Pulmonary embolismand

methods of treatment

Pulmonary embolismand

methods of treatment

Nizhny Novgorod state medical Academy

Department of Hospital Surgery

Medvedev A.P.Sobolev Y.A.

Annually0,1% of population die

from venous thromboembolic complications in the world

StatisticsStatistics

1. Cohen A.T. et al. 2007 2. Heit J.A. et al. 2005

And 3 million deaths in the world.

Nearly 300,000 deaths in USA.(2)

Pulmonary embolism causes more than 500,000 deaths in Europe (1)

1. Dobesh P.P. Pharmacotherapy, 20092. House of Commons Health Committee Second Report of Session 2004-2005

Every year more than 640 million £ is spent in the UK (2)

In the USA the economic losses from VTEC are $ 1.5 billion $ per year (1)

ExpendituresExpenditures

Acute pulmonary embolism:

the myths and misconceptions.

Acute pulmonary embolism:

the myths and misconceptions. …the massive PE always leads to the death of the patient…

…if the patient has survived, it means that he's had an embolism of peripheral branches of PA…

…patients with pulmonary embolism of peripheral branches of PA do not need any specialized assistance…

Defenition:Defenition:

• Pulmonary thromboembolism – is a sudden

obstruction of the branches of the pulmonary artery

by thromboemboli, initially formed in the veins of the

systemic circulation or in the right heart which is the

greatest threat in the development of pulmonary

hypertension and failure of the right ventricle, which

is observed in occlusion over 50% of the arterial

channel.

Etiology: Etiology: Sources of emboli:• The SVC system – 0,4%• Right heart – 10,4%• The IVC system – 84,5%

Sources of emboli:• The SVC system – 0,4%• Right heart – 10,4%• The IVC system – 84,5%

Localization emboli:• Smaller branches – 27,1%• Equity and segmental– 17,1%• Trunk and main branches– 55,8%

Localization emboli:• Smaller branches – 27,1%• Equity and segmental– 17,1%• Trunk and main branches– 55,8%

* Embolism of segmental and equity branches causes death in only 6.4% of patients.

* Embolism of main PA and major branches causes fulminant death in 61,3% of patients

Mortality riskat acute PE

Risk factors

Clinical (shock or hypotension)

RVdysfunction

Myocardial

damage High risk >15% + +* +*

Intermediate risk 3-15% – + + – + – +

Low risk <1% – – –* is not necessary to confirm RV dysfunction to determination high-risk of death if the shock or hypotension is present.

Mortality risk stratification in acute pulmonary embolism.

Mortality risk stratification in acute pulmonary embolism.

Guidelines on the diagnosis and management of acute pulmonary embolism (2008)

Clinical types of pulmonary embolismClinical types of pulmonary embolism

Acute (12,8%) Acute start, chest pain, breathlessness, hypotension, acute heart failure.

Subacute (31,4%) Progressive lung and heart failure , pneumonia, cough with bloody sputum.

Reccurent (41,8%)Reccurent episodes of breathlessness, syncope, pneumonia.

Aims of diagnostic: Aims of diagnostic:

• To confirm the presence of pulmonary

embolism.

• To identify the localization and lesion

area.

• To estimate the severity of

hemodynamic disorders

• To determine the source of

embolization

Сlinical presentation Сlinical presentation

Pulmonary and pleural syndrome

*Breathlessness

*Cyanosis of the face and the upper

half of the body

*Chest pain

*Cough with bloody sputum

Cardiac syndrome

*Angina

*Tachycardia

*Hypotension

Cerebral syndrome

*Syncope

*Hemiplegia

(V.S. Saveliev, E.G. Yablokov, A.I. Kirienko, 1979)

DIAGNOSTICSDIAGNOSTICS

Echo:Allows us to detect the thromboemboli

in the pulmonary artery and determine the severity of pulmonary hypertension.

ECG: acute RBBB, overload of RA

MSCT: determination of localization of tromboemboli

X-rayExpansion of the roots of the lungs decrease of

pulmonary patternPathological pulmonary shadows

(atelectasis)Pleurisy

High standing of the diaphragm

Cardiac Cath :«Amputation» syndrome of branches of the pulmonary arteryManometry (35-80 mm Hg)Scintigraphy- violation of lung perfusion

Dysfunction of the right ventricle in acute pulmonary embolism

Dysfunction of the right ventricle in acute pulmonary embolism

Overstrain signs of the right ventricle.

Dilatation of the right ventricleEDV >30 mm

Hypokinesis of free wall of the right ventricle

The velocity of tricuspidregurgitation in systole >2,6 м/с

Victor Savelyev – a Russian pioneer

in diagnostics, treatment

and prophylaxis

of pulmonary embolism

*Normalization of hemodynamics

*Restoration ofpulmonary arteries

*Recurrency prevention

Treatment objectives:Treatment objectives:

I. Ohotin

Aims of treatment of PE Aims of treatment of PE 1. Removing threat of death from acute

heart failure

2. Improvement of lung perfusion and prevention of chronic pulmonary hypertension

3. Recurrency prevention

Treatment choiceTreatment choice??1. Pharmacological

embolectomy

(thrombolytic therapy)

2. Open embolectomy

3. Endovascular embolectomy

Types of localization of emboli in PETypes of localization of emboli in PE

5- year Pressure in PA survival

rate < 30 90 %

31 - 40 50 %

41 - 50 35 %

> 50 10 %

ThrombolysisThrombolysis

• Thrombolytic therapy leads to a fast recovery of

the occluded pulmonary artery, reducing

pulmonary hypertension and overstrain of the

right ventricle.

