Case Of Fatal Pulmonary Embolism Research Articles

Fatal pulmonary embolism related to anti-psychotics: forensic implications. About four autopsy cases with review of the literature

IntroductionThe association between the intake of antipsychotic drugs and the occurrence of thromboembolic complications is widely described in the literature. The occurrence of this complication may call into question the medical responsibility of the attending physician.ObjectivesThe objective of this work is to describe the physiopathological mechanisms involved in the occurrence of thromboembolic complications in a patient under antipsychotic treatment, whether or not associated with physical restraint and to discuss the forensic implications.MethodsOur study is retrospective on cases of fatal pulmonary embolism, discovered at autopsy, in connection with the taking of antipsychotics. The autopsies were carried out in the Department of Forensic Medicine of the Tahar Sfar University Hospital in Mahdia. The cases were collected over a period of 04 years. A review of the literature was carried out. We only selected articles published until February 2021 and dealing with cases of patients on antipsychotics, diagnosed with pulmonary embolism by performing a chest CT scan or during an autopsy.Results915 autopsy cases were performed during the study period. Twenty cases of pulmonary embolism, discovered at autopsy, were collected. Four cases were related to the taking of antipsychotics (incidence 0.004%), including two men and two women, aged between 25 and 52 years. They were all on antipsychotic treatment for at least 5 years, with the exception of one case who was put on 3 antipsychotics, 7 days before his death, with indication of physical restraint. After analysis of the memorial data, the external examination and the autopsy, the results of additional examinations, the death was attributed, in the 4 cases, to a massive fibrino-cruoric pulmonary embolism. A selection of 45 studies regarding thromboembolic complications associated with taking antipsychotics, was included in the final review.ConclusionsThe reported cases provided additional evidence on the involvement of antipsychotics in the occurrence of thromboembolic complications. Psychiatrists should be careful when prescribing these treatments. The establishment of therapeutic guidelines, taking into account the thromboembolic risk factors, becomes essential, in order to avoid the occurrence of a complication which could engage both the vital prognosis of patients and the responsibility of the physician.Disclosure of InterestNone Declared

Death from Pulmonary Embolism Caused by Vaginal Injection of Hyaluronic Acid: a Case Report and a Literature Review.

A 40-year-old woman underwent vaginoplasty with intramural injection of fillers from an illegal medical practitioner. Approximately 2 h after the injection, she developed lower abdominal pain. The patient was taken to the hospital approximately 5 h later due to worsening pain. When the patient was admitted for physical examination, she suddenly experienced cardiac and respiratory arrest. She was resuscitated but remained in a coma. Unfortunately, the patient died approximately 12 h after being admitted to the hospital. The forensic autopsy revealed extensive amorphous basophilic emboli in the small interstitial vascular lumen of both lungs, and a large amount of the same type of substances were also found in the vaginal wall. Hyaluronidase digestion and Alcian blue staining confirmed that most components of the injection were hyaluronic acid (HA). HA is widely used as a cosmetic filler in the field of plastic surgery and is generally considered to have few adverse effects. This paper reports the first anatomical case of fatal pulmonary embolism caused by vaginal injection of HA. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

8-year follow-up of a successful outcome of massive pulmonary embolism with cardiogenic shock

