Intraoperative circulatory arrest secondary to high-risk pulmonary embolism. Case series and updated literature review

Abstract

Background: Intraoperative pulmonary embolism (PE) with cardiac arrest (CA) represents a critical and potentially fatal condition. Available treatments include systemic thrombolysis, catheter-based thrombus fragmentation or aspiration, and surgical embolectomy. However, limited studies are focused on the optimal treatment choice for this critical condition. We present a case series and an updated review of the management of intraoperative CA secondary to PE.

Methods: A retrospective review of patients who developed high-risk intraoperative PE was performed between June 2012 and June 2022. For the updated review, a literature search on PubMed and Scopus was conducted which resulted in the inclusion of a total of 46 articles.

Results: A total of 196 174 major non-cardiac surgeries were performed between 2012 and 2022. Eight cases of intraoperative CA secondary to high-risk PE were identified. We found a mortality rate of 75%. Anticoagulation therapy was administered to one patient (12.5%), while two patients (25%) underwent thrombolysis, and one case (12.5%) underwent mechanical thrombectomy combined with thrombus aspiration. Based on the literature review and our 10-year experience, we propose an algorithm for the management of intraoperative CA caused by PE.

Conclusion: The essential components for adequate management of intraoperative PE with CA include hemodynamic support, cardiopulmonary resuscitation, and the implementation of a primary perfusion intervention. The prompt identification of the criteria for each specific treatment modality, guided by the individual patient's characteristics, is necessary for an optimal approach.

Keywords: Anticoagulation; Cardiac Arrest; High-risk; Intraoperative; Pulmonary Embolism; Thrombolysis. Surgical embolectomy.

Fig. 1

Process of article selection

Fig. 2

Diagnosis and treatment of intraoperative cardiac arrest with suspected high-risk pulmonary embolism IOP: intraoperative, CA: cardiac arrest, PE: pulmonary embolism, TEE: transthoracic echocardiogram, TEE: transesophageal Echocardiogram, PERT: pulmonary embolism response team, ROSC: Return of Spontaneous Circulation, CPR: cardiopulmonary resuscitation, ECMO: extracorporeal membrane oxygenation, CTA: computed tomography angiography, CI: contraindication, AC: anticoagulation *High support: norepinephrine > 0.2ug/kg/min and vasopressin > 0.04 UI/min *Low support: norepinephrine < 0.2ug/kg/min and/or vasopressin < 0.04 UI/min