A case of surgical treatment of acute pulmonary embolism without the use of extracorporeal circulation

To the Editors:

Massive pulmonary embolism (PE) is a life-threatening condition. In bedridden postoperative patients, incidence of lethal PE involves 0.2% to 0.6% of patients. A 44-year-old man with a known PE had a hemorrhagic stroke with intracerebral hematoma and urinary tract hemorrhage caused by anticoagulation. Therefore thrombolysis or operation with extracorporeal circulation being performed on a fully heparinized patient were absolutely contraindicated. During surgery tapes were placed on the tourniquets around the great veins. The 4/0 polypropylene suture stays were placed on the pulmonary trunk. After the great veins were occluded and the blood inflow was stopped, the pulmonary artery was opened longitudinally, the blood was sucked into the Cell-Saver (Cell-Saver BRAT 2, Cobe Cardiovascular Division of Sorin Biomedica, Arvada, Colo), and then the pulmonary artery branches were probed with use of an ordinary suction aspirator with a higher negative pressure applied. A decrease of blood pressure to 50/20 was tolerated, and the pulmonary artery was closed using a partial clamp and the blood inflow into the heart was restored. This maneuver was repeated 7 times. A 20×1 cm thrombus was retrieved from the right pulmonary artery branch and a 5 cm×7 mm thrombus from the left. In addition, a finger was inserted through the right atrial appendage to search for an atria sepal defect; none was found. The pulmonary artery was again accessed to make sure that no further embolic material from the right side of the heart had been mobilized into the pulmonary artery. On the seventh postoperative day, the patient was transferred to a regional hospital for neurologic rehabilitation. Trendelenberg first reported pulmonary embolectomy in 1908. In 1965 Vossschulte et al first reported in Surgery a successful pulmonary embolectomy through a trans-sternal approach by inflow occlusion of the great veins at normothermia. Our patient shows that in some clinical situations, surgical methods regarded as of historical interest only may contribute to saving the patient's life.