J Extra Corpor Technol 2025, 57, 171--173 Ó The Author( s), published by EDP Sciences, 2025 https:// doi. org / 10.1051 / ject / 2025024 Available online at: ject. edpsciences. org CASE REPORT
Pulmonary thrombectomy and extracorporeal membrane oxygenation: a case study
Mariah DeRenzo( MCPS) * Emory University Perfusion Program, Emory University, Atlanta GA 30322, USA Received 29 January 2025, Accepted 20 May 2025
Abstract – A 71-year-old male with a history of chronic thromboembolic pulmonary hypertension scheduled for an elective pulmonary thrombectomy was removed from the surgical list in 2019 for unknown reasons. Four years later, a different surgeon elected to perform the surgery with cardiopulmonary bypass support. Following surgery, the patient was placed on extracorporeal membrane oxygenation and ultimately died. This case report highlights the surgical and perfusion techniques, as well as the rare events that occurred during his care.
Key words: Cardiopulmonary bypass( CPB), Pulmonary thrombectomy( PTE), Extracorporeal membrane oxygenation( ECMO).
Introduction
Pulmonary thrombectomy( PTE) or pulmonary endarterectomy is a surgical procedure used to remove blood clots or fibrous tissue from the pulmonary vasculature. Chronic thromboembolic pulmonary hypertension( CTEPH) is the most common cause of precapillary pulmonary hypertension. CTEPH is characterized by a mean pulmonary pressure greater than 25 mmHg at rest and a pulmonary wedge pressure above 15 mmHg [ 1 ]. A patient with a mean pulmonary artery pressure above 50 mmHg has a three-year mortality rate of 90 % [ 2 ]. Currently, PTE is the only potentially curative measure for the treatment of CTEPH. PTE procedures are rare as they require a high level of surgical skill. Currently, the University of California, San Diego Hospital( UCSD) is the top center for the procedure and has performed 4800 PTEs since 1987, with a mortality rate of 1 % [ 3 ]. As of 2018, the national average of PTE procedures was 300 per year [ 2 ].
The surgical procedure includes placing the patient on cardiopulmonary bypass support, cooling to profound hypothermia [ 14--20 ° C ], followed by circulatory arrest, and excision of the fibrous tissue from each pulmonary artery [ 2 ]. The length of these procedures is approximately 4--6 h [ 4 ].
The most common causes of death post-operatively are right ventricular failure and reperfusion pulmonary edema [ 1 ]. Thus, some patients require initiation of extracorporeal membrane oxygenation( ECMO) as a bridge-to-recovery [ 1 ]. However, mortality associated with ECMO in this population is high, with a 30-65 % survival rate [ 1 ]. Pulmonary hemorrhage is documented in 2 % of cases [ 5 ]. ECMO is used in rare cases
* Corresponding author: mariah. joyd @ gmail. com of pulmonary hemorrhage to offload the blood flow to the lungs.
Case description
A 71-year-old male with a history of CTEPH was diagnosed with a pulmonary embolism in 2019. The patient was recommended to undergo a PTE surgical procedure to alleviate his pulmonary hypertension in 2021. However, for unknown reasons, he was dropped from the surgical list. Results of cardiac catheterization revealed the following: Ejection fraction 65--70 %, right atrial 16 / 13 mmHg( mean 14 mmHg), right ventricular( RV) pressure 76 / 12 mmHg, pulmonary artery( PA) pressure 76 / 27 mmHg( mean 43.3 mmHg), pulmonary wedge pressure 24 mmHg, and a cardiac output of 7.38 L / min. His baseline blood pressure was 139 / 71 mmHg, heart rate of 84 bpm, temperature of 36.6 C, respiratory rate of 18 breaths / min, and SaO 2 of 85 %. The patient was 178 cm tall and weighed 102kgwithaBSAof2.2m 2.
During the pre-incision time-out, cannulation and surgical strategy were discussed. The team agreed on central cannulation with a 22 Fr EOPA arterial cannula, a 28 Fr DLP singlestage for the superior vena cava( SVC), and a 29 Fr 3-stage MC2X™ Three Stage Venous Cannula for femoral cannulation EOPA( Medtronic, USA). The conduct of anesthesia was at the discretion of the attending anesthesiologist using narcotic and inhalation agents. Target mean arterial blood pressure and heart rate were maintained within ± 20 % of mean baseline values. Hemodynamic control was provided by modification of the concentration of anesthetic agents, intravenous vasoactive drugs, and volume repletion [ 6 ].
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