Seminars in vascular surgery
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The management of acute massive pulmonary embolism (PE) constitutes a major clinical problem because of the associated derangement of hemodynamic and respiratory functions from obstruction to pulmonary blood flow. Despite advances in management with thrombolytic therapy or open embolectomy, the mortality rate remains high. To improve the chance of survival, catheter techniques that are capable of removing or fragmenting the clot have been developed. ⋯ The overall success rate is approximately 76%, with a mortality rate of 25%. Transvenous pulmonary embolectomy and thrombofragmentation are safe and effective techniques for treating patients with massive PE. The success of each of the techniques depends on a thorough understanding of the mechanism of action of each of the devices used and a facile catheterization technique.
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Thrombolytic therapy for pulmonary embolism can rapidly reverse right ventricular failure and reduce mortality and morbidity among appropriately selected patients. Individuals being considered for this treatment should be screened for potential major bleeding problems, which, if present, should lead to alternative management with catheter or surgical embolectomy. There is no ideal thrombolytic agent; nor have indications for thrombolysis been precisely defined. Available data indicate that patients with moderate or severe right ventricular dysfunction gain the most from this pharmacologic strategy.