Improved midterm outcomes for type A (central) pulmonary emboli treated surgically

Objectives: We propose a simplified anatomic classification for pulmonary emboli that algorithmically differentiates those who might be best treated with surgical pulmonary embolectomy (type A) from those best treated medically (type B). We hypothesized that patients with type A pulmonary emboli treated with immediate surgical embolectomy demonstrate superior long-term survival compared with patients with type A pulmonary emboli treated medically.

Methods: Patients admitted between 2002 and 2008 with a diagnosis of pulmonary emboli made based on computed tomographic angiographic imaging (n = 779) were analyzed. Computed tomographic angiographic images were reviewed in a blind fashion, and anatomic classification of emboli was made. Patients with central thrombus, defined by location medial to the lateral mediastinal boundaries (ie, involving the main, primary, or both branch pulmonary arteries), were classified as having type A pulmonary emboli (n = 107), whereas those with peripheral pulmonary emboli located beyond these boundaries were classified as having type B pulmonary emboli (n = 672). Four patients with type A pulmonary emboli treated with catheter embolectomy were excluded from the analysis.

Results: Of the 103 patients with type A pulmonary emboli, 15 (14%) were treated with immediate surgical pulmonary embolectomy, and 88 (85%) were treated medically. Patients with type A pulmonary emboli treated surgically had similar 30-day mortality compared with those treated medically (13% vs 17%, P = .532). At a mean of 24 ± 18 months' follow-up (range, 1-82 months), survival at 1, 3, and 5 years for patients with type A pulmonary emboli treated surgically was significantly better than that in the patients with type A pulmonary emboli treated medically (P = .0001).

Conclusions: For patients with type A pulmonary emboli, immediate surgical intervention appears to offer superior midterm survival compared with medical treatment alone. Although the medical and surgical groups were substantially different and the differences might have affected survival, this simplified classification for pulmonary emboli might help direct optimal treatment strategies.