Severe pulmonary embolism: surgical aspects

Severe pulmonary embolism is a life-threatening disease requiring a wellbalanced therapeutic approach. It is of upmost importance to differentiate between acute pulmonary embolism and chronic pulmonary embolism in this setting. The management of acute embolism is predominantly carried out by the internal specialist, whereas the therapy of chronic pulmonary embolism is in the domain of the surgical community. Acute, untreated pulmonary embolism has a mortality of >30%, with two thirds of deaths occurring within the first 60 minutes. It is the most common cause of death without a prior clinical diagnosis because of its vague and nonspecific clinical symptoms and undefined laboratory parameters. The nature of chronic pulmonary embolism is different since it is based on recurrent pulmonary emboli without complete resolution. Five-year survival is pressure dependent, with a mere 10% survival rate in patients having a mean pulmonary arterial pressure of more than 50 mm Hg. It has an incidence of up to 3.8% in survivors of acute pulmonary embolism, as well as an incidence of >10% in patients with recurrent embolism. There are various treatment options for acute pulmonary embolism based on the haemodynamic stability or instability of the patient. If the patient is stable, anticoagulation is to be administered with a potential subsequent implantation of an inferior vena cava filter. If the patient is unstable, thrombolytic therapy has to be considered first. If this fails, mechanical embolectomy or even surgical embolectomy should be taken into account. Patients with chronic pulmonary embolism should be treated surgically with a bilateral endarterectomy of the pulmonary arteries. This is the standard and recommended treatment. The role of the emerging percutaneous pulmonary angioplasty is not yet defined and needs further evaluation. Patients suffering from acute or chronic pulmonary embolism should be transferred to a certified centre. There, specialists decide on the appropriate treatment with potential implantation of life-supporting systems (e.g., extracorporeal membrane oxygenation).