Repeat Pulmonary Embolectomy For Recurrent Pulmonary Embolism Demonstrates Necessity Of Inferior Vena Cava Filter Placement
Elbert E. Williams, Amit Pawale, Karthik Seetharam, Ramachandra C. Reddy.
Mount Sinai Medical Center, New York, NY, USA.
A 57-year-old female at an outside facility was found to have a large saddle pulmonary embolus after going into cardiopulmonary arrest on her eighth postoperative day (POD) from a distal pancreatectomy and splenectomy. The patient was transferred for an emergent pulmonary embolectomy. She was bicavally cannulated, placed on cardiopulmonary bypass and cooled to 28 degrees Celsius. The pulmonary artery was opened under a low flow state and an 18 cm saddle embolus was removed. Both pulmonary arterial branches were inspected with no residual clot seen. Heparin was only partially reversed before the chest was closed. A heparin drip was started on POD 1 with plans for inferior vena cava (IVC) filter placement on POD 2. However, the patient’s oxygenation remained marginal and required increasing dosing of inotropes, showing signs of right heart failure. A CT scan was performed on POD 3 revealing a large pulmonary embolus in the right main pulmonary artery with multiple smaller bilateral emboli. The patient was taken to the operating room for a repeat pulmonary embolectomy. Again, the patient was bicavally cannulated, cooled to 28 degrees Celsius, and the pulmonary artery was opened. Under a low flow state, a large 15 cm clot was removed from the right main pulmonary artery as well as a large clot wedged into the distal left pulmonary artery. Further inspection revealed no additional clot. The tricuspid valve was repaired with a 28 mm ring via a right atriotomy. Once off bypass, the vascular surgeons placed an IVC filter via the right femoral vein. Postoperatively the patient did well, was extubated on POD 3 and discharged home with warfarin on POD 8.
CONCLUSIONS: Massive pulmonary embolism is life threatening but can be treated with pulmonary embolectomy. This case demonstrates the importance of IVC filter placement. Had an IVC filter been placed during the first embolectomy operation, the patient’s postoperative course would have been smoother and a second operation could have been avoided. It is now our standard practice and recommendation to place an IVC filter at the time of the embolectomy surgery in order to avoid recurrent embolic events.
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