About Pulmonary Embolism ‌

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What is pulmonary embolism (PE)?

Pulmonary embolism is a condition in which blood clots block the pulmonary arteries of right, left or both the lungs.
Due to the restricted blood supply to the lungs, oxygen level in the blood is reduced. Also , the pressure in the right side of the heart increases, damaging vital organs of the body like heart, liver, kidney, and the brain.
If the blood clots are multiple or large, it could prove to be fatal.
Most of the time blood clots form in the leg veins first, a condition called 'Deep Vein Thrombosis' and gradually moves up into the right heart and pulmonary arteries.

Acute pulmonary embolism

Acute pulmonary embolism is a condition in which the blood clots suddenly block the branches of the pulmonary arteries, causing severe breathing difficulties and chest pain.
Acute pulmonary embolism can be treated most of the time without surgery by using blood clot-dissolving drugs or removing the clots with the catheter inserted from the thigh vein.
Many times the symptoms of acute pulmonary embolism are mistaken for a heart attack.
Chronic pulmonary embolism, if untreated, can cause severe right heart failure called 'Cor Pulmonale'.

What is acute saddle pulmonary embolism?

Acute saddle pulmonary embolism is a condition in which a large pulmonary embolism at the pulmonary trunk straddles both right and left pulmonary artery branches. If untreated, it can be fatal.

Chronic pulmonary embolism

Most blood clots following acute pulmonary embolism over a period of time get absorbed.
However, about 5% of time, large multiple blood clots and recurrent pulmonary embolism from 'deep vein thrombosis' do not get absorbed and continue to block the blood supply to the lungs. This condition is called 'Chronic pulmonary embolism'.
If untreated, chronic pulmonary embolism leads to chronic thromboembolic pulmonary hypertension (CTEPH), resulting in gross right heart failure.
The best treatment for chronic pulmonary embolism is a surgery called Pulmonary Thrombo Endarterectomy (PTE) or Pulmonary Endarterectomy which should be done before vital organs get damaged.

Pulmonary embolism can be fatal if untreated.
Without treatment, about 30% of the cases with acute pulmonary embolism could be fatal.
However, if adequately treated, less than 8% cases could prove to be fatal.
Most of the deaths happen within the first two hours of symptoms. That is the reason why any patient with sudden chest pain or sudden breathlessness must rush to the intensive care unit irrespective of the time of the day.

Exercise regularly. If you are unable to walk, move your legs and arms at least once in an hour.
Take plenty of fluids especially water and juice.
Avoid tobacco in all forms.
Try to reduce your weight and keep it in check.
Avoid sitting cross-legged.
Avoid wearing tight-fitting clothes.

Drink plenty of water/juice.
Every hour, stand up and walk for a few minutes.
Keep changing position in your seat.
If you’re vulnerable, wear leg compression stockings.
Move the ankle and knee joints periodically while seated.

Parenteral blood thinner (anticoagulant) are given to prevent deep vein thrombosis, which can lead to pulmonary embolism.
Compression stockings can stop blood from stagnating and prevent clot formation.
Elevation of legs can help the circulation.
Early mobilisation after major surgery prevents deep vein thrombosis.
Pneumatic compression by massaging the calf muscle can improve blood supply.

Symptoms & Causes‌ ‌

What are the causes of pulmonary embolism?

Pulmonary embolism is caused by a blood clot blocking the branches of pulmonary arteries.
Almost all blood clots that cause pulmonary embolism are formed in the deep leg veins called 'deep vein thrombosis'.
Surgery or prolonged bed rest is one of the leading causes of clot formation.
Rarely, fast growing tumours, infected materials (septic pulmonary embolism), fat, air bubbles or amniotic fluid during childbirth can cause pulmonary embolism.
Heart disease, especially heart failure, predisposes to clot formation.
Certain cancers predispose to clot formation.
Patients with inherited blood clotting disorders are vulnerable. e.g. elevated levels of homocysteine.
Sitting in a cramped position for a long time during air travel can lead to clot formation.
Smoking predisposes to clot formation.
Oestrogen in birth control pills can induce clot formation.
During pregnancy, weight of the baby pressing on the pelvic vein can induce clots in leg veins. Tendency to form clots can continue even for a few weeks after childbirth.

