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BMC Anesthesiology

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Open Access 01-12-2023 | Tissue Plasminogen Activator | Research

Intraoperative circulatory arrest secondary to high-risk pulmonary embolism. Case series and updated literature review

Authors: Gustavo Cruz, Santiago Pedroza, Miller Giraldo, Alvaro D. Peña, Camilo A. Calderón, Ivan F. Quintero

Published in: BMC Anesthesiology | Issue 1/2023

Abstract

Background

Intraoperative pulmonary embolism (PE) with cardiac arrest (CA) represents a critical and potentially fatal condition. Available treatments include systemic thrombolysis, catheter-based thrombus fragmentation or aspiration, and surgical embolectomy. However, limited studies are focused on the optimal treatment choice for this critical condition. We present a case series and an updated review of the management of intraoperative CA secondary to PE.

Methods

A retrospective review of patients who developed high-risk intraoperative PE was performed between June 2012 and June 2022. For the updated review, a literature search on PubMed and Scopus was conducted which resulted in the inclusion of a total of 46 articles.

Results

A total of 196 174 major non-cardiac surgeries were performed between 2012 and 2022. Eight cases of intraoperative CA secondary to high-risk PE were identified. We found a mortality rate of 75%. Anticoagulation therapy was administered to one patient (12.5%), while two patients (25%) underwent thrombolysis, and one case (12.5%) underwent mechanical thrombectomy combined with thrombus aspiration. Based on the literature review and our 10-year experience, we propose an algorithm for the management of intraoperative CA caused by PE.

Conclusion

The essential components for adequate management of intraoperative PE with CA include hemodynamic support, cardiopulmonary resuscitation, and the implementation of a primary perfusion intervention. The prompt identification of the criteria for each specific treatment modality, guided by the individual patient’s characteristics, is necessary for an optimal approach.

Böttiger BW, Wetsch WA. Pulmonary Embolism Cardiac Arrest: Thrombolysis during Cardiopulmonary Resuscitation and Improved Survival. Chest. 2019;156:1035–6. https://doi.org/10.1016/j.chest.2019.08.1922CrossRefPubMed

Yavuz S, Toktas F, Goncu T, et al. Surgical embolectomy for acute massive Pulmonary Embolism. Int J Clin Exp Med. 2014;7(12):5362–75. PMID: 25664045; PMCID: PMC4307492.PubMedPubMedCentral

Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An update on the management of Acute High-Risk Pulmonary Embolism. J Clin Med. 2022;11. https://doi.org/10.3390/jcm11164807

Al-Bawardy R, Rosenfield K, Borges J, et al. Extracorporeal membrane oxygenation in acute massive Pulmonary Embolism: a case series and review of the literature. Perfusion (United Kingdom). 2019;34:22–8. https://doi.org/10.1177/0267659118786830CrossRef

Chicangana G, Zapata L, Gómez JC, Zuluaga JP. Trombólisis sistémica exitosa en un paciente con tromboembolismo pulmonar masivo, luego de reanimación cardiocerebropulmonar prolongada. Informe De Caso. Revista Colombiana De Anestesiologia. 2016;44:246–9. https://doi.org/10.1016/j.rca.2016.02.001CrossRef

Jacobs B, Pannucci C. Scoring systems for estimating risk of venous thromboembolism in Surgical patients. Semin Thromb Hemost. 2017;43:449–59. https://doi.org/10.1055/s-0036-1597288CrossRefPubMed

Weinberg A, Tapson VF, Ramzy D. Massive Pulmonary Embolism: extracorporeal membrane oxygenation and Surgical Pulmonary Embolectomy. Semin Respir Crit Care Med. 2017;38:066–72. https://doi.org/10.1055/s-0036-1597559CrossRef

Cho YH, Sung K, Kim WS, et al. Management of acute massive Pulmonary Embolism: is surgical embolectomy inferior to thrombolysis? Int J Cardiol. 2016;203:579–83. https://doi.org/10.1016/j.ijcard.2015.10.223CrossRefPubMed

Ghobadi H, Amirajam Z, Habibzadeh A. Successful treatment of massive pulmonary thromboembolism with reteplase: Case Series. Tanaffos. 2018;17(1):53–6. PMID: 30116280; PMCID: PMC6087528.PubMedPubMedCentral

10.

