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. 2025 Apr 15;14(8):2704.
doi: 10.3390/jcm14082704.

Management of Hemodynamic and Respiratory Instability and Anesthetic Approaches in Patients Undergoing Pulmonary Thrombectomy for Pulmonary Embolism

Susana González-Suárez  1   2   3 , John Camacho Oviedo  4 , José Maria Suriñach Caralt  5   6 , Maria Grao Roca  2 , Isuru M Dammala Liyanage  2 , Mercedes Pérez Lafuente  4 , Elisabeth Mena Muñoz  6 , Carla González Junyent  4 , María Martínez-Martínez  7   8 , Daniel Barnés Navarro  4 , Juan Carlos Ruíz-Rodríguez  7   8
Affiliations

Management of Hemodynamic and Respiratory Instability and Anesthetic Approaches in Patients Undergoing Pulmonary Thrombectomy for Pulmonary Embolism

Susana González-Suárez et al. J Clin Med. .

Abstract

Background/Objectives: The incidence, timing, and predictors of hemodynamic and respiratory deterioration in patients with high-risk or intermediate-high-risk pulmonary embolism (PE) undergoing pulmonary mechanical thrombectomy (PMT) remain poorly understood. This hemodynamic and respiratory instability can lead to modifications in the anesthetic management. This study investigates these key factors and quantifies the 30-day mortality following thrombectomy. Methods: A retrospective study was conducted on 98 patients aged ≥18 years who underwent PMT. Patients were categorized based on the occurrence of cardiac arrest (CA). Results: Of the 98 patients, 34 had high-risk PE, 62 intermediate/high-risk, and 2 low risk. There were 27 cases of CA, 17 pre- and 10 intra-PMT. An SBP < 90 mmHg increases the risk of CA by 33 (p < 0.001); men have an 8-fold higher risk than women (p = 0.004); SpO2 <90% by 6 (p = 0.012); and pre-existing respiratory conditions increase the risk by 4 (p = 0.047)). N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were 8206 ± 11660.86 and 2388.50 ± 5683.71 pg/mL (p = 0.035) in patients with and without CA, respectively. During PMT, 14% of patients required increased vasoactive drug use, and 38.77% were intubated, including 12 who required ECMO support. Sedation was administered in 64.3% of patients, while general anesthesia was used in 38.8%, with a preemptive indication in 23.5%. The survival rate of patients without CA before and/or during PMT was 96%. Conclusions: While PMT was successfully performed in all patients, hemodynamic and respiratory instability remained a significant concern. More than 10% of patients experienced severe hemodynamic instability, primarily during thrombus extraction, requiring conversion from sedation to general anesthesia. Male sex, pre-existing respiratory disease, SpO2 < 90%, and SBP < 90 mmHg were associated with an increased risk of CA. Additionally, elevated NT-proBNP levels were linked to a higher incidence of CA.

Keywords: cardiorespiratory arrest; hemodynamic instability; hypotension; pulmonary embolism; pulmonary mechanical thrombectomy.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
NT-proBNP values and risk of cardiac arrest (CA). Box plot by CA and ROC curve for predicting CA based on NT-proBNP values. Values of sensitivity and specificity, determined by the cut-off maximizing the Youden index (dashed line), are shown. An NT-proBNP value of ≥6395 achieves the most balanced rates of false negatives and false positives. This value closely aligns with the 75th percentile of NT-proBNP levels in the non-CA group. Above this threshold, more than 50% of NT-proBNP values in the CA group are found, while only 25% of NT-proBNP values in the non-CA group exceed this level Extreme outlier is indicated by asterisk (*), while moderate outliers are indicated by small open circles (∘). ROC curve; blue line: reference line, red line: NT-proBNP. CA, cardiac arrest; non-CA, non-cardiac arrest.
Figure 2
Figure 2
Troponin values and risk of cardiac arrest (CA). Box plot by CA and ROC curve for predicting CA based on troponin values. Values of sensitivity and specificity, determined by the cut-off maximizing the Youden index (dashed line), are shown. A troponin value of ≥1173.5 achieves the most balanced rates of false negatives and false positives. Extreme outliers are indicated by asterisk (*), while moderate outliers are indicated by small open circles (∘). ROC curve; blue line: reference line, red line: troponins. CA, cardiac arrest; non-CA, non-cardiac arrest.
Figure 3
Figure 3
D-dimer values and risk of cardiac arrest (CA). Box plot by CA and ROC curve for predicting CA based on D-dimers values. Values of sensitivity and specificity, determined by the cut-off maximizing the Youden index (dashed line), are shown. A D-dimer value of ≥9212.5 achieves the most balanced rates of false negative and false positives. Extreme outlier is indicated by asterisk (*), while moderate outliers are indicated by small open circles (∘). CA, cardiac arrest; non-CA, non-cardiac arrest. ROC curve; blue line: reference line, red line: D-dimer.
Figure 4
Figure 4
Mortality in patients with cardiac arrest pre-PMT or during PMT. CA, cardiac arrest; PMT, pulmonary mechanical thrombectomy.
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