Currently pulmonary embolism (PE) is already on the 3rd place in terms of the frequency of occurrence among vascular diseases, and there is a global trend towards an increase in its frequency. PE is also considered as the most common cause of preventable death in the hospital. In the countries of Europe, Asia and the USA, there is a tendency to reduce the cases of fatal PE due to the use of more effective conservative therapy, invasive interventions and following the Recommendations. Since 2019, the European Guidelines for the diagnosis and treatment of PE have made the use of direct oral anticoagulants preferable in comparison with oral vitamin K antagonists.A case of massive PE in a 42-year-old patient developed in the specialized department of the hospital shortly after being transferred from the intensive care unit with verified PE of small branches (D-dimer, lung scintigraphy, Echo-cardiography) is presented. The debut of a massive PE in the form of a syncopal state with cardiogenic shock, required an urgent transfer of the patient to artificial lung ventilation, the use of vasopressors and systemic thrombolysis. During Echo-cardiography, a mobile blood clot was located in the right atrium. An emergency thrombectomy was performed from the pulmonary trunk and pulmonary arteries in conditions of artificial blood circulation, later a cava filter was installed. The features of anamnesis characteristic of PE (hormonal contraceptives), complaints (sudden shortness of breath, heaviness behind the sternum at admission) and concomitant pathology (drug-induced thyrotoxicosis) are analyzed.The results of the subsequent 8-year follow-up without relapses of PE are considered, the feature of which was the use of Rivaroxaban as an anticoagulant and angiovit (B vitamins – 6, 9 and 12) for the correction of hereditary hyperhomocysteinemia. Risk factors and modern standards of treatment of massive PE in the acute period and in the long term are discussed.

AB212. SOH21AS262. Venous thromboembolism prophylaxis in orthopaedic surgical admissions at Beaumont Hospital

Background: Orthopaedic surgery patients have long been recognized to be at increased risk of venous thromboembolism (VTE). VTE is a significant cause of mortality, long-term disability and chronic ill-health. VTE is considered internationally to be a silent killer with fewer than 1 in 10 fatal cases of pulmonary embolism diagnosed before death. In the UK, the cost of treating non-fatal symptomatic VTE and associated long-term disability is around £640 million per year.

Venous thromboembolism in patients with adrenocortical carcinoma after surgery.

Background:Adrenocortical carcinoma is a rare malignancy with a poor prognosis. We hypothesized that patients with adrenocortical carcinoma are at high risk for venous thromboembolism, given the numerous risk factors such as malignancy, abdominal surgery, immobility and hormonal excess. The aim of this study was to determine retrospectively the incidence of venous thromboembolisms after surgical treatment in patients with adrenocortical carcinoma.Materials and methods:A retrospective study was performed, collecting data from all patients diagnosed with adrenocortical carcinoma from 2003 to 2018 at the Radboud University Medical Centre, The Netherlands.Results:In 34 patients, eight postoperative venous thromboembolisms, all pulmonary embolisms, were diagnosed in the first 6 months after adrenalectomy (23.5%). In addition, one patient developed pulmonary embolism just prior to surgery and one patient 7 years after surgery. Five of the eight patients with postoperative venous thromboembolisms presented with symptomatic pulmonary embolism whereas the other three pulmonary embolisms were incidentally found on regular follow up CT scans. Seven of the eight venous thromboembolisms occurred within 10 weeks after surgery. Seven of the eight patients had advanced stage adrenocortical carcinoma and four patients already received low-molecular weight heparin during the development of the venous thromboembolism. There was one case of fatal pulmonary embolism in a patient with a cortisol producing tumor with pulmonary metastases, despite the use of a therapeutic dose thromboprophylaxis.Conclusion:Patients with adrenocortical carcinoma are at high risk of developing postoperative venous thromboembolisms. Prolonged postoperative thromboprophylaxis could be considered in these patients.

Use of Prophylaxis for Prevention of Venous Thromboembolism in Patients with Isolated Foot or Ankle Surgery: A Systematic Review and Meta-Analysis.