Peberdy MA, Kaye W, Ornato JP, et al. Cardiopulmonary resuscitation of adults in the hospital: a report of 14 720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 2003;58:297–308. https://doi.org/10.1016/S0300-9572(03)00215-6CrossRefPubMed

11.

Hoybye M, Stankovic N, Lauridsen KG, Holmberg MJ, Andersen LW, Granfeldt A. Pulseless electrical activity vs. asystole in adult in-hospital Cardiac Arrest: predictors and outcomes. Resuscitation. 2021;165:50–7. https://doi.org/10.1016/j.resuscitation.2021.05.036CrossRefPubMed

12.

Konstantinides SV, Meyer G, Bueno H, et al. 2019 ESC guidelines for the diagnosis and management of acute Pulmonary Embolism developed in collaboration with the European respiratory society (ERS). Eur Heart J. 2020;41:543–603. https://doi.org/10.1093/eurheartj/ehz405CrossRefPubMed

13.

Ismail M, Bsooki M, Allehyani B, Alessa A. Inhaled nitric oxide (iNO) with a massive Pulmonary Embolism: a Case Report. Cureus 2022 https://doi.org/10.7759/cureus.27122

14.

Tanus-Santos JE, Theodorakis MJ. Is there a place for inhaled nitric oxide in the therapy of acute pulmonary embolism? Am J Respir Med. 2002;1(3):167 – 76. https://doi.org/10.1007/BF03256606. PMID: 14720054.

15.

Reisinger AC, Fandler-Höfler S, Kreuzer P, et al. VA-ECMO and thrombus aspiration in a Pulmonary Embolism patient with Cardiac Arrest and contraindications to thrombolytic therapy. Vasa - European Journal of Vascular Medicine. 2022;51:315–9. https://doi.org/10.1024/0301-1526/a001019CrossRefPubMed

16.

Reeves ST, Finley AC, Skubas NJ, Council on Perioperative Echocardiography of the American Society of Echocardiography; Society of Cardiovascular Anesthesiologists, et al. Basic perioperative transesophageal echocardiography examination: a consensus statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26(5):443–56. https://doi.org/10.1016/j.echo.2013.03.005CrossRefPubMed

17.

Smeltz AM, Kolarczyk LM, Isaak RS. Update on Perioperative Pulmonary Embolism Management: a decision Support Tool to Aid in diagnosis and treatment. Adv Anesth. 2017;35(1):213–28. https://doi.org/10.1016/j.aan.2017.08.001CrossRefPubMed

18.

Martillotti G, Boehlen F, Robert-Ebadi H, Jastrow N, Righini M, Blondon M. Treatment options for severe Pulmonary Embolism during pregnancy and the postpartum period: a systematic review. J Thromb Haemost. 2017;15:1942–50. https://doi.org/10.1111/jth.13802CrossRefPubMed

19.

Beckerman Z, Bolotin G. Surgical treatment of acute massive Pulmonary Embolism. Adv Exp Med Biol. 2017;906:75–88. https://doi.org/10.1007/5584_2016_107CrossRefPubMed

20.

Erkens PM, Prins MH. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2010. https://doi.org/10.1002/14651858.cd001100.pub3

21.

Laher AE, Richards G. Cardiac Arrest due to Pulmonary Embolism. Indian Heart J. 2018;70:731–5. https://doi.org/10.1016/j.ihj.2018.01.014CrossRefPubMedPubMedCentral

22.

Porres-Aguilar M, Rivera-Lebron BN, Anaya-Ayala JE, León MCG, Mukherjee D. Perioperative Acute Pulmonary Embolism: a concise review with emphasis on Multidisciplinary Approach. Int J Angiol. 2020;29(3):183–8. https://doi.org/10.1055/s-0040-1709501CrossRefPubMedPubMedCentral

23.

Logan JK, Pantle H, Huiras P, Bessman E, Bright L. Evidence-based diagnosis and thrombolytic treatment of Cardiac Arrest or periarrest due to suspected Pulmonary Embolism. Am J Emerg Med. 2014;32:789–96. https://doi.org/10.1016/j.ajem.2014.04.032CrossRefPubMed

24.

