Differential Approach to Surgical and Endovascular Treatments of Pulmonary Thromboembolism in Patients with Neurological and Neurosurgical Problems

Abstract

INTRODUCTION: Pulmonary embolism (PE) is one of the most threatening complications in patients with neurological and neurosurgical problems. The high epidemiological threshold values and mortality in the considered group of patients attracted the interest of researchers in the methods of early diagnosis and selection of methods of reperfusion of the pulmonary arterial bed.

AIM: To analyze clinical and hemodynamic results of the surgical and endovascular treatment of PE of the high and intermediate–high risks in the group of patients with neurological and neurosurgical problems.

MATERIALS AND METHODS: This study involved 24 patients with PE of high and intermediate — high-risks. The first group involved seven patients with neurosurgical problems who underwent thromboembolectomy from the main and lobular branches of the pulmonary artery in conditions of parallel perfusion of the artificial circulation. The duration of perfusion was 26.0 ± 7.4 min. The second group consisted of 17 patients with acute hemorrhagic stroke, in whom endovascular mechanical fragmentation of thromboemboli was performed using a modified Pig-Tail type catheter introduced by puncture through the subclavian or jugular vein. The first clinical manifestations of PE appeared 4.78 ± 2.02 days after the neurosurgical intervention and 8.45 ± 2.6 days after the onset of stroke. The initial systolic pressure in the pulmonary artery was 67.24 ± 5.15 mm Hg in the first group and 70.53 ± 4.53 mm Hg in the second group. Both groups had American Society of Anesthesiologist physical status IV and V classes of surgical risk and Pulmonary Embolism Severity Index class V (130–174 points).

RESULTS: The hospital survival rates were 100% and 82.36% in the first and second groups, respectively (three lethal cases due to progressing right-ventricular failure in the first 18 h after the procedure). On discharge, signs of reverse remodeling of the right heart chambers and reduction of the mean and systolic pressure in the pulmonary artery to 21 ± 2.16 and 31 ± 4.12 mm Hg, respectively, were noted in the first group and to 46 ± 5.23 and 57 ± 3.16 mm Hg, respectively, in the second group.

CONCLUSION: Surgical treatment of PE is effective and safe with predictable results. Endovascular catheter — induced destruction of the thromboembolus substrate is an alternative to the surgical treatment of patients with a high-risk of open surgery and absolute contraindications for thrombolytic therapy.

Keywords

pulmonary thromboembolism / PE / embolectomy / thrombus destruction

References

[1] Tian R, Gao J, Chen A, et al. Silent pulmonary thromboembolism in neurosurgery patients: Report of 2 cases and literature review. Medicine. 2016;95(33):e4589. doi: 10.1097/MD.0000000000004589

[2] Tian R., Gao J., Chen A., et al. Silent pulmonary thromboembolism in neurosurgery patients: Report of 2 cases and literature review // Medicine. 2016. Vol. 95, № 33. P. e4589. doi: 10.1097/MD.0000000000004589

[3] Rossiyskiye klinicheskiye rekomendatsii po diagnostike, lecheniyu i profilaktike venoznykh tromboembolicheskikh oslozhneniy (VTEO). Phlebology. 2015;9(4, Pt 2):3–52. (In Russ).

[4] Российские клинические рекомендации по диагностике, лечению и профилактике венозных тромбоэмболических осложнений (ВТЭО) // Флебология. 2015. Т. 9, № 4, вып. 2. С. 3–52.

[5] Medvedev AP, Fedorov SA, Trofimov NA, et al. Errors in diagnosis and treatment of pulmonary embolism. Kardiologiya i Serdechno-Sosudistaya Khirurgiya. 2021;14(1):54–9. (In Russ). doi: 10.17116/kardio20211401154

[6] Медведев А.П., Федоров С.А., Трофимов Н.А., и др. Ошибки диагностики и лечения тромбоэмболии легочной артерии // Кардиология и сердечно-сосудистая хирургия. 2021. Т. 14, № 1. С. 54–59. doi: 10.17116/kardio20211401154

[7] Hohl JB, Lee JY, Rayappa SP, et al. Prevalence of venous thromboembolic events after elective major thoracolumbar degenerative spine surgery. Journal of Spinal Disorders & Techniques. 2015;28(5):E310–5. doi: 10.1097/BSD.0b013e31828b7d82

[8] Hohl J.B., Lee J.Y., Rayappa S.P., et al. Prevalence of venous thromboembolic events after elective major thoracolumbar degenerative spine surgery // Journal of Spinal Disorders & Techniques. 2015. Vol. 28, № 5. P. E310–E315. doi: 10.1097/BSD.0b013e31828b7d82

[9] Nikulina NN, Terekhovskaya YuV. Epidemiology of pulmonary embolism in today’s context: analysis of incidence, mortality and problems of their study. Russian Journal of Cardiology. 2019;24(6):103–8. (In Russ). doi: 10.15829/1560-4071-2019-6-103-108

[10] Никулина Н.Н., Тереховская Ю.В. Эпидемиология тромбоэмболии легочной артерии в современном мире: анализ заболеваемости, смертности и проблем их изучения // Российский кардиологический журнал. 2019. Т. 24, № 6. C. 103–108. doi: 10.15829/1560-4071-2019-6-103-108

[11] Goldhaber SZ. Venous Thromboembolism in Heart Failure Patients: Pathophysiology, Predictability, Prevention. Journal of American College of Cardiology. 2020;75(2):159–62. doi: 10.1016/j.jacc.2019.11.028

[12] Goldhaber S.Z. Venous Thromboembolism in Heart Failure Patients: Pathophysiology, Predictability, Prevention // Journal of American College of Cardiology. 2020. Vol. 75, № 2. P. 159–162. doi: 10.1016/j.jacc.2019.11.028

[13] Koehl JL, Hayes BD, Al-Samkari H, et al. A comprehensive evaluation of apixaban in the treatment of venous thromboembolism. Expert Review of Hematology. 2020;23(1):155–73. doi: 10.1080/17474086.2020.1711731

[14] Koehl J.L., Hayes B.D., Al-Samkari H., et al. A comprehensive evaluation of apixaban in the treatment of venous thromboembolism // Expert Review of Hematology. 2020. Vol. 13, № 2. Р. 155–173. doi: 10.1080/17474086.2020.1711731

[15] Reis SP, Zhao K, Ahmad N, et al. Acute pulmonary embolism: endovascular therapy. Cardiovascular Diagnosis and Therapy. 2018;8(3):244–52. doi: 10.21037/cdt.2017.12.05

[16] Reis S.P., Zhao K., Ahmad N., et al. Acute pulmonary embolism: endovascular therapy // Cardiovascular Diagnosis and Therapy. 2018. Vol. 8, № 3. Р. 244–252. doi: 10.21037/cdt.2017.12.05

[17] Schmitz–Rode T, Günther RW. Apparatus for fragmentation of a lung embolus. Germanpatent DE G 9409863.8, US patent 5,630,823, PCT WO 95/35066. Available at: https://patentscope.wipo.int/search/en/detail.jsf?docId=WO1995035066. Accessed: 2021 November 18.

[18] Schmitz–Rode T., Günther R.W. Apparatus for fragmentation of a lung embolus. German patent DE G 9409863.8, US patent 5,630,823, PCT WO 95/35066. Доступно по: https://patentscope.wipo.int/search/en/detail.jsf?docId=WO1995035066. Ссылка активна на 18.11.2021.

[19] Khripun AI, Alimov AN, Priamikov AD, et al. Venous thromboembolic complications in patients with intracranial hemorrhage and tumors of the central nervous system. Khirurgiia. 2014;(3):49–52.

[20] Khripun A.I., Alimov A.N., Priamikov A.D., et al. Venous thromboembolic complications in patients with intracranial hemorrhage and tumors of the central nervous system // Khirurgiia. 2014. № 3. Р. 49–52.

[21] Yilmaz MB, Durdag E, Egemen E, et al. Role of vena cava inferior filter on neurosurgical deep venous thrombosis. Turkish Neurosurgery. 2012;22(3):269–73. doi: 10.5137/1019-5149.JTN.5521-11.0

[22] Yilmaz M.B., Durdag E., Egemen E., et al. Role of vena cava inferior filter on neurosurgical deep venous thrombosis // Turkish Neurosurgery. 2012. Vol. 22, № 3. P. 269–273. doi: 10.5137/1019-5149.JTN.5521-11.0

[23] Khubulava GG, Volkov AM, Gavrilov EK, et al. Open Thromboembolectomy for Massive and Submassive Pulmonary Embolism in High-Risk Patients. Phlebology. 2020;14(4):296–302. (In Russ). doi: 10.17116/flebo202014041296

[24] Хубулава Г.Г., Волков А.М., Гаврилов Е.К., и др. Открытая тромбэмболэктомия в хирургическом лечении массивной и субмассивной тромбоэмболии легочных артерий у пациентов с высоким риском смерти // Флебология. 2020. Т. 14, № 4. С. 296–302. doi: 10.17116/flebo202014041296

[25] Claeys MJ, Vandekerckhove Y, Cosyns B, et al. Summary of 2019 ESC Guidelines on chronic coronary syndromes, acute pulmonary embolism, supraventricular tachycardia and dislipidaemias. Acta Cardiologica. 2021;76(1):1–8. doi: 10.1080/00015385.2019.1699282

[26] Claeys M.J., Vandekerckhove Y., Cosyns B., et al. Summary of 2019 ESC Guidelines on chronic coronary syndromes, acute pulmonary embolism, supraventricular tachycardia and dislipidaemias // Acta Cardiologica. 2021. Vol. 76, № 1. Р. 1–8. doi: 10.1080/00015385.2019.1699282

[27] Zakaryan NV, Molokhoev EB, Davtyan AG, et al. Endovascular treatment of acute pulmonary embolism in a patient with contraindications to thrombolytic therapy. Russian Journal of Endovascular Surgery. 2021; 8(3):310–4. (In Russ). doi: 10.24183/2409-4080-2021-8-3-310-314

[28] Закарян Н.В., Молохоев Е.Б., Давтян А.Г., и др. Эндоваскулярное лечение тромбоэмболии легочной артерии у пациента с наличием противопоказаний к тромболитической терапии // Эндоваскулярная хирургия. 2021. Т. 8, № 3. С. 310–314. doi: 10.24183/2409-4080-2021-8-3-310-314

RIGHTS & PERMISSIONS

Fedorov S.A., Medvedev A.P., Tselousova L.M., Kudykin M.N., Pichugin V.V., Zhurko S.A., Chiginev V.A., Gamzaev A.B., Trofimov N.A., Gamayunov S.V., Deryabin R.A.