Trombolitik Kontrendike Masif Pulmoner Embolide Embolektomi Olgusu
Özet
Bu bölüm, trombolitik tedavinin kontrendike olduğu masif pulmoner emboli (PE) olgusunda cerrahi embolektomi yaklaşımını, güncel literatür ve yoğun bakım perspektifi eşliğinde ele almaktadır. Pulmoner embolinin epidemiyolojisi, risk faktörleri, klinik bulguları ve ESC kılavuzlarına dayalı risk sınıflaması ayrıntılı biçimde sunulmakta; özellikle sağ ventrikül disfonksiyonu, biyobelirteçler ve hemodinamik instabilitenin prognozdaki rolü vurgulanmaktadır. Tanısal algoritmada CTPA, ekokardiyografi ve kritik hastada POCUS’un yeri tartışılmaktadır. Yüksek riskli PE’de organ desteği, oksijen tedavisi, sıvı yönetimi ve vazopresör kullanımı gibi yoğun bakım stratejileri açıklanmakta; antikoagülasyon ve fibrinoliz endikasyonları gözden geçirilmektedir. Trombolizin kontrendike olduğu veya başarısız kaldığı durumlarda cerrahi embolektomi, VA-ECMO ve kateter-yönlendirmeli tedaviler gibi alternatif reperfüzyon yöntemleri değerlendirilmiştir. Sunulan olgu, spinal cerrahi sonrası gelişen ve fibrinoliz uygulanamayan masif PE’de başarılı cerrahi embolektomi ile klinik iyileşmeyi göstermektedir. Bölüm, kritik PE yönetiminde multidisipliner yaklaşımın önemini vurgulamaktadır.
This chapter presents the management of massive pulmonary embolism (PE) when thrombolytic therapy is contraindicated, focusing on a case treated with surgical embolectomy. Epidemiology, risk factors, and ESC-based risk stratification are reviewed, with particular emphasis on right ventricular dysfunction, biomarkers, and hemodynamic instability as key prognostic determinants. The diagnostic approach highlights the roles of CTPA, echocardiography, and point-of-care ultrasound in critically ill patients. Intensive care strategies—including oxygen support, fluid management, vasopressor use, and organ support—are discussed in the context of high-risk PE. The indications and limitations of anticoagulation and fibrinolysis are outlined, followed by alternative reperfusion strategies such as surgical embolectomy, VA-ECMO, and catheter-directed therapies. The presented case illustrates successful surgical management of massive PE in a patient with recent spinal surgery, where thrombolysis was contraindicated. The chapter underscores the importance of rapid risk stratification, timely reperfusion decisions, and a multidisciplinary PE response approach in critically ill patients.
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