Javaudin F, Lascarrou JB, Le Bastard Q, et al. Thrombolysis during Resuscitation for Out-of-hospital Cardiac Arrest caused by Pulmonary Embolism increases 30-Day survival: findings from the French National Cardiac Arrest Registry. Chest. 2019;156:1167–75. https://doi.org/10.1016/j.chest.2019.07.015CrossRefPubMed

25.

Scheeren TW, Hopf HB, Peters J. Intraoperative thrombolyse mit rt-PA bei massiver lungenembolie während venöser thrombektomie [Intraoperative thrombolysis with rt-PA in massive Pulmonary Embolism during venous thrombectomy]. Anasthesiol Intensivmed Notfallmed Schmerzther. 1994;29(7):440–5. https://doi.org/10.1055/s-2007-996782CrossRefPubMed

26.

Jackson D, Botea A, Gubenko Y, Delphin E, Bennett H. Successful intraoperative use of recombinant tissue plasminogen activator during liver transplantation complicated by massive intracardiac/pulmonary Thrombosis. Anesth Analg. 2006;102(3):724–8. https://doi.org/10.1213/01.ane.0000197779.03866.adCrossRefPubMed

27.

Wenk M, Pöpping DM, Hillyard S, Albers H, Möllmann M. Intraoperative thrombolysis in a patient with cardiopulmonary arrest undergoing caesarean delivery. Anaesth Intensive Care. 2011;39(4):671–4. https://doi.org/10.1177/0310057X1103900422CrossRefPubMed

28.

Aniskevich S, Ladlie BL, Pai SL, Perry DK, Canabal JM, Taner CB. Postoperative Stroke Following Administration of Intraoperative Recombinant Tissue plasminogen activator for the treatment of intracardiac Thrombus during liver transplantation. J Cardiothorac Vasc Anesth. 2015;29(5):1314–8. https://doi.org/10.1053/j.jvca.2014.07.010CrossRefPubMed

29.

Cao J, Liu Y, Wang Y, Wang L, Zhang M, Feng M, Luo H, Ma Y, Hou X. Salvage thrombolysis and extracorporeal membrane oxygenation for massive Pulmonary Embolism during the distal femur fracture Surgery. Am J Emerg Med. 2016;34(6):1189e3–5. https://doi.org/10.1016/j.ajem.2015.11.019CrossRef

30.

Roy KM, Rajan GR. Reversal of ε-Aminocaproic Acid-Induced massive Thromboemboli using tissue plasminogen activator during cardiac Surgery: a Case Report. A A Pract. 2019;12(10):372–4. https://doi.org/10.1213/XAA.0000000000000933CrossRefPubMed

31.

Holland R, Houten JK, Elsamragy S, Kim J, Leyvi G, Kinon MD. Intraoperative thrombolysis of massive pulmonary Embolus during spine Surgery: Case Report of Survival complicated by Massive Bleeding and review of the literature. World Neurosurg. 2021;146:59–63. https://doi.org/10.1016/j.wneu.2020.10.018CrossRefPubMed

32.

Karakosta A, Evangelou T, Flindris S et al. Systemic thrombolysis for treatment of Acute Life-threatening Pulmonary Embolism during Cesarean Section followed by Post-partum Rescue Hysterectomy: a Case Report and Review of the literature. In Vivo 2023 Jan-Feb;37(1):498–502 https://doi.org/10.21873/invivo.13106

33.

Wang C, Zhai Z, Yang Y, et al. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest. 2010;137:254–62. https://doi.org/10.1378/chest.09-0765CrossRefPubMed

34.

Boone JD, Sherwani SS, Herborn JC, Patel KM, De Wolf AM. The successful use of low-dose recombinant tissue plasminogen activator for treatment of intracardiac/pulmonary Thrombosis during liver transplantation. Anesth Analg. 2011;112:319–21. https://doi.org/10.1213/ANE.0b013e31820472d4CrossRefPubMed

35.

Kafi A, Friedman O, Kim I. Use of low-dose thrombolytics for treatment of intracardiac thrombus and massive pulmonary embolus after aborted liver transplant leads to recovery of right ventricular function and redo liver transplantation. BMJ Case Rep 2017;2017 https://doi.org/10.1136/bcr-2017-219837

36.

