Acute pulmonary embolism: a current surgical approach
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《血管的通路杂志》
Department of Cardiovascular Surgery, Pitié Salpêtrière Hospital, University Pierre et Marie Curie, 47-83 boulevard de l'hpital, 75651 Paris Cedex 13, France
Abstract
Acute massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. Thrombolysis and catheter embolectomy have recently shown various degrees of failure and adverse effect. Surgical embolectomy has now been liberalised for haemodynamic stable patients with right ventricular dysfunction. We report our surgical experience in the last ten years including massive and sub-massive pulmonary embolism. A retrospective review of charts of all patients undergoing pulmonary embolectomy at our institution over the last ten years was performed. Patients were followed up until December 2005, end point of our study. Between March 1995 and December 2005, 21 patients underwent pulmonary embolectomy. Fourteen patients had a massive pulmonary embolism and were in cardiogenic shock (group A). Seven patients had a sub-massive embolism and were haemodynamically stable with right ventricular dysfunction (group B). In group A, 43% of patients survived and were discharged from the hospital. In group B, all the patients survived and were discharged from the hospital. After a follow-up of 57±12 months no late death linked to pulmonary embolism was observed. Our approach by initial surgical embolectomy improved outcome in sub-massive PE. Rescue embolectomy for very compromised patients remains a current treatment for massive PE. Furthermore, surgical embolectomy in haemodynamically stable patients is an immediate and definitive treatment for PE, with excellent long-term results. Keeping in mind that thrombolysis and catheter embolectomy have varying degrees of failure and risk, we propose surgical embolectomy in (sub)massive pulmonary embolism as an alternative procedure, or even as a primary treatment.
Key Words: Embolectomy; Thrombolysis; Massive pulmonary embolism
1. Introduction
Acute major pulmonary embolism (PE) has a high mortality rate despite advances in diagnosis and therapy. The principal criteria for categorising PE as massive are arterial hypotension and cardiogenic shock [1]. Arterial hypotension is defined as a systolic arterial pressure <90 mmHg or a drop in systolic arterial pressure of at least 40 mmHg for at least 15 min. Cardiogenic shock is manifested by tissue hypoperfusion and hypoxemia [2]. Sub-massive PE is defined as a haemodynamically stable patient with right ventricular dysfunction [1] usually confirmed by echocardiography. Although thrombolysis in massive PE is approved by the Food and Drug Administration, recent studies showed that thrombolysis, often responsible for haemorrhagic complications, did not reduce mortality at 90 days [3]. Moreover, catheter embolectomy might not retrieve all the clot material, putting patients at higher risk to develop chronic pulmonary hypertension [4]. Surgical embolectomy, which used to be reserved for massive PE, has been now liberalised for haemodynamically stable patients [5,6]. We report our experience in surgical embolectomy in the last 10 years, including massive and sub-massive PE.
2. Material and methods
A retrospective review of hospital records of all patients who underwent pulmonary embolectomy at our institution over the past 10 years was performed. The hospital charts were reviewed for initial clinical presentation, haemodynamic status, mode of diagnosis, preoperative echocardiogram, operative procedure, cardiopulmonary bypass (CPB) and cross-clamp times, morbidity and mortality. The long-term follow up was done using the consultations at our hospital, and by the patient's physician. At the end point of our study we performed a phone questionnaire assessing dyspnea (NYHA), recurrence of PE, medication, replacement of inferior vena cava (IVC) filter, other medical problems or new surgery.
3. Surgical technique
After a median sternotomy, the patients were heparinised and cannulated for cardiopulmonary bypass. The arterial cannula was placed in the ascending aorta with either bicaval or a single venous cannula placed through the right atrium. The operation was performed under normothermic conditions. Embolectomy was performed with (n=7) or without aortic cross-clamp (n=14). The choice between cross-clamp and fibrillating hearts was done according to possible associated procedures.
All patients had dilated hypokinetic right ventricle at the time of surgery, confirming the diagnosis of (sub)massive PE. Clots were extracted under direct vision using Mirrizi forceps through a longitudinal incision made in the main pulmonary artery (PA), and if necessary through an additional arteriotomy of the right PA. A right atriotomy was performed in all cases to assess the presence of patent foramen ovale (PFO). The localisations of thrombi are summarised in Table 2.