• The indication for therapy with thrombolytics is

the development of acute massive pulmonary

embolism with symptoms of arterial

hypotension, or shock.

• Thrombolytic therapy is associated with

increased risk of bleeding.

Modes of thrombolytic therapyin acute pulmonary embolism

Modes of thrombolytic therapyin acute pulmonary embolism

Streptokinase250 000 IU as a loading dose over 30 minutes, then 100 000 IU/h for 12-24 hoursBoost mode: 1500000 IU for 2 hours.

Urokinase4400 IU/kg as a loading dose over 10 minutes, then 4400 IU/kg/h in 12-24 hoursBoost mode: 3000000 IU for 2 hours.

Alteplaza10 mg intravenous bolus, then 90 mg for 2 hours,or 0.6 mg/kg for 15 minutes (maximum dose of 50 mg)

• Shock phase - acute condition, with severe disturbances of hemodynamics (clinically apparent);

• The period of relative compensation of the right ventricle;

• The acute deterioration in hemodynamics, due to decompensation of the right ventricle.

Surgical treatment in these cases is accompanied by high mortality

«Wait for death to operate???»

TLT with "open eyes" TLT with "open eyes"

We support the accelerated mode of conducting TLT for dynamic control of pressure in the pulmonary artery.

TLT is effective if there is a progressive reduction of pressure in the pulmonary artery.

THROMBOLYTIC THERAPYHELPS:

THROMBOLYTIC THERAPYHELPS:

Lysis of thromboemboli (86%);

To increase the effectiveness of antishock therapy;

To increase the period of relative compensation function of the right heart;

To improve the peripheral blood flow in the pulmonary artery;

To restore the patency of the veins of systemic circulation and recurrency prevention of pulmonary embolism.

Contraindications to thrombolytic therapy

Contraindications to thrombolytic therapy

Absolute contraindications:

Hemorrhagic stroke or stroke of unknown character

Ischemic stroke for the last 6 months

A tumor of the central nervous system

Trauma or surgery (for 3 weeks)

Recent gastrointestinal bleeding (last month)

Bleeding of unknown genesis

Van de WF et al. Eur. Heart J. 2003. Vol. 24. P. 28-60.

Contraindications to thrombolytic therapy

Contraindications to thrombolytic therapy

Relative contraindications:

Transient ischemic attack for the last 6 months

Taking oral anticoagulants

Pregnancy or the postpartum period for 1 month

Puncture vessels with impossibility compression

Injury in consequence after resuscitation

Refractory hypertension

Systolic blood pressure of more than 180 mm Hg

Infectious endocarditis

Active peptic ulcer

Van de WF et al. Eur. Heart J. 2003. Vol. 24. P. 28-60.

Residual pulmonary hypertension more than 30 mm Hg requires:

Residual pulmonary hypertension more than 30 mm Hg requires:

MSCT or APG

central occlusion is indication to

surgery

(open or endovascular)

in other variants - pharmacotherapy (under the

control of the pulm.pressure)

Basic therapy(cardiac glycosides, diuretics,

anticoagulantsPhlebotonic)

Specific drugs(Sildenofil, Vasaprostan

Ventavis)

Indications for surgery(in inefficiency or inability TLT)

Indications for surgery(in inefficiency or inability TLT)

1. The pressure in the pulmonary artery > 50 mm Hg with a shock, progressive dysfunction of RV and severe arterial hypoxemia;

• 2. The existence of intracardiac tromboemboli;

• 3. Central or "mixed" localization of emboli in the pulmonary arteries.

Patiens Patiens • 81 patients with subtotal obstruction of

the main pulmonary artery or it΄s main branches were operated: 41 male, and 40 female patients;

• Mean age – 39,52 (from 17 to 83) years;

• In all cases, pulmonary embolism (PE) was determined as massive.

The algorithm of surgical treatmentThe algorithm of surgical treatment

Ppulm > 50

Central 2-sided defeat

APG, MSCT

Open embolectomy in the specialized clinic

The algorithm of surgical treatmentThe algorithm of surgical treatment

Ppulm > 50

APG, MSCT

Central and

peripheral

defeat

Open embolectomy with retrograde

perfusion

ResultsResults

Positive echocardiography dynamics to the third day of the postoperative period

before the operation after the operation

Finding the source of embolization

Finding the source of embolization

ultrasound duplex scanning

It is impossible to

predict which of

patients will develop

recurrence of PE.

You can prevent thrombotic complications

by using adequate preventive measures.

The duration of prophylaxis of thrombosis

The duration of prophylaxis of thrombosis

Diagnosis The duration of anticoagulant prophylaxis

Trauma, surgery 3 months (shin) 6 months (hip)

Idiopathic thrombosis 6 months

Relapsing course of diseaseHereditary thrombophilia, implantation cava-filter

Lifelong therapy

Oncology To eliminate the causes of the disease

ConclusionsConclusions

• TLT increases the efficiency of

antishock therapy, prolongs the period

of relative compensation function of

the right heart, improves peripheral

blood in the pulmonary arteries and

prevents recurrence of pulmonary

embolism

ConclusionsConclusions

• In 50% of cases TLT is a radical method of treatment of pulmonary embolism. And only when it is not efficient or when there are contraindications an open embolectomy is needed to be performed.

ConclusionsConclusions

• Surgical treatment is an effective method

of correction of PE and its complications.

Which leads to a complete regression of

cardio-pulmonary pathology.

Thank you

for attention !

Thank you

for attention !