1. Surgical Techniques of Pulmonary Embolectomy for Acute Pulmonary Embolism 
Pankaj Saxena, FRACS, PhD, Hassiba Smail, MD, David C. McGiffin, FRACS 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 21, Issue 2, Pages (June 2016)
DOI: /j.optechstcvs
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2. Figure 1
Once a clinical decision has been made to proceed to pulmonary embolectomy, the patient should be expeditiously transferred to the operating room (OR). Patients with massive PE are probably best placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support prior to transfer to the OR to avoid the inevitable precipitous and perhaps chaotic anesthetic induction and institution of cardiopulmonary bypass (CPB). Although, by definition, the circulation is maintained in patients with high-risk submassive PE, circulatory collapse is an ever-present possibility, and preparations for rapid anesthetic induction and expeditious median sternotomy and institution of CPB should be made. This usually includes prepping and draping as well as securing the lines on the table for CPB before anesthetic induction. Both groins are kept in the sterile field to facilitate the institution of ECMO if required. Intraoperative transesophageal echo (TEE) provides valuable information regarding RV dilatation or dysfunction; LV function; presence of thrombus in the right atrium (RA) or right ventricle, or a paradoxical embolus in transit; or presence of a patent foramen ovale (PFO) or atrial septal defect (ASD). A median sternotomy incision is used and pericardial stays are placed. Ascending aortic and bicaval cannulation with caval tapes is used. A mild degree of systemic hypothermia or normothermia is used for CPB. In the classic technique, the ascending aorta is not clamped unless an intracardiac defect such as a PFO or ASD requires repair. Intracardiac thrombus from the right atrium or right ventricle can be removed without cross clamping if there is no interatrial communication.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 80-88DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

3. Figure 2
A longitudinal incision is made in the main pulmonary artery (MPA) and extends out onto the left pulmonary artery (PA). Stay sutures of 5-0 polypropylene are placed on the edges of the arteriotomy. A sump sucker is used to improve visualization of the interior of the PAs. Russian forceps or Desjardin gall stone forceps is used to remove the pulmonary emboli. Application of gentle pressure to the forceps holding the clot during retrieval facilitates their complete removal. Desjardin forceps are available in different angles and are useful in navigating the pulmonary arterial lobar and segmental branches for removal of clot material lodged distally. The use of a Fogarty embolectomy catheter (Edwards Lifesciences, Irvine, CA) or a Foley catheter that can be passed into the distal PA through the arteriotomy has been described. Reducing the cardiopulmonary bypass (CPB) flows during the retrieval of distal clots improves visibility. Copious irrigation with saline of PAs is carried out, and the clot material is sucked out using a Yankauer sucker tip attached to the wall suction.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 80-88DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

4. Figure 3
A separate incision in the right pulmonary artery (RPA) is used commonly to remove clots from the RPA and right pulmonary segments. This requires mobilization of the ascending aorta from the proximal RPA and from the superior vena cava (SVC). Traction on the SVC tape to the patient's right side and using a tape around the ascending aorta and placing it on tension toward the patient's left side improves the exposure. A self-retaining Weitlaner retractor with blunt ends of the retractor or ends covered with shods may be used to retract the ascending aorta from the SVC. A longitudinal incision in the proximal part of the RPA is made, which can be extended into the interlobar artery. Loose clots can be found inside the lumen of RPA or there might be an extension of clot from the main pulmonary artery (MPA) which might be adherent to the intima. This incision is the same as the one used for pulmonary endarterectomy (PEA). Incisions in the pulmonary arteries (PAs) are closed with a double layer of running 5-0 polypropylene suture.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 80-88DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

5. Figure 4
There is another strategy for performing pulmonary embolectomy that is used routinely by the senior author of this paper (DCM). Moderate systemic hypothermia, cardioplegic arrest and separate incisions in the right pulmonary artery (RPA) and left pulmonary artery (LPA) (as for pulmonary endarterectomy [PEA]), low flow cardiopulmonary bypass (CPB) to improve visualization and exploration, and clearance of all segmental and subsegmental branches are used. The rationale for this approach is that any concerns regarding the cardioplegic arrest of an injured right ventricle are offset by a more thorough clearance of thrombus from the pulmonary vasculature.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 80-88DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

6. Figure 5
Free-floating thrombus in the right atrium (RA) or right ventricle is removed by an incision in the RA free wall. Thrombus may be seen protruding into the RA from the abdominal inferior vena cava (IVC) alongside the IVC cannula. Thrombus in the abdominal IVC can be removed by temporarily clamping and removing the IVC cannula, and under low flow cardiopulmonary bypass (CPB) exploring the abdominal IVC through the RA. If it is known preoperatively that thrombus is straddling the IVC-RA junction, femoral venous cannulation can be used for CPB. If a paradoxical embolus in transit is present, it is removed through the RA and left atrium incisions following cardioplegic arrest.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 80-88DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

7. Figure 6
Generally, the above techniques help retrieve most of the thrombus from the pulmonary circulation. Retrograde pulmonary vein flush may help to remove the thrombus which has lodged distally. This technique requires opening the left atrium (LA) via a classic approach or transeptal incision if the right atrium (RA) has been opened. A Foley catheter is passed into each pulmonary vein orifices, the balloon is inflated with 5 cc of saline, and saline is then injected into the lumen of the catheter to dislodge the thrombi retrogradely, which are retrieved through the pulmonary artery (PA) incisions. Alternatively, the Foley catheter can be connected to the pump, and oxygenated blood is infused into each pulmonary vein orifice for 1-2 minutes, maintaining pressure <40 mm Hg.2,3 Ventilation of the lungs during this maneuver may help to dislodge the thrombi. PV = pulmonary vein; LIPV = left inferior pulmonary vein.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 80-88DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

8. Figure 7
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may have been instituted in patients who are in cardiogenic shock prior to arrival to the operating room (OR). This helps transfer the patient to the OR safely, and the circuit can be converted to cardiopulmonary bypass (CPB) for performing pulmonary embolectomy. Options for mechanical support of the dysfunctional right ventricle following discontinuation of CPB include VA-ECMO via the femoral vessels or a temporary right ventricular assist device (RVAD) with inflow from a cannula in a femoral vein and outflow through a cannula inserted into a Dacron graft anastomosed to the main pulmonary artery (MPA).4
Operative Techniques in Thoracic and Cardiovascular Surgery  , 80-88DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions