• Recent major trauma or operation (within 10 days)

• Recent cerebrovascular accident (within 2 months)

• Bleeding diathesis

• Active internal bleeding Relative

• Prolonged cardiopulmonary resuscitation

• Diabetic proliferative retinopathy fragmentation, transvenous catheter embolectomy, or surgical embolectomy.33 Insertion of an inferior vena caval filter should be considered in the presence of active haemorrhage to prevent further potentially fatal embolism. Surgical embolectomy may be appropriate in the setting of an experienced cardiovascular surgical unit. It should be reserved for severely compromised patients in refractory cardiogenic shock or patients requiring intermittent resuscitation.39 To be effective it must be performed as soon as possible. Total perioperative mortality is approximately 30%, with the highest mortality rates (~60%) in those patients who require preoperative cardiopulmonary resuscitation.40 41 An approach to the treatment of a patient with massive PE is shown in fig 14.2. In this setting, it is vitally important that chronic thromboembolic disease is excluded as the treatment of these two conditions is vastly different. Attempted surgical embolectomy (as opposed to pulmonary endarterectomy) in a patient with chronic thromboembolic PHT is fraught with disaster.

For patients with chronic thromboembolic PHT, the treatment of choice is pulmonary endarterectomy. In experienced hands this procedure results in a sustained reduction in pulmonary pressures and RV remodelling.43 Within the UK, Papworth Hospital is the National Specialist Commissioning Advisory Group (NSCAG) designated centre for pulmonary endarterectomy.

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