Although prophylaxis for venous thromboembolism (VTE) is recommended after many surgeries, evidence base for use of VTE prophylaxis after foot or ankle surgery has been elusive, leading into varying guidelines recommendations and notable practice variations. We conducted a systematic review of the literature to determine if use of VTE prophylaxis decreased the frequency of subsequent VTE, including deep vein thrombosis (DVT) or pulmonary embolism (PE), compared with control. We searched PubMed, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov through May 2018, for randomized controlled trials (RCTs) or prospective controlled observational studies of VTE prophylaxis in patients undergoing foot and ankle surgery. Our search retrieved 263 studies, of which 6 were finally included comprising 1,600 patients. Patients receiving VTE prophylaxis had lower risk for subsequent DVT (risk ratio [RR]: 0.72; 95% confidence interval [CI]: 0.55-0.94) and subsequent VTE (RR: 0.72; 95% CI: 0.55-0.94). There was only one case of nonfatal PE, no cases of fatal PE, and no change in all-cause mortality (RR: 3.51; 95% CI: 0.14-84.84). There was no significant difference in the risk for bleeding (RR: 2.12; 95% CI: 0.53-8.56). Very few RCTs exist regarding the efficacy and safety of VTE prophylaxis in foot and ankle surgery. Prophylaxis appears to reduce the risk of subsequent VTE, but the event rates are low and symptomatic events are rare. Future studies should determine the subgroups of patients undergoing foot or ankle surgery in whom prophylaxis may be most useful.

Inferior Vena Cava Filter Malpractice Litigation: Damned if You Do, Damned if You Don't

The aim of this study was to analyze malpractice litigation trends and to better understand the causes and outcomes of suits involving inferior vena cava filters (IVCF) to prevent future litigation and improve physician education. Jury verdict reviews from the Westlaw database from January 1, 2000, to December 31, 2015, were reviewed. The search term "inferior vena cava filter" was used to compile data on the demographics of the defendant, plaintiff, allegation, complication, and verdict. A total of 156 cases were identified. Duplicates and cases in which the IVCF was incidentally included were excluded from the analysis. Forty-nine cases involving either failure to place or a complication of IVCF placement were identified. Throughout the last 15years, there has been increased number of jury verdicts toward IVCF. The most frequent defendants were internal medicine physicians (38%), vascular surgeons (19%), and cardiothoracic surgeons (12%). The most frequent claims were denied treatment or delay in treatment (in 35% of cases), negligent surgery (in 24% of cases), and failure to diagnose and treat complications (in 24% of cases). Of these, the most frequent specific claims were failure to place IVC filter (41%), implantation failure such as misplacement and/or misaligned implant (24%), erosion of IVC/retroperitoneal bleed (6%), and discontinuation of anticoagulation prematurely (6%). Seventeen cases (35%) were found for the plaintiff, with median awards worth of $1,092,500. In the 21 cases where pulmonary embolism (PE) was involved (43% of cases), 19 were fatal (90%). Of the fatal PE cases, 8 cases ended with verdicts in favor of the plaintiff (42%). Both nonfatal PE cases were won by the defense. IVCF placement with subsequent PE and death results in verdicts that favor the plaintiffs. This study emphasizes that adequate and transparent communication regarding preoperative planning, decision for IVCF placement, and informed consent may reduce the frequency of litigation. Public awareness of complications related to the placement of IVCF is increasing largely and spurned by aggressive advertising and marketing by plaintiff attorneys. Conditions for which IVCF placement is contemplated carry significant risk of malpractice litigation.

Predicting the risk of recurrent venous thromboembolism in patients with cancer: A prospective cohort study

BackgroundThe risk of recurrent venous thromboembolism (VTE) in cancer patients despite anticoagulant therapy is high. Clinical factors and pro-coagulant markers may identify high-risk patients and guide decisions about intensifying anticoagulation therapy. AimsTo evaluate whether serial measurements of pro-coagulant markers can identify patients at high risk of recurrent VTE. MethodsIn this multicenter, prospective cohort study, patients with active cancer and acute deep vein thrombosis or pulmonary embolism were enrolled. Patients received standard low-molecular-weight heparin therapy and were followed for 6 months. D-dimer and soluble P-selectin levels were measured at baseline and 1, 4, 5, 12, and 24 weeks post treatment initiation. The association between recurrent VTE and a previously developed risk score, baseline values of the biomarkers, and individual relative changes from baseline were assessed. ResultsWe enrolled 117 cancer patients (22% lung, 21% colorectal, 9% breast) with a mean age of 63 years; 62% had metastatic cancer. Eleven patients (9.4%) developed recurrent VTE, including two cases of fatal pulmonary embolism. VTE recurrence rates were 7.8% (95% CI, 3.1–18) in patients with a risk score of ≤0 points compared to 11% (95% CI, 5.2–20) for those with a score of ≥1 point (hazard ratio 1.3; 95% CI, 0.39–4.5). Baseline P-selectin levels but not D-dimer levels were significantly associated with a high risk of recurrence; the risk was four-fold higher in patients with elevated P-selectin levels than in those with normal levels (hazard ratio 4.0; 95% CI, 1.1–14). Changes in biomarker levels during treatment were not associated with recurrent VTE. ConclusionBaseline P-selectin but not D-dimer levels predict recurrent VTE and may be a valuable addition to clinical prediction rules to select patients for more intensive therapy or closer observation.

Analysis of clinical factors affecting the rates of fatal pulmonary embolism and bleeding in cancer patients with venous thromboembolism.

BackgroundIn cancer patients with symptomatic venous thromboembolism (VTE) (deep-vein thrombosis (DVT) and/or pulmonary embolism (PE)), clinical factors that influence the benefit-risk balance of anticoagulation need to be identified so treatment intensity and duration can be optimally adjusted for the individual patient.MethodsUsing clinical data for cancer patients with VTE obtained from the RIETE registry, we compared how rates of fatal PE and fatal bleeding during and after anticoagulation vary depending on patients‘ clinical characteristics.ResultsData were analysed from the 10,962 cancer patients with VTE (5,740 with PE with or without DVT; 5,222 with DVT alone) in RIETE registry as of March 2016. Fatal PE occurred in 2.18% of patients, while fatal bleedings occurred in 1.55%. During the 12 months from initial VTE, fatal PE was the most common cause of death, after disseminating cancer, and bleeding the fourth most common. In patients initially presenting with PE, fatal PE during anticoagulation was 4-fold more frequent than fatal bleeding (204 vs 51 deaths) and occurred mostly during the first month of treatment (196/223, 88%). In patients initially presenting with DVT, fatal PE was 3-fold lower than fatal bleeding during (25 vs 85 deaths) and after anticoagulation treatment (8 vs 37 deaths). During the 12-month follow-up, other characteristics of cancer patients with VTE were identified as more common in fatal cases of PE and/or bleeding than in surviving cases.InterpretationBaseline clinical characteristics may determine anticoagulation outcomes in cancer patients with VTE and should be further investigated as possible factors for guiding changes in current practices of anticoagulation, such as adjusting anticoagulation intensity and duration in selected patients.

Prevalence of pulmonary embolism at autopsy among elderly patients in a Chinese general hospital.

ObjectivesTo investigate the prevalence and characteristics of pulmonary embolism (PE) at autopsy in a Chinese general hospital over a period of 10 years, and to evaluate the antemortem achievement of the prophylaxis, diagnosis, and treatment of PE.MethodsAll medical records of deaths from the West Branch of the Chinese People's Liberation Army (PLA) General Hospital were retrospectively reviewed, for the period of January 1, 2006 to December 31, 2015. Cases in which autopsies had been performed were identified and further analyzed. The numbers and detailed characteristics of patients who had PEs were noted. Prophylactic measures, along with diagnosis and treatment of PE, were recorded, if performed.ResultsDuring the 10-year period, 1057 patients died in the study hospital and 278 necropsies were performed (autopsy rate: 26.3%). Nine patients were found to have PE (3.2%), and in seven of these patients (2.5%), the PE was considered to be fatal. Embolisms were found in the trunk and bilateral main branches of the pulmonary artery tree in all seven of the fatal PE cases. Right intracardiac thrombosis was detected in five of the nine PE patients (55.6%). All patients with PE had been hospitalized in medical departments, and only one had undergone surgery during hospitalization. Antemortem prophylaxis was performed in two of the nine PE cases (22.2%). None of the 9 patients had received a clinical diagnosis of PE before death.ConclusionsThe incidence of and death rate associated with PE may vary among different races and regions. Continuous monitoring of PE by means of necropsy in certain representative medical institutions is necessary.

Preventing Venous Thromboembolism with Use of Intermittent Pneumatic Compression after Total Hip Arthroplasty in Korean Patients.

Intermittent Pneumatic Compression (IPC) device has been used to prevent venous thromboembolism (VTE). This study investigated the effectiveness of IPC device. We evaluated incidences of deep vein thrombosis (DVT) and pulmonary embolism (PE) in total hip arthroplasty (THA) patients after use of IPC device, and compared with historical incidences from our institution. We applied IPC device in 741 patients who underwent 870 elective primary THAs from January 2010 to December 2013, DVT was detected in 3 patients (0.3%) by sonography, and one (0.1%) of them was symptomatic. Symptomatic PE occurred in 1 patient (0.1%) and there were no cases of fatal PE. The incidence of symptomatic DVT was significantly lower than the historical control (P = 0.042). The IPC is a safe and effective prophylaxis of VTE after primary THA in Korea.

Distended diameter of the inferior vena cava is suggestive of pulmonary thromboembolism on unenhanced post-mortem CT

Abstract Introduction Cases of fatal pulmonary embolism (PE) represent a diagnostic challenge on post-mortem imaging. The aim of this study was to investigate the correlation between distended inferior vena cava (IVC) on post-mortem CT (PMCT) and PE at autopsy. Materials and methods We retrospectively measured the diameter of the IVC at the origin of the superior mesenteric artery in 164 cases on PMCT. Thereof 26 cases with PE, 24 selected control cases with myocardial infarction (MI), and 114 randomized control cases were investigated. Results Mean IVC diameters were 11.2 mm in the PE group; 7.4 mm in the MI group; and 6.7 mm in the randomized control group. Mean IVC diameters in the PE group were significantly wider than in the randomized control group (p=0.004), but not significantly wider than in the MI group (p=0.111). The difference between the IVC diameters of both control groups was also not significant (p=0.400). Receiver operating characteristics (ROC) curve revealed that the optimal cut-off value was at an IVC diameter of 12.5 mm, which indicates the presence of pulmonary artery embolism with a sensitivity of 54% and a specificity of 83%. Conclusions This study revealed that increased diameter of the inferior vena cava is suggestive of pulmonary embolism on PMCT. However, other causes of right heart failure may also cause distension of the inferior vena cava. Further research is needed to enable a reliable distinction between cases of PE and MI.

Fatal pulmonary embolism following ankle fracture in a 23-year-old man

Patients with lower extremity injuries are at increased risk of venous thromboembolism. We report a case of fatal pulmonary embolism following a simple ankle fracture in a 23-year-old man. The diagnosis was confirmed post-mortem. The incidence of such complications and the importance of deep venous prophylaxis in such cases are discussed.

HHS – full or prophylactic anticoagulation?

Diabetes mellitus and, in particular, the hyperosmolarity associated with the hyperosmolar hyperglycaemic state (HHS) is associated with an increased risk of thrombotic events. This risk is acknowledged by the authors of the national HHS guideline who recommend prophylactic low molecular weight heparin (LMWH) for all patients with HHS for the full duration of their admission. We present a case of fatal pulmonary embolism in a 39-year old man admitted with HHS who was treated according to local hospital trust and national guidance with prophylactic LMWH. In the absence of evidence from randomised studies comparing prophylactic and treatment dose anti- coagulation in thrombosis prevention in HHS further research is needed to facilitate development of evidence-based guidelines.

2.5. Evaluation of vascular diameter and cases of pulmonary embolism sudden death

Objective Cases of fatal pulmonary embolism (PE) represent a diagnostic challenge to post-mortem imaging. The aim of this study was to investigate the relationship between the diameter of the inferior cava vein and cases of fatal pulmonary embolism on post-mortem CT (PMCT). Material and methods We retrospectively measured the diameter of the inferior cava vein (ICV) at the level of the superior mesenteric artery in 164 cases on PMCT (26 cases of confirmed pulmonary embolism, 24 age and sex matched cases of myocardial infarction (MI), and 114 randomized control cases (CC)) and investigated levels of significance between these groups and the diagnostic power of a cut-off value for the ICV. Results Mean ICV diameters were 7 mm (SD 8.1 mm) in the CC, 7 mm (SD 5.5 mm) in the MI, and 11 mm (SD 8.1 mm) in the PE group. Mann−Whitney U -Test revealed a significant difference in ICV diameters between PE and CC ( p =0.004) and between PE and both CC and MI together ( p =0.006), but not between MI and CC ( p =0.40), and between PE and MI (p=0.11). The receiver operating characteristics (ROC) curve revealed the optimal cut-off value: at 12.5 mm the diameter of the ICV features a specificity of 83% and a sensitivity of 54% to indicate the presence of pulmonary embolism. Conclusion This study revealed that increased diameter of the inferior cava vein is an indicator of pulmonary embolism on PMCT. However, this radiologic sign has a poor prognostic value and further research is needed to reliably distinguish between cases of PE and MI.

Race and Venous Thromboembolism

Conventional teaching is that a racial gradient exists for the frequency of venous thromboembolism (VTE) in the United States. Asian Americans have the lowest risk, and blacks have the highest risk. Hispanic Americans and Americans of European ancestry have an intermediate risk, with Hispanic Americans having less frequent VTE than those of European but non-Hispanic heritage. The most apparent paradox is that blacks have the highest rate of VTE, even though they rarely carry the prothrombin gene mutation or factor V Leiden mutation, 2 genetic abnormalities that predispose to VTE. Based on genetic profiling (nature), one might have predicted that blacks would have a low rate of VTE. In 1 study, in comparison with individuals of European ancestry and adjusting for age and sex, blacks had a 30% to 60% higher incidence of VTE than European Americans.1 This finding suggests that environmental and socioeconomic factors and perhaps healthcare disparities (nurture) play an important role in determining the risk of developing VTE. Article see p 1502 In New York City, 578 consecutive out-of-hospital fatal pulmonary embolism (PE) cases were investigated by the Office of the Chief Medical Examiner.2 All underwent autopsy, toxicology, microbiology, and genetic testing. Race-adjusted incidence rates per 100 000 people per year were as follows: blacks 3.73, whites, 1.15, and Hispanics, 0.93. The percentage of PE deaths in comparison with the New York City population was as follows: blacks (58% versus 25%), whites (25% versus 35%), and Hispanics (16% versus 28%). Obesity was 2.5- to 3-fold higher in fatal PE cases than in the New York City population as a whole. The observation of race correlating with VTE frequency has been accepted with little disagreement or critique. One compelling cross-sectional study challenges existing dogma and shows that the topic is far more complex than initially thought. …

Fatal pulmonary embolism following spinal surgery in a patient with permanent inferior vena cava filter placement

It has been proven that the use of an inferior vena cava filter (IVCF) is effective in decreasing the incidence of pulmonary embolism (PE) in high-risk spinal surgery patients. A case of fatal PE after spinal surgery in a 78-year-old woman who had a history of pulmonary hypertension due to peripheral PE treated with a permanent IVCF and anticoagulant therapy for 3 years is reported. The patient had experienced an episode of recurrent PE during the withdrawal of anticoagulants, but she had uneventfully undergone two orthopedic surgeries with a preoperative unfractionated heparin infusion instead of oral warfarin. Three months after the second operation, she underwent posterior lumbar spinal fusion. The following morning, she suddenly complained of chest discomfort and dyspnea with SpO(2) 78 %. An electrocardiogram showed a right bundle branch block. Then, 30 min later, she suddenly lost consciousness, and her carotid pulse was not palpable. The patient died 2 h and 30 min after onset. Acute PE probably occurred because of a massive thrombus above the IVCF. This case suggests that the efficacy of long- term use of a permanent IVCF is limited in cases when anticoagulants must be withdrawn, such as for orthopedic surgery.

Fatal Pulmonary Tumor Embolic Microangiopathy in Young Lady without Known Primary Malignancy

Pulmonary embolism (PE) is a common cause of morbidity and mortality in hospitalized patients. Malignancy, prolonged recumbence, and chemotherapy are renowned risk factors for development of clinically significant PE. Cancer exerts a multitude of pathophysiological processes, for example, hypercoagulability and abnormal vessels with sluggish circulation that can lead to PE. One of the peculiar characteristics of tumor cells is their ability to reach the circulation and behave as blood clot—not a metastasis-occluding the pulmonary circulation. We present a case of fatal pulmonary embolism diagnosed histologically to be due to tumor cell embolism.

Required frequency of ultrasonography for detection of thrombosis with high risk for embolism in patients with malignancies

Aim. To determine the optimal terms for detection of thrombosis with high risk for embolism in patients with malignancies receiving specialized treatment. Methods. 117 patients (50 males, 67 females - the main group) with malignancies were randomly picked out (using the random numbers tables) underwent daily ultrasonography of inferior vena cava tributaries for detection of thrombosis with high risk for embolism. Ultrasonography of inferior vena cava distal part, both common iliac veins and veins of lower extremities was done in patients while on surgical treatment, chemotherapy or radiotherapy. The control group consisted of 130 patients (58 males, 72 females) with malignancies in whom ultrasonography was performed only if clinical signs of venous thrombosis were present. Results. Ultrasonic features of venous blood flow decrease (spontaneous contrast phenomenon) in veins of lower extremities were found in 27 out of 117 main group patients on the second day. On the third day features of saphenous veins thrombosis were found in 13 patients. On the fourth day, 4 patients were diagnosed with iliofemoral thrombosis. 5 more patients developed ultrasonic features of venous blood flow decrease (spontaneous contrast phenomenon) on the fourth and fifth day. Signs of thrombosis progression and floating thrombus were found in 6 patients on the 6th and 7th day. No fatal cases of pulmonary embolism were registered in the main group. 10 patients of the control group had clinical signs of inferior vena cava tributaries and underwent distal part of inferior vena cava, both common iliac veins and veins of lower extremities ultrasonography while on specialized treatment. 5 cases of pulmonary embolism were reported in the rest of the control group patients (120 patients). Conclusion. Inferior vena cava tributaries thrombosis with high risk for embolism in patients with malignancies can be reliably detected by repeating ultrasonography every 3-4 days; Reliable diagnosis of thrombosis with high risk for embolism by means of ultrasonography during the post-surgical period allows to prevent pulmonary embolism in a timely and targeted manner.

High dose urokinase against massive pulmonary embolism in nephrotic syndrome

Patients with nephrotic syndrome carry a high risk of pulmonary embolism due to the abnormalities in coagulation and fibrinolysis. Thrombolytic therapy for critical pulmonary embolism in nephrotic syndrome patients was rarely reported and remains controversial in the regimen selection so far. We reported a case of fatal pulmonary embolism, complicating in hepatitis B virus-associated nephrotic syndrome. The patient presented with chest pain, hemoptysis and shortness of breath on admission and his initial vital signs showed a high risk of developing hypotension. Urgent radiological examinations confirmed massive embolisms in bilateral pulmonary arteries. Prompt thrombolytic therapy was performed right after the diagnosis of pulmonary embolism with an intravenous infusion of urokinase (20 000 U/kg) in 2 h. Complete resolution of pulmonary embolism was achieved after urokinase administration and the patient was discharged in good conditions. This report highlighted the efficacy and safety of prompt thrombolytic therapy with urokinase for nephrotic syndrome patients presented with massive pulmonary embolism. In this study, we also briefly discuss the recent findings on the current state of urokinase in the clinical practice of thrombolysis.