Mercer RM, Bowen JST, Armstrong RJ. All contraindications to thrombolysis for life-threatening pulmonary embolus should be considered relative. BMJ Case Rep. 2013. https://doi.org/10.1136/bcr-2013-009724CrossRefPubMedPubMedCentral

37.

Koroneos A, Koutsoukou A, Zervakis D, et al. Successful resuscitation with thrombolysis of a patient suffering fulminant Pulmonary Embolism after recent intracerebral haemorrhage. Resuscitation. 2007;72:154–7. https://doi.org/10.1016/j.resuscitation.2006.06.019CrossRefPubMed

38.

Alqahtani F, Munir MB, Aljohani S, Tarabishy A, Almustafa A, Alkhouli M. Surgical thrombectomy for Pulmonary Embolism: updated performance rates and outcomes. Tex Heart Inst J. 2019;46:172–4. https://doi.org/10.14503/THIJ-18-6751CrossRefPubMedPubMedCentral

39.

Choi JH, O’Malley TJ, Maynes EJ, et al. Surgical Pulmonary Embolectomy outcomes for Acute Pulmonary Embolism. Ann Thorac Surg. 2020;110:1072–80. https://doi.org/10.1016/j.athoracsur.2020.01.075CrossRefPubMed

40.

Pasrija C, Kronfli A, Rouse M, et al. Outcomes after surgical pulmonary embolectomy for acute submassive and massive Pulmonary Embolism: a single-center experience. J Thorac Cardiovasc Surg. 2018;155:1095–106. https://doi.org/10.1016/j.jtcvs.2017.10.139CrossRefPubMed

41.

Meneveau N, Séronde MF, Blonde MC, et al. Management of unsuccessful thrombolysis in acute massive Pulmonary Embolism. Chest. 2006;129:1043–50. https://doi.org/10.1378/chest.129.4.1043CrossRefPubMed

42.

Tajima H, Murata S, Kumazaki T, et al. Recent advances in interventional radiology for acute massive pulmonary thromboembolism. J Nippon Med School. 2005;72:74–84. https://doi.org/10.1272/jnms.72.74CrossRef

43.

Licha CRM, McCurdy CM, Maldonado SM, Lee LS. Current management of acute Pulmonary Embolism. Annals of Thoracic and Cardiovascular Surgery. 2020;26:65–71. https://doi.org/10.5761/atcs.ra.19-00158CrossRef

44.

Loyalka P, Ansari MZ, Cheema FH, Miller CC 3rd, Rajagopal S, Rajagopal K. Surgical pulmonary embolectomy and catheter-based therapies for acute Pulmonary Embolism: a contemporary systematic review. J Thorac Cardiovasc Surg. 2018;156(6):2155–67. https://doi.org/10.1016/j.jtcvs.2018.05.085CrossRefPubMed

45.

Rozycki S, Iyengar A, Vadnais B, et al. Contemporary outcomes of surgical pulmonary embolectomy. Ann Thorac Surg. 2017;104(1):117–24. https://doi.org/10.1016/j.athoracsur.2017.02.005CrossRef

46.

Jamieson WR, Kapelanski DP. Pulmonary thromboendarterectomy. Ann Thorac Surg. 2002;73:1643–8. https://doi.org/10.1016/s0003-4975(01)03317-7CrossRef

Title: Intraoperative circulatory arrest secondary to high-risk pulmonary embolism. Case series and updated literature review
Authors: Gustavo Cruz
Santiago Pedroza
Miller Giraldo
Alvaro D. Peña
Camilo A. Calderón
Ivan F. Quintero
Publication date: 01-12-2023
Publisher: BioMed Central
Keywords: Tissue Plasminogen Activator
Cardiopulmonary Resuscitation
Thrombectomy
CT Angiography
Published in: BMC Anesthesiology / Issue 1/2023
Electronic ISSN: 1471-2253
DOI: https://doi.org/10.1186/s12871-023-02370-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Intraoperative circulatory arrest secondary to high-risk pulmonary embolism. Case series and updated literature review

Abstract

Background

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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