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.