Indications for Surgical Embolectomy

Pulmonary Embolism Indications

The European Society of Cardiology recommends surgical embolectomy for patients with high-risk PE (with hypotension/shock) who have contraindications to thrombolysis 2, 3
Surgical embolectomy should be considered when thrombolytic therapy has failed to improve hemodynamics in high-risk PE, as suggested by the American Heart Association 3, 4
The American College of Chest Physicians recommends surgical embolectomy when shock is likely to cause death before thrombolysis can take effect (within hours) 1, 5
Surgical embolectomy may be considered for selected patients with intermediate-high-risk PE (without hypotension but with RV dysfunction and myocardial necrosis), particularly if thrombolysis is contraindicated, according to the European Heart Journal 3, 4

The American College of Radiology recommends isolated suprainguinal emboli removal surgically as a consensus recommendation 6
Surgical embolectomy is indicated for viable limbs with acute limb ischemia, and surgical approaches should be reserved for patients in whom thrombolysis or endovascular thrombectomy has failed, as stated by the Journal of the American College of Radiology 6
Surgical embolectomy is indicated when an unacceptable delay due to attempted endovascular techniques would jeopardize limb viability, according to the American College of Radiology 6

Pulmonary embolectomy is technically a relatively simple operation, and following rapid transfer to the operating room and induction of anesthesia and median sternotomy, normothermic cardiopulmonary bypass should be instituted, as described by the European Heart Journal 2, 3
Aortic cross-clamping and cardioplegic cardiac arrest should be avoided, as recommended by the European Heart Journal 3
With bilateral PA incisions, clots can be removed from both pulmonary arteries down to the segmental level under direct vision, according to the European Heart Journal 3

Pre-operative thrombolysis increases the risk of bleeding but is not an absolute contraindication to surgical embolectomy, as stated by the European Heart Journal 3
Surgical embolectomy should be avoided in patients who have received prolonged CPR, as recommended by the American Heart Association 5
The site of surgical care does not significantly affect operative outcomes; patients need not be transferred to a specialized cardiothoracic center if on-site embolectomy using extracorporeal circulation is possible, according to the European Heart Journal 3

With a rapid multidisciplinary approach and individualized indications for embolectomy before hemodynamic collapse, perioperative mortality rates of 6% or less have been reported for pulmonary embolectomy, as reported by the European Heart Journal 3