. Because of a worsening clinical condition despite adequate anticoagulation, the patient was submitted to PTE. He was also discharged after complete resolution of a nosocomial pneumonia.
Nowadays surgical embolectomy is rarely performed. These two cases underwent this unusual form of therapy with a good outcome; however, it is certainly an alternative form of treatment for PE. Although whether considered a last resource to be reserved for desperate situations, some authors suggest it as one of several available treatments that could be also used for anatomically extensive PE without hemodynamic compromise.