Outcomes Improving for Surgical Embolectomy in Pulmonary Embolism Treatment

Marc Pelletier, MD, MSc

Results of a new study suggest outcomes of surgical embolectomies for acute pulmonary embolism in patients with contraindications to thrombolysis may be better than previous studies have indicated.

Conducted by Marc Pelletier, MD, MSc, of the University Hospitals Cleveland Medical Center, along with colleagues from Brigham and Women’s Hospital and Albany Medical College, the analysis of the National Inpatient Sample (NIS) reported an in-hospital mortality rate of 19.8%—suggesting the outcomes for the procedure have improved in recent years.

"Over the past decade, we have seen the rise of multidisciplinary team-based care in the treatment of acute pulmonary embolism. We looked at treatment patterns and outcomes in a contemporary sample, with a focus on the role of surgical embolectomy,” said study authors in a statement to HCPLive ®. “Those patients who underwent embolectomy were a very high risk cohort, however their in-hospital mortality was lower than reported in previous samples of this database and other institutional studies. This is likely a reflection of improved techniques, perioperative care, and improved patient selection associated with a multidisciplinary approach.”

With guidelines outlining the role of surgical embolectomy for acute pulmonary embolism consensus-based, investigators sought to examine trends, outcomes, and predictors of mortality in for patients treated with surgical embolectomy, systemic thrombolysis, and catheter-directed therapies from 2010-2014 in the NIS. The use of NIS data from this time period resulted in a cohort of 58,974 patients—of which 33,553 were treated with systemic thrombolysis, 22,336 with catheter-directed therapies, and 3085 underwent surgical embolectomy.

The primary outcome of interest for the analysis was all-cause in-hospital mortality. Secondary outcomes were in-hospital myocardial infarction (MI), complete heart block, cardiac arrest, major bleed, stroke, blood transfusion, length of stay, and cost. Investigators also noted the evaluation of overall trends in use of each treatment over time.

The median age of the study cohort was 59 years and 49.4% of the individuals were female. Compared to those undergoing systemic thrombolysis and catheter-directed therapies, patients undergoing surgical embolectomies were more likely to have atrial fibrillation (21.6% vs. 12.1% vs. 13.2%), congestive heart failure (17.8% vs. 13.5% vs. 13.3%), and paralysis or hemiplegia (4.6% vs. 4.0% vs. 2.6%) (all P <.01). Investigators pointed out surgical embolectomy patients were less likely to be smokers with chronic lung disease or malignancy.

Upon analysis, results indicated patients undergoing surgical embolectomy had significantly higher rates of unadjusted in-hospital mortality compared to those undergoing systemic thrombolysis and catheter-directed therapies (19.8% vs. 15.8% vs. 6.5%, P <0.01). Additionally, results pointed to increased (7.2% vs. 5.9% vs. 2.6%), cardiac arrest (15.6% vs. 11.2% vs. 3.9%) and blood transfusion (31.8% vs. 16.1% vs. 10.2%)(all P <.01) among patients undergoing surgical embolectomy.

Conversely, patients undergoing systemic thrombolysis had the greatest rates of major bleeding (15.8% vs. 17.7% vs. 12.2%; P <.01) and intracranial hemorrhage (1.6% vs. 2.1% vs. 0.7%; P <.01).

Multivariate analysis for predictors of in-hospital mortality revealed being older than 60 years of age (OR, 1.29; 95% CI, 1.17-1.52; P <.01), presence of atrial fibrillation (OR 1.41; 95% CI, 1.21-1.65; P <.01), congestive heart failure (OR, 1.36; 95% CI, 1.16-1.58; P <.01), and non-saddle pulmonary embolism (OR, 1.33; 95% CI, 1.07-1.63, P <.01) were associated with increased odds of in-hospital mortality. In contrast, private insurance (OR, 0.79; 95% CI, 0.69-0.90; P <.01), hypertension (OR, 0.86; 95% CI, 0.76-0.98; P=.02) and obesity (OR, 0.85; 95% CI, 0.74-0.98; P=0.02) were associated with a decrease in odds of in-hospital mortality.

“We believe that this supports the continued role of surgical embolectomy within the treatment algorithm of acute pulmonary embolism, in those with anatomically suitable disease or contraindications to thrombolysis,” authors wrote to HCPLive®. “Emerging data has shown that surgery may be particularly useful in sub-massive embolism, before patients get to the point of hemodynamic instability."

This study, “National Outcomes of Surgical Embolectomy for Acute Pulmonary Embolism,” was published in the Annals of Thoracic Surgery.