Intraoperative Thrombolysis of Massive Pulmonary Embolus During Spine Surgery: Case Report of Survival Complicated by Massive Bleeding and Review of the Literature

Venoarterial extracorporeal membrane oxygenation for "protected" catheter-based embolectomy in high-risk/massive pulmonary embolism

High-risk/massive pulmonary embolism (PE) has a high mortality rate, especially when cardiac arrest occurs. Venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) can rapidly restore and maintain circulation while a decision regarding further care or performance of other interventions takes place. Catheter-based embolectomy (CBE) is a technology that allows for percutaneous access, clot removal, and potential resolution of shock while avoiding sternotomy required for traditional pulmonary embolectomy. Rapid placement of V-A ECMO in patients with high-risk/massive PE prior to CBE may confer circulatory protection before, during, and after the procedure.

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

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.

Intraoperative massive pulmonary embolism during revision lumbar fusion managed with extracorporeal membrane oxygenation

STUDY DESIGN

Case report.

PURPOSE

The purpose of this case report is to illustrate the utility of ECMO as possible treatment in the management of perioperative massive pulmonary embolism (PE) during spine surgery. We present a case report of an intra-operative massive PE managed with ECMO and review relevant literature of perioperative massive PE. Treatment poses substantial risk given the need for anticoagulation. ECMO has not previously been described in the management of this condition in spine surgery.

METHODS

The patient is a 75-year-old male with hypertension, diabetes mellitus type II, chronic obstructive pulmonary disease, and prior cerebral infarction with minimal residual deficits who presented for Lumbar 2-Sacral 1 (L2-S1) revision posterior spinal decompression and fusion with L3-4 TLIF (Transforaminal Lumbar Interbody Fusion). The operation was routine until removing him from the operative table when he suffered a massive pulmonary embolism.

RESULTS

The patient became extremely unstable hemodynamically requiring massive doses of three vasopressors. He was too unstable for additional imaging or to transport for mechanical thrombectomy so with the guidance of our cardiologist we initiated ECMO. The patient ultimately recovered well and was discharged from the hospital at his neurological baseline and preserved cardiac function.

CONCLUSION

ECMO is a viable option for management of acute perioperative massive pulmonary embolism when less invasive treatments are not sufficient.