IVC filter placement was performed either by the surgeon or by the interventional radiologist during the first 48 h.
4. Results
March 1995 to December 2005, 21 patients (13 males, 8 females, mean age 62±12.5 years) underwent surgical embolectomy for acute PE. Fourteen patients presented a cardiogenic shock (group A), six of them had cardiac arrest and required cardiopulmonary resuscitation (CPR). The remaining seven patients (group B) were haemodynamically stable. In this group, indication for surgery was endocarditis with septic embolism (2), severe right ventricular dysfunction (3), contraindication to thrombolysis (1), growth of the thrombus under heparin (1). Diagnostic tools and risk factors of PE are reported in Table 1. In this group all the patients had trans-thoracic echocardiography showing in all cases at least a right ventricular dysfunction.
In group A: Eight patients had a cross-clamp (mean 46±16 min), with a mean CPB time of 79±37 min. Among those, six patients had associated procedures (four PFO, one coronary arterial bypass graft (CABG), one aortic valve replacement, one atrial septotomy). Seven patients had fibrillating heart with a mean CPB time of 44 min±13 min. None of them had associated procedures. Four patients could not be weaned from CPB and in four extra-corporeal membrane oxygenation (ECMO) was performed.
In group B: Two patients had a cross clamp (24, 31 min) with CPB time of 38 and 39 min. These two patients had associated procedures (two for removal of pace-maker leads, and one PFO). Five patients had fibrillating hearts with a mean CPB time of 34 min and two of them had associated procedures (two PFO closures).
IVC filter placement was performed in eight patients (four in each group).
Thirteen patients (62%) survived and were discharged from the hospital. Six were in group A, among those, two were in cardiac arrest before surgery. In group B, all the seven patients survived. Eight (38%) patients died within six days after the operation. All were in group A and died from multi-organ failure, including patients under ECMO.
During the postoperative period, one of the cardiac arrest surviving patients received an ECMO during seven days, for an acute reperfusion lung injury. One patient (group B) had ventilatory support during 25 days for respiratory failure. The postoperative course for two other patients was complicated by pneumonia in one patient (group A) and by acute renal failure in the other one (group B). Follow-up was completed in the 13 surviving patients (mean 57± 12 months). There were five late deaths after surgery (mean 37±19.2 months). The causes of death were not correlated to PE (four cancers, one septic shock). At the end point of our study, no recurrence of PE was observed, four patients presented dyspnea (NYHA II), and no replacement of IVC had been done. All patients still received oral anticoagulation (vitamin K antagonist).
5. Comment
Massive PE is still associated with a high mortality of 52.4% at 90 days and represents 4.5% of all PEs [3]. In patients treated by thrombolysis, intracranial haemorrhage occurred in 3% [4,7]. Recurrence of PE was observed in 12 (6%) at 90 days [3]. Furthermore, 50% of massive PEs presented contraindication for thrombolysis [2]. Moreover, in a prospective study comparing surgical versus medical treatment in patients with massive PE, the medical group had an increased mortality and a higher recurrence of PE [8]. This was confirmed by a recent prospective study showing the superiority of surgery over thrombolysis after one failed thrombolysis for massive PE [9].
In group B, surgical embolectomy saved all the patients. No late death was ascribable to PE and no recurrence of PE was observed. Besides, all of our surviving patients have a good quality of life. The results of our study are in accordance with all the recent studies dealing with the use of open embolectomy for the treatment of sub-massive PE [5,6,10,11]. But the principal finding of our study was to show the efficiency of the treatment through time. Indeed none of the four previously reported series have been undertaken with a long follow-up comparing to us (57 months).
All deaths were in group A, and in this group 57% of patients died. Earlier studies of open pulmonary embolectomy showed comparable results with a mortality rate ranging from 57 to 44% [12–14]. Our study showed a high mortality rate but our patients were much compromised. Four could not be weaned from the CPB, one had a massive left embolus with mesenteric and kidney ischaemia. Another patient had a massive neoplasic embolus from a metastatic kidney-cancer and the two remaining patients died of multi-organ failure in the intensive care unit. Thus we believe that embolectomy must be performed earlier in the natural course of the disease. This point emphasises the importance of an early diagnosis in this pathology.
