pulmonary embolectomy

As early as 1908, Trendelenberg proposed the use of pulmonary embolectomy for pulmonary embolism. In 1924, Kirschner had successfully performed one case, but due to the level of understanding and technical conditions at that time, most patients in repeated practice in the future. Became a failure. In 1961, Sharp and Cooley succeeded in the successful removal of pulmonary emboli in the extracorporeal circulation. After that, Lewis and Clarke also succeeded in performing the operation under the simple blocking cycle. As for various transvenous interventional pulmonary embolectomy procedures, the technology and understanding have not been consistent, and it has not been widely applied. Treatment of diseases: pulmonary embolism Indication Concerning the treatment of pulmonary embolism surgery, there has been no disagreement so far. Some people think that about 2/3 of patients with pulmonary embolism die within 2 hours after the onset of illness. It is difficult to send the patient to a conditional hospital in such a short time and determine the diagnosis. It is difficult to decide to perform surgery. In the early stages of this crisis, there are many possibilities for rescue under active medical treatment. Therefore, surgical treatment is considered to have no status in this disease. Those who are positive believe that emergency surgery can make part of the hopeless, even patients who have had cardiac arrest, resurrected. In patients who continue to deteriorate under medical treatment, there is no other way to save them. Moreover, medical treatment, especially thrombolytic therapy, also has contraindications. Therefore, it is considered that the value of surgical emboli is still used. Moreover, patients who do not have severe circulatory dysfunction should undergo surgery, the so-called prophylactic embolectomy. In summary, pulmonary embolectomy is a rescue operation. There is no mature and unified format for the decision of surgery. Each patient must be carefully analyzed, treated differently, and the advantages and disadvantages and risks of surgery should be weighed comprehensively. Make a decision. In general, surgery should be performed in one of the following situations: 1. Obvious circulatory breathing disorder: blood pressure <90mmHg, urine volume <20ml per hour, arterial oxygen partial pressure <60mmHg, and there is no improvement in the positive treatment after about 1h. 2. Thrombolysis treatment failed to achieve early results (short-time thrombolysis before surgery does not increase the risk of surgical bleeding). 3. Thrombolytic therapy has contraindications (active gastrointestinal bleeding; recent brain and spinal cord trauma, surgery; brain tumors; liver and kidney dysfunction; coagulation mechanism disorders; recent childbirth or major surgery, etc.). 4. Pulmonary angiography showed that the extent of pulmonary artery occlusion was more than 50%. 5. Sudden cardiac arrest due to pulmonary embolism, emergency surgery. Contraindications The diagnosis was not established, especially when acute myocardial infarction was not clearly identified. Preoperative preparation 1. It is generally necessary to make a pulmonary angiography and/or lung scan to determine the diagnosis and to understand the location and extent of the embolus. However, patients who have been diagnosed with deep venous thrombosis in the lower extremities, or who are unable to perform angiography in a situation, may be relieved after partial extracorporeal diversion. 2. Intravenous infusion of isoproterenol 0.5 ~ 5g / min, in order to improve cardiac output, the drug also reduces pulmonary vascular resistance and relieve bronchospasm in large pulmonary embolism. 3. Enter the colloidal solution to dilate blood volume to increase blood pressure. 4. High concentration of oxygen inhalation to increase arterial oxygen partial pressure. Surgical procedure 1. Emergency part of extracorporeal circulation: in severe shock, respiratory and circulatory function has been difficult to maintain vital organs or oxygen has been stopped, emergency part of the flow must be urgently to improve circulation and blood oxygenation. Because the blood can not fully flow into the pulmonary artery for oxygenation, all other resuscitation measures will not be effective, and the heartbeat has been stopped, and can be performed while the other group is doing cardiac resuscitation. The thigh is slightly externally rotated, starting from the upper part of the inguinal ligament, along the femoral artery and vein, and making a 10 cm long longitudinal incision to the distal side, dissecting the femoral artery and vein and temporarily blocking the proximal and distal wrap around the block. Blood flow. The femoral vein was cut transversely to half of the circumference, and the F32-36 intravenous catheter with a side hole was inserted, and the proximal side was inserted into the inferior vena cava, the blocking band was tightened, and the catheter was fixed. The femoral artery was cannulated with a catheter of suitable caliber, and the tip of the catheter was placed in the common iliac artery. Partial diversion begins after heparinization. When the flow rate is only 1000ml/min, the patient's condition will be significantly improved, and the general anesthesia can be intubated at this time. 2. The midline incision of the chest, open the sternum, reveal the heart, and establish extracorporeal circulation as usual. Blocking the ascending aorta with coronary artery cardioplegic perfusion and myocardial local cooling arrest. Patients who have undergone partial bypass may not have aortic and inferior vena cava intubation, and only block the aorta and vena cava to establish complete extracorporeal circulation. 3. The longitudinal incision of the anterior wall of the pulmonary artery was made about 2 cm above the pulmonary valve annulus. After the incision was taken, the common bile duct stone clamp or small sponge forceps were inserted into the bilateral pulmonary artery to remove the embolus and blood clot. 4. Cut the bilateral pleural cavity, squeeze the lungs by hand to help the discharge of deep emboli, or use the Fogarty balloon catheter to extend into the bilateral pulmonary artery to pull out the remaining emboli. Cut the right atrium and right ventricle, check for emboli or wall thrombus and blood clots that remain in the heart chamber, remove them, and rinse the heart chamber. 5. Continuously suture the pulmonary artery incision with a 4-0 polypropylene thread. The right atrium and right ventricular incision were sutured. 6. Auxiliary flow, gradually reduce the perfusion flow, and stop after the cycle is stable. 7. Conventional drainage and suturing the incision such as the chest. complication 1. ARDS: The alveolar epithelium and alveolar-capillary membrane are damaged due to severe shock before surgery, hypoxia, ischemic damage to the embolized lung, and serotonin and other fluid substances such as serotonin. The reperfusion injury, the incidence of postoperative ARDS is above 10%. 2, pulmonary hemorrhage: pulmonary hemorrhage may occur in the operation and early postoperative period, and even because of the large amount of bleeding can not be controlled, becoming the second main cause of postoperative death.

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