Symptoms of acute pulmonary embolism (PE)

Breathlessness
Severe chest pain, like almost having a heart attack. Pain gets worse on coughing.
Cough, sometimes produces bloodstained sputum
Excessive sweating
Dizziness

Symptoms of chronic pulmonary embolism

Shortness of breath which gradually gets worse.
Eventually patient will need oxygen at home, even at rest.
Without treatment the patient might develop right heart failure resulting in swelling of the legs, bloating of the abdomen, liver and kidney failure.

Diagnosis & Treatment

How is a pulmonary embolism diagnosed?

Chest x-ray is done to rule out other common medical conditions like pneumonia and pneumothorax.
ECG is done to show sinus tachycardia and evidence of acute cor pulmonale or right heart strain.
D dimer test is done for acute pulmonary embolism.
CT pulmonary angiography has virtually become the gold standard to diagnose pulmonary embolism.
Cardiac catheterisation can reveal the actual pulmonary artery pressure.
Ventilation perfusion scan is done to quantify the extent of blockages.

With adequate medical treatment, nearly 95% of acute pulmonary embolism will resolve without much long-term side-effects.
Acute pulmonary embolism is treated with clot-dissolving drugs which are given intravenously in the critical care unit under intense monitoring to prevent bleeding.
All patients who had acute pulmonary embolism and all the chronic pulmonary embolism patients must be treated with anticoagulants (blood thinners) to prevent expansion of the existing blood clots and stop formation of fresh clots. Commonly used oral anticoagulants are Vitamin K antagonist and Acitrom. They need to be taken till the blood clots get absorbed and for some patients could be administered lifelong.
About 5% of the patients with acute pulmonary embolism continue to experience the symptoms due to persistent blood clots in the lungs, a condition called chronic pulmonary embolism, causing chronic thrombo embolic pulmonary hypertension (CTEPH).
The best treatment for chronic pulmonary embolism with the significant symptoms is surgical pulmonary thrombo endarterectomy (PTE).

Pulmonary Thrombo Endarterectomy (PTE)

What is pulmonary thrombo endarterectomy (PTE) surgery?

Pulmonary thrombo endarterectomy (PTE) surgery generally takes about 6 to 8 hours.
The surgery is done under general anaesthesia with a tube inside the windpipe. The chest is opened by cutting the sternal bone with a saw.
The heart is connected to a heart lung machine and the patient is cooled to 18°C to protect the brain and vital organs when the blood circulation is stopped to create a bloodless field to perform the most delicate operation.
At 18°C, blood circulation to the body and brain is stopped briefly for 15 minutes and pulmonary arteries are opened to remove all the clots. After 15 minutes, blood circulation is re-established.
Two or three times, the same cycle of arresting and restarting the circulation is done until both pulmonary arteries are cleared of blood clots with the special instruments.
Then, the body temperature is raised to 37°C and slowly the patient is weaned off the cardiopulmonary bypass.
The patient remains in the ICU on the ventilator - the time could range from a few hours to a few days.
Occasionally, some patients develop complications due to low levels of oxygen in the blood or bleeding into the lungs, requiring extra corporeal membrane oxygenation (ECMO) temporarily.
Generally, patients are fit to be discharged in about 10 to 15 days after the surgery.

About 5% of patients who had acute pulmonary embolism will continue to develop Chronic Thrombo Embolic Pulmonary Hypertension (CTEPH).
Pulmonary arteries of these patients are filled with blood clots which are often fibrotic. In the process, pulmonary artery pressure rises significantly, gradually damaging the right heart, liver, and kidneys.
If the mean pulmonary arterial pressure of these patients reaches 50 mm of Mercury or higher, the three-year mortality approaches 90% without surgery.
Pulmonary Endarterectomy is a technically challenging operation performed only in select centres across the world. Even in countries like the USA, only 300 Pulmonary Endarterectomies are performed annually.
Most of the time Pulmonary Endarterectomy virtually cures the patients suffering from severe pulmonary hypertension due to pulmonary thromboembolism.

Selection and timing of the operation requires a multidisciplinary expert team of pulmonologists, radiologists, cardiologists, cardiac surgeons, and intensivists. It is important to get the CT pulmonary angiogram with a 256-slice CT scanner to visualise the branch pulmonary arteries clearly. Also, the images of the CT scan should be interpreted by a cardiac radiologist who has extensive experience in interpreting cardiac images.
At NICS Bangalore, it is the team of experts who decide for or against pulmonary endarterectomy rather than the surgeons as the main deciding authority.
Till the time we performed the first 100 pulmonary thrombo endarterectomies, we avoided distal diseases called segmental and sub segmental diseases. Now, patients with segmental and sub-segmental diseases are operated routinely.
Earlier, we used to avoid patients with gross right heart failure who were dependent on oxygen at home and had bloated tummy due to fluid accumulation and massively swollen thighs and feet due to water collection. Now, such patients are routinely operated.
A few patients who had pulmonary thrombo endarterectomy surgery in other hospitals, but continued to have high pulmonary artery pressure due to incomplete removal of clots with the significant symptoms, underwent Pulmonary Endarterectomy for the second time (Redo PTE) successfully at our centre.
We perform pulmonary endarterectomies on HIV positive patients.
One of the main causes of mortality following pulmonary endarterectomy is bleeding. Our team has developed an innovative technique to detect and block the bleeding pulmonary artery branch at the end of the surgery. This technique was published in the prestigious annals of thoracic surgery from the USA. Across the world, many lives are saved with our technique.

Most patients are able to get back to normal life three months after the PTE surgery. In fact, a good number of them can work from home in two weeks after surgery.
Anticoagulation with Vitamin K antagonist is mandatory in all the patients after the pulmonary endarterectomy for the entire life. They need to check the blood for INR once in six weeks.
Anticoagulation tablets should never be stopped without consulting the specialist. Stopping the anticoagulation can induce fresh clots in the lungs.
Patients should drink plenty of fluids especially water and juice to keep the body well hydrated.
Avoid liquor and tobacco.
Overweight patients must lose weight.
Exercise is very important to prevent deep vein thrombosis which can lead to pulmonary embolism.

Trans-venous catheter pulmonary embolectomy for acute pulmonary embolism has been tried with limited success.
A few centres have tried pulmonary artery balloon dilatation for distal disease with mixed results.

Why choose Narayana Health for treating Pulmonary Embolism(PE) and
Chronic Thromboembolic Pulmonary Hypertension(CTEPH)

Pulmonary thromboendarterectomy (PTE) is one of the most difficult operations to master in cardiothoracic surgery. This procedure requires a long learning curve and consequently, there are less than 50 surgeons in the world who have had an experience of performing more than 500 operations, the outcomes improve with more experience. Post-operative management in patients who have had PTE is not the same as treating other post-operative cardiac surgical patients and requires intense monitoring, specialized training and experience. Many of the complications of this operation require the patient to be treated with ECMO, though most people can put a patient on ECMO, managing these patients require a lot of experience. At Narayana Health we have a cumulative experience of nearly 1,000 ECMO runs. A multidisciplinary team is involved in the evaluation of each and every patient to decide on the best way of treatment, which is known to improve the outcomes. The unpredictability of financial burden to the patient in case of complications or need for ECMO (which can far exceed the original estimate of operation cost) is offered as part of the operative package assuring predictability of expenses related to the operation. An expert centre for this disease, by definition, needs to have a volume of over 50 operations annually and be able to offer all the therapeutic options for these patients.

At present, no other hospital in the subcontinent meets the volume criteria for being an expert centre.