Daniel Ryan Ziazadeh, MD, MSc and Igor Gosev, MD, PhD
University of Rochester Medical Center, Rochester, NY, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Amit Pawale, MD, FRCS, and Ramachandra Reddy, MD, MBA.
Background
Historically, surgical pulmonary embolectomy was considered as a salvage procedure with high surgical mortality ever since
Trendeleburg attempted the first surgical pulmonary embolectomy in 1905. However, the implementation of a collaborative
multidisciplinary approach with a Pulmonary Embolism Response Team and improvements in surgical practice have
substantially improved outcomes in intermediate and high-risk PE patients. A variety of surgical techniques have been used to
treat these patients, leading to a growing heterogeneous surgical armamentarium. Given the unique presentation in these highly
complex patients, a patient tailored approach must be used which may employ the use of full sternotomy, off pump
embolectomy, beating heart embolectomy, ECMO supported embolectomy, or embolectomy via mini-thoracotomy.
Essential Operative Steps
- Right internal jugular 8Fr MAC catheter, radial arterial line, and foley catheter with temperature probe (Do NOT place
a pulmonary artery catheter) - General endotracheal anesthesia
- Transesophageal echocardiography
- Mini left thoracotomy (2nd interspace)
- Division of left pectoralis major muscle
- Selective ligation of the left internal mammary vessels
- Disarticulation of the left third rib from sternum
- Alexis soft tissue wound retractor and intercostal rib spreader
- Horizontal pericardiotomy, creation of pericardial well at the level of the pulmonary artery bifurcation
- Right groin cutdown, exposure of right femoral artery and vein
- Full dose IV heparin to maintain ACT >480 seconds
- Femoral arterial cannulation via Seldinger technique with Next Gen Cannula (17Fr)
- Femoral venous cannulation via Seldinger technique with Biomedicus 25Fr peripheral venous cannula under TEE
guidance - Initiation of cardiopulmonary bypass
- Maintenance of normothermia 37oC
- Main pulmonary arteriotomy
- Removal of saddle pulmonary embolus in one piece
- Removal of segmental thrombi under direct vision using 5mm Olympus Endoscope and Chitwood crossclamp
- Closure of the pulmonary arteriotomy
- Trendelenburg with aggressive deairing
- Weaning from cardiopulmonary bypass
- Decannulation and heparin reversal with protamine
- Hemostasis
- Placement of 24Fr Blake chest tubes in the pericardium and left pleural space
- Closure of left mini-thoracotomy
- Closure of right groin cutdown
Potential Complications and Pitfalls
- Patients can have significant hemodynamic collapse with induction of general anesthesia due to loss of preload
- Pulmonary valve can be injured during pulmonary arteriotomy if arteriotomy is not distal enough
- Inadvertent branch pulmonary artery tear can occur during selective removal of segmental emboli
- Patients may be unable to wean from cardiopulmonary bypass due to stunned RV and right groin cannulation makes
transition to peripheral VA ECMO favorable
Template Dictation
Preoperative Diagnosis: Acute saddle pulmonary embolism with evidence of right ventricular strain
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Minimally invasive, endoscopically assisted pulmonary embolectomy via left thoracotomy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with history of COPD, HTN, HLD, and prior DVT (provoked on a long
flight). Patient presented with a four day history of chest pain and shortness of breath to urgent care. There, the patient was
found to be tachycardic in the 140s and hypoxic with ambulation. Patient was referred to the ED where CTA Chest revealed a
large saddle pulmonary embolus and bedside ECHO by PERT team demonstrated evidence of RV strain.
Description of the Procedure: The patient was taken to the operating room on [DATE] and placed in supine position. The
patient’s identity and planned procedure were verified. Patient was placed under general anesthesia. The patient was prepped
and draped in the appropriate fashion for open heart surgery. Appropriate invasive monitoring lines were placed including a
radial arterial line, right internal jugular MAC catheter, Foley catheter, and a TEE probe.
Transesophageal echocardiogram was performed in real time. It showed a large saddle embolus in the main pulmonary artery
with apparent extension into the segmental pulmonary arteries. There was evidence of severe RV dysfunction and septal
flattening. Left ventricular function was preserved and hyperdynamic. A timeout was performed.
A 6cm incision was then made in the left 2nd rib space next to the sternum. The left pectoralis major muscle was split, and the
left internal mammary vessels were clipped and ligated. The left 3rd rib was disarticulated from the sternum using
electrocautery. An Alexis soft tissue wound retractor and intercostal rib spreader were placed in the wound. The pericardium
was then incised and opened in a horizontal fashion from the pericardial reflection to the level of the PA bifurcation providing
exposure of the main PA. Pericardial sutures were placed and a pericardial well was created.
Next, a 2cm right femoral groin cutdown was performed and the right common femoral artery and vein were exposed. Full
dose IV heparin was given to the patient to maintain an ACT of greater than 480 seconds. Concentric 5-0 prolene sutures were
placed in a pursestring fashion in the artery and vein. TEE guidance was used to visualize the descending thoracic aorta. The
right common femoral artery was accessed with needle and 0.35-inch Amplatz Extra Stiff wire which was advanced into the
descending thoracic aorta. The artery was serially dilated in Seldinger technique and a 17Fr Next Gen Arterial Cannula was
placed. Next, the right common femoral vein was accessed with a needle and 0.35inch Amplatz Extra Stiff wire which was
advanced into the SVC under TEE guidance. The vein was serially dilated and a 25Fr Biomedicus peripheral venous cannula
was advanced to the cavo-atrial junction. Cardiopulmonary bypass was then initiated. Normothermia was maintained.
A linear pulmonary arteriotomy was performed at the level of the distal main PA with the heart beating. Using the Chitwood
cross clamp, a large amount of saddle pulmonary clot was removed intact in one piece. A 5mm 30o Olympus endoscope was
brought onto the field and under direct visualization, the right and left branch PAs were inspected, and the thrombus was again
removed with the Chitwood crossclamp. Once all thrombi had been cleared, the PA was irrigated and suctioned. The pulmonary
arteriotomy was then closed with a two layer running 4-0 prolene suture, but not tied.The patient was placed in steep
Trendelenburg and aggressively deaired under TEE guidance. The 4-0 prolene sutures were then tied.
Milrinone and epinephrine infusions were initiated for RV support. An ICU vent was brought into the OR and inhaled Flolan
was misted into the endotracheal tube. The patient was weaned off cardiopulmonary bypass on the first attempt. TEE showed
evidence of significantly improved RV function with a hyperdynamic LV. Protamine was administered and the right femoral
arterial and venous cannulas were removed. Two 24Fr Blake drains were placed in the left pleural space and mediastinum.
Hemostasis was confirmed. The intercostal and wound retractors were removed, and the thoracotomy was closed with 2-0
vicryl suture. The wound was copiously irrigated, and the subcutaneous tissue and skin was closed in layers. The right groin
incision was closed in layers. Dermabond was applied to the incisions.
All instrument, sponge, and needle counts were confirmed to be correct at the end of the operation. The patient was
subsequently transferred to the Cardiac Intensive Care Unit in stable, but critical, condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Figure 1: Saddle pulmonary embolism removed from the main, right, and left pulmonary artery.
Multiple Choice Question(s)
A 34-year-old female smoker presents to the ED with dyspnea, tachycardia, and hypoxia. Her only home medication is oral
contraceptives. PERT team is activated, and bedside ECHO shows dilated RV with strain, septal D-sign, and underfilled,
hyperdynamic LV. Patient is deemed to be a candidate for pulmonary embolectomy for suspected saddle PE. Which of the
following is a contraindication for minimally invasive pulmonary embolectomy?
A. Morbid obesity (body habitus)
B. RV clot in transit
C. Thrombus extending into the sub segmental pulmonary arteries on CTA Chest
D. Prior sternotomy
E. Mediastinal radiation
Answer: B. Patients with RV clot in transit should not undergo pulmonary embolectomy via minimally invasive approach with
left anterior thoracotomy. Visualization of the right ventricle thrombus would be extremely limited given the geometry and
anatomy of the right ventricle. Patients with RV clot in transit are better approached through a right atriotomy, where
mobilization of the septal leaflet of the tricuspid valve can significantly aid in exposure and thrombus extraction. All of the
other answer choices listed represent clinical situations where a minimally invasive endoscopic approach truly shines.
Sources
Trendelenburg F. Ueber die operative Behandlung der Embolie der Lungenarterie. Langenbecks Arch Klin Chir. 1908; 86:
686-700.
Goldhaber SZ. ECMO and Surgical Embolectomy: Two Potent Tools to Manage High-Risk Pulmonary Embolism. J Am
Coll Cardiol. 2020;76(8):912-915.
Goldberg JB, Spevack DM, Ahsan S, et al. Survival and Right Ventricular Function After Surgical Management of Acute
Pulmonary Embolism. J Am Coll Cardiol. 2020;76(8):903-911.
Ayers B, Wood K, Bjelic M, Gosev I. Minimally invasive off-pump surgical pulmonary embolectomy for improved patientcentred care [published online ahead of print, 2020 Nov 22]. Eur J Cardiothorac Surg. 2020;ezaa380.
Ayers B, Wood K, Cameron S, et al. Surgical Pulmonary Embolectomy With No Systemic Anticoagulation for Patient With
Recent Stroke. Ann Thorac Surg. 2020;110(6):e493-e495.
