Case Of Massive Pulmonary Embolism Research Articles

First Documented Case of Massive Pulmonary Embolism and Massive Ilio-Femoral Deep Venous Thrombosis Treated Simultaneously

Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE) cause major morbidity and mortality. A PE develops from a DVT. Surprisingly there are very few reports of a DVT and a PE being documented together, and there are no reports of a simultaneous treatment of both by a CDT.

A case of massive pulmonary embolism causing cardiac arrest managed with successful systemic thrombolytic in the emergency department

Pulmonary Embolism (PE), when complicated by cardiac arrest, is almost always fatal despite all resuscitative efforts. However, a more favorable is possible when PE is rapidly identified as the cause of cardiac arrest and pulmonary circulation is quickly re-established by specific therapy. A 54-year-old woman was brought to the Emergency Department (ED) by 112 emergency ambulance service with the complaint of shortness of breath that had started 2 hours ago. She developed cardiac arrest while being physical examined 2 minutes after admission, and Cardiopulmonary Resuscitation (CPR) was immediately begun. Massive PE was considered the most likely diagnosis in the light of her history, physical examined, and bedside ultrasonography findings; thus, recombinant tissue Plasminogen Activator (r-tPA) was administered during CPR. The second CPR attempt achieved return of spontaneous circulation within 5 minutes. She was treated at intensive care unit for 32 days and discharged from the hospital with complete recovery.

Prehospital Ultrasound Diagnosis of Massive Pulmonary Embolism by Non-Physicians: A Case Series

Massive pulmonary embolism (hemodynamically unstable, defined as systolic BP <90 mmHg) has significant morbidity and mortality. Point of care ultrasound (POCUS) has allowed clinicians to detect evidence of massive pulmonary embolism much earlier in the patient’s clinical course, especially when patient instability precludes computerized tomography confirmation. POCUS detection of massive pulmonary embolism has traditionally been performed by physicians. This case series demonstrates four cases of massive pulmonary embolism diagnosed with POCUS performed by non-physician prehospital personnel.

Management of a patient with cardiac arrest: a clinical case of massive pulmonary embolism in an obese young man

Pulmonary artery thromboembolism is one of the few life-threatening conditions. Today, with less mobility due to their professional activities (prolonged sitting at a computer) and social behavior, the number of cases of venous thromboembolism has increased. The recommendations of the European Society of Cardiology for pulmonary embolism (2008, 2014, 2019) have become a powerful tool for diagnosing, treating and stratifying the risk of death. Prevention of recurrence of thromboembolic complications and its duration depends on the fact of provocation of pulmonary embolism. Recommendations for the development of thromboembolic complications take into account the presence of heart failure, coronary heart disease, atrial fibrillation (AF), which to some extent blurs the distinction between arterial and venous thrombosis. The fact that the incidence of pulmonary embolism increases with age is indisputable, but in contrast to atherothrombosis, venous thrombosis occurs much earlier, in the younger population. Thus, venous thrombosis is somewhat “younger” than arterial. Regarding gender differences, it is more common in men with age, and women tend to “rejuvenate”. Contraceptives play an important role in this, the risks of venous thromboembolism are pregnancy and childbirth. Although less influential in the development of venous thromboembolism and pulmonary embolism are bed rest (more than three days), immobilization in a sitting position (long flight, