Technique
We applied our technique to seven consecutive patients (one man and six women) between July 2020 and December 2021. The patient characteristics are shown in Table 1. The median patient age was 52 (23–77) years. All patients had massive PE, and two cases required preoperative circulatory extracorporeal membrane oxygenation (ECMO).
A summary of the operative procedure is presented in Video 1. All patients underwent PA thrombectomy using the median sternotomy approach. Cardiopulmonary bypass (CPB) was established with ascending aortic cannulation and bicaval drainage. A left ventricular vent was inserted into the right superior pulmonary vein. After establishing total bypass, the ascending aorta was cross-clamped, and cardiac arrest was achieved via antegrade cardioplegia. The surgical assistant arm was then used to compress the right ventricular outflow tract caudally, leading to a sufficient view of the left PA (Fig. 1a). A longitudinal incision was made in the anterior aspect of the main and left PA, and the thrombus was removed. A tourniquet taping the superior vena cava (SVC) with a cannula was pulled up, and the ascending aorta was compressed to the left with a surgical assistant arm (Fig. 1b). A longitudinal incision was made in the anterior aspect of the left PA, enabling us to directly examine the second branch of the left PA after thrombectomy. In contrast to the left side, the thrombus on the right side was torn off several times; however, all thrombi up to the second branch were removed step by step. The median operative, CPB, and cardiac ischemic times were 265, 149, and 62 min, respectively.
Five patients who did not require preoperative ECMO were successfully weaned off CPB. Two patients who underwent preoperative veno-arterial ECMO required temporary postoperative veno-arterial ECMO support. One patient developed PE and cardiopulmonary arrest during orthopedic surgery in another hospital and died of multiple organ failure on postoperative day 112. The median postoperative intubation time, ICU stay, and hospital stay were 14 h, 3 days, and 16 days, respectively. Computed tomography at discharge of six living patients showed no thrombus within the PA up to the second branch. The patients provided informed consent for the publication of this case series and the need for approval was waived by our institutional review board.