However, in group A, surgical embolectomy saved 50% of patients without CPR (n=8) and 33% of patients previously resuscitated by CPR (n=6). We did not observe late death due to PE in group A. The four patients with an ECMO died. Two deaths were linked to clotting of the membrane, which is now rarely observed at our institution with improvement of anticoagulation management. In this instance, we believe in the usefulness of ECMO in this kind of indication.
In our study eight patients had an IVC filter placement. In most previously reported studies IVC filters were systematically used. In the International Cooperative Pulmonary Embolism Registry (ICOPER), IVC appears to reduce mortality at 90 days in massive PE. But as mentioned by these authors, these findings should be interpreted with caution because only 10% of the patients received an IVC filter, and patients with IVC were younger than those without IVC. Moreover, in the ICOPER study only three patients have been treated by embolectomy. Furthermore, IVC filters are known to increase deep vein thrombosis [15]. As recommended by Kucher et al. [3], we think that further studies should be performed before a definitive recommendation is made.
Our approach by initial surgical embolectomy improved outcome in sub-massive PE. Rescue embolectomy for very compromised patients remains a current treatment for massive PE. Although circulatory assist devices did not improve survival in our study, we still believe in their importance in our surgical approach. Furthermore, surgical embolectomy in haemodynamically stable patients is an immediate and definitive treatment for PE, with excellent long-term results. Keeping in mind that thrombolysis and catheter embolectomy have varying degrees of failure and risk, we propose surgical embolectomy in (sub)massive PE as an alternative procedure, or even as a primary treatment.
References
Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J 2000; 21:1301–1336.
Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, Rauber K, Iversen S, Redecker M, Kienast J. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997; 30:1165–1171.
Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation 2006; 113:577–582.
Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353:1386–1389.
Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Acute pulmonary embolectomy: a contemporary approach. Circulation 2002; 105:1416–1419.
Leacche M, Unic D, Goldhaber SZ, Rawn JD, Aranki SF, Couper GS, Mihaljevic T, Rizzo RJ, Cohn LH, Aklog L, Byrne JG. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 2005; 129:1018–1023.
Thabut G, Thabut D, Myers RP, Bernard-Chabert B, Marrash-Chahla R, Mal H, Fournier M. Thrombolytic therapy of pulmonary embolism: a meta-analysis. J Am Coll Cardiol 2002; 40:1660–1667.
Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC. Medical compared with surgical treatment for massive pulmonary embolism. Lancet 1994; 343:576–577.
Meneveau N, Seronde MF, Blonde MC, Legalery P, Didier-Petit K, Briand F, Caulfield F, Schiele F, Bernard Y, Bassand JP. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006; 129:1043–1050.
Dauphine C, Omari B. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Thorac Surg 2005; 79:1240–1244.
Yalamanchili K, Fleisher AG, Lehrman SG, Axelrod HI, Lafaro RJ, Sarabu MR, Zias EA, Moggio RA. Open pulmonary embolectomy for treatment of major pulmonary embolism. Ann Thorac Surg 2004; 77:819–823. discussion 823.
Mattox KL, Feldtman RW, Beall AC Jr, DeBakey ME. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Surg 1982; 195:726–731.
Laas J, Schmid C, Albes JM, Borst HG. Surgical aspects of fulminant pulmonary embolism. Zeitschrift fur Kardiologie 1993; 82:Suppl_225–28.
Surgical management of acute pulmonary embolism. French society of thoracic and cardiovascular surgery. French society of thoracic and cardiovascular surgery Spring session France, 1980 Gandjbakhch IVJ, Pavie A, Barra J, Mattei MF, Cabrol C, Cabrol A.
Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral FG, Huet Y, Simonneau G. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. New Engl J Med 1998; 338:409–415.(Antoine Digonnet, Antoine Moya-Plana, St)
Abstract
Acute massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. Thrombolysis and catheter embolectomy have recently shown various degrees of failure and adverse effect. Surgical embolectomy has now been liberalised for haemodynamic stable patients with right ventricular dysfunction. We report our surgical experience in the last ten years including massive and sub-massive pulmonary embolism. A retrospective review of charts of all patients undergoing pulmonary embolectomy at our institution over the last ten years was performed. Patients were followed up until December 2005, end point of our study. Between March 1995 and December 2005, 21 patients underwent pulmonary embolectomy. Fourteen patients had a massive pulmonary embolism and were in cardiogenic shock (group A). Seven patients had a sub-massive embolism and were haemodynamically stable with right ventricular dysfunction (group B). In group A, 43% of patients survived and were discharged from the hospital. In group B, all the patients survived and were discharged from the hospital. After a follow-up of 57±12 months no late death linked to pulmonary embolism was observed. Our approach by initial surgical embolectomy improved outcome in sub-massive PE. Rescue embolectomy for very compromised patients remains a current treatment for massive PE. Furthermore, surgical embolectomy in haemodynamically stable patients is an immediate and definitive treatment for PE, with excellent long-term results. Keeping in mind that thrombolysis and catheter embolectomy have varying degrees of failure and risk, we propose surgical embolectomy in (sub)massive pulmonary embolism as an alternative procedure, or even as a primary treatment.
Key Words: Embolectomy; Thrombolysis; Massive pulmonary embolism
1. Introduction
Acute major pulmonary embolism (PE) has a high mortality rate despite advances in diagnosis and therapy. The principal criteria for categorising PE as massive are arterial hypotension and cardiogenic shock [1]. Arterial hypotension is defined as a systolic arterial pressure <90 mmHg or a drop in systolic arterial pressure of at least 40 mmHg for at least 15 min. Cardiogenic shock is manifested by tissue hypoperfusion and hypoxemia [2]. Sub-massive PE is defined as a haemodynamically stable patient with right ventricular dysfunction [1] usually confirmed by echocardiography. Although thrombolysis in massive PE is approved by the Food and Drug Administration, recent studies showed that thrombolysis, often responsible for haemorrhagic complications, did not reduce mortality at 90 days [3]. Moreover, catheter embolectomy might not retrieve all the clot material, putting patients at higher risk to develop chronic pulmonary hypertension [4]. Surgical embolectomy, which used to be reserved for massive PE, has been now liberalised for haemodynamically stable patients [5,6]. We report our experience in surgical embolectomy in the last 10 years, including massive and sub-massive PE.
2. Material and methods
A retrospective review of hospital records of all patients who underwent pulmonary embolectomy at our institution over the past 10 years was performed. The hospital charts were reviewed for initial clinical presentation, haemodynamic status, mode of diagnosis, preoperative echocardiogram, operative procedure, cardiopulmonary bypass (CPB) and cross-clamp times, morbidity and mortality. The long-term follow up was done using the consultations at our hospital, and by the patient's physician. At the end point of our study we performed a phone questionnaire assessing dyspnea (NYHA), recurrence of PE, medication, replacement of inferior vena cava (IVC) filter, other medical problems or new surgery.
3. Surgical technique
After a median sternotomy, the patients were heparinised and cannulated for cardiopulmonary bypass. The arterial cannula was placed in the ascending aorta with either bicaval or a single venous cannula placed through the right atrium. The operation was performed under normothermic conditions. Embolectomy was performed with (n=7) or without aortic cross-clamp (n=14). The choice between cross-clamp and fibrillating hearts was done according to possible associated procedures.
All patients had dilated hypokinetic right ventricle at the time of surgery, confirming the diagnosis of (sub)massive PE. Clots were extracted under direct vision using Mirrizi forceps through a longitudinal incision made in the main pulmonary artery (PA), and if necessary through an additional arteriotomy of the right PA. A right atriotomy was performed in all cases to assess the presence of patent foramen ovale (PFO). The localisations of thrombi are summarised in Table 2.
IVC filter placement was performed either by the surgeon or by the interventional radiologist during the first 48 h.
4. Results
March 1995 to December 2005, 21 patients (13 males, 8 females, mean age 62±12.5 years) underwent surgical embolectomy for acute PE. Fourteen patients presented a cardiogenic shock (group A), six of them had cardiac arrest and required cardiopulmonary resuscitation (CPR). The remaining seven patients (group B) were haemodynamically stable. In this group, indication for surgery was endocarditis with septic embolism (2), severe right ventricular dysfunction (3), contraindication to thrombolysis (1), growth of the thrombus under heparin (1). Diagnostic tools and risk factors of PE are reported in Table 1. In this group all the patients had trans-thoracic echocardiography showing in all cases at least a right ventricular dysfunction.
In group A: Eight patients had a cross-clamp (mean 46±16 min), with a mean CPB time of 79±37 min. Among those, six patients had associated procedures (four PFO, one coronary arterial bypass graft (CABG), one aortic valve replacement, one atrial septotomy). Seven patients had fibrillating heart with a mean CPB time of 44 min±13 min. None of them had associated procedures. Four patients could not be weaned from CPB and in four extra-corporeal membrane oxygenation (ECMO) was performed.
In group B: Two patients had a cross clamp (24, 31 min) with CPB time of 38 and 39 min. These two patients had associated procedures (two for removal of pace-maker leads, and one PFO). Five patients had fibrillating hearts with a mean CPB time of 34 min and two of them had associated procedures (two PFO closures).
IVC filter placement was performed in eight patients (four in each group).
Thirteen patients (62%) survived and were discharged from the hospital. Six were in group A, among those, two were in cardiac arrest before surgery. In group B, all the seven patients survived. Eight (38%) patients died within six days after the operation. All were in group A and died from multi-organ failure, including patients under ECMO.
During the postoperative period, one of the cardiac arrest surviving patients received an ECMO during seven days, for an acute reperfusion lung injury. One patient (group B) had ventilatory support during 25 days for respiratory failure. The postoperative course for two other patients was complicated by pneumonia in one patient (group A) and by acute renal failure in the other one (group B). Follow-up was completed in the 13 surviving patients (mean 57± 12 months). There were five late deaths after surgery (mean 37±19.2 months). The causes of death were not correlated to PE (four cancers, one septic shock). At the end point of our study, no recurrence of PE was observed, four patients presented dyspnea (NYHA II), and no replacement of IVC had been done. All patients still received oral anticoagulation (vitamin K antagonist).
5. Comment
Massive PE is still associated with a high mortality of 52.4% at 90 days and represents 4.5% of all PEs [3]. In patients treated by thrombolysis, intracranial haemorrhage occurred in 3% [4,7]. Recurrence of PE was observed in 12 (6%) at 90 days [3]. Furthermore, 50% of massive PEs presented contraindication for thrombolysis [2]. Moreover, in a prospective study comparing surgical versus medical treatment in patients with massive PE, the medical group had an increased mortality and a higher recurrence of PE [8]. This was confirmed by a recent prospective study showing the superiority of surgery over thrombolysis after one failed thrombolysis for massive PE [9].
In group B, surgical embolectomy saved all the patients. No late death was ascribable to PE and no recurrence of PE was observed. Besides, all of our surviving patients have a good quality of life. The results of our study are in accordance with all the recent studies dealing with the use of open embolectomy for the treatment of sub-massive PE [5,6,10,11]. But the principal finding of our study was to show the efficiency of the treatment through time. Indeed none of the four previously reported series have been undertaken with a long follow-up comparing to us (57 months).
All deaths were in group A, and in this group 57% of patients died. Earlier studies of open pulmonary embolectomy showed comparable results with a mortality rate ranging from 57 to 44% [12–14]. Our study showed a high mortality rate but our patients were much compromised. Four could not be weaned from the CPB, one had a massive left embolus with mesenteric and kidney ischaemia. Another patient had a massive neoplasic embolus from a metastatic kidney-cancer and the two remaining patients died of multi-organ failure in the intensive care unit. Thus we believe that embolectomy must be performed earlier in the natural course of the disease. This point emphasises the importance of an early diagnosis in this pathology.
However, in group A, surgical embolectomy saved 50% of patients without CPR (n=8) and 33% of patients previously resuscitated by CPR (n=6). We did not observe late death due to PE in group A. The four patients with an ECMO died. Two deaths were linked to clotting of the membrane, which is now rarely observed at our institution with improvement of anticoagulation management. In this instance, we believe in the usefulness of ECMO in this kind of indication.
In our study eight patients had an IVC filter placement. In most previously reported studies IVC filters were systematically used. In the International Cooperative Pulmonary Embolism Registry (ICOPER), IVC appears to reduce mortality at 90 days in massive PE. But as mentioned by these authors, these findings should be interpreted with caution because only 10% of the patients received an IVC filter, and patients with IVC were younger than those without IVC. Moreover, in the ICOPER study only three patients have been treated by embolectomy. Furthermore, IVC filters are known to increase deep vein thrombosis [15]. As recommended by Kucher et al. [3], we think that further studies should be performed before a definitive recommendation is made.
Our approach by initial surgical embolectomy improved outcome in sub-massive PE. Rescue embolectomy for very compromised patients remains a current treatment for massive PE. Although circulatory assist devices did not improve survival in our study, we still believe in their importance in our surgical approach. Furthermore, surgical embolectomy in haemodynamically stable patients is an immediate and definitive treatment for PE, with excellent long-term results. Keeping in mind that thrombolysis and catheter embolectomy have varying degrees of failure and risk, we propose surgical embolectomy in (sub)massive PE as an alternative procedure, or even as a primary treatment.
References
Guidelines on diagnosis and management of acute pulmonary embolism. Task Force on Pulmonary Embolism, European Society of Cardiology. Eur Heart J 2000; 21:1301–1336.
Kasper W, Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser KD, Rauber K, Iversen S, Redecker M, Kienast J. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997; 30:1165–1171.
Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation 2006; 113:577–582.
Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353:1386–1389.
Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Acute pulmonary embolectomy: a contemporary approach. Circulation 2002; 105:1416–1419.
Leacche M, Unic D, Goldhaber SZ, Rawn JD, Aranki SF, Couper GS, Mihaljevic T, Rizzo RJ, Cohn LH, Aklog L, Byrne JG. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 2005; 129:1018–1023.
Thabut G, Thabut D, Myers RP, Bernard-Chabert B, Marrash-Chahla R, Mal H, Fournier M. Thrombolytic therapy of pulmonary embolism: a meta-analysis. J Am Coll Cardiol 2002; 40:1660–1667.
Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC. Medical compared with surgical treatment for massive pulmonary embolism. Lancet 1994; 343:576–577.
Meneveau N, Seronde MF, Blonde MC, Legalery P, Didier-Petit K, Briand F, Caulfield F, Schiele F, Bernard Y, Bassand JP. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006; 129:1043–1050.
Dauphine C, Omari B. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Thorac Surg 2005; 79:1240–1244.
Yalamanchili K, Fleisher AG, Lehrman SG, Axelrod HI, Lafaro RJ, Sarabu MR, Zias EA, Moggio RA. Open pulmonary embolectomy for treatment of major pulmonary embolism. Ann Thorac Surg 2004; 77:819–823. discussion 823.
Mattox KL, Feldtman RW, Beall AC Jr, DeBakey ME. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Surg 1982; 195:726–731.
Laas J, Schmid C, Albes JM, Borst HG. Surgical aspects of fulminant pulmonary embolism. Zeitschrift fur Kardiologie 1993; 82:Suppl_225–28.
Surgical management of acute pulmonary embolism. French society of thoracic and cardiovascular surgery. French society of thoracic and cardiovascular surgery Spring session France, 1980 Gandjbakhch IVJ, Pavie A, Barra J, Mattei MF, Cabrol C, Cabrol A.
Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard P, Laporte S, Faivre R, Charbonnier B, Barral FG, Huet Y, Simonneau G. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis. Prevention du Risque d'Embolie Pulmonaire par Interruption Cave Study Group. New Engl J Med 1998; 338:409–415.(Antoine Digonnet, Antoine Moya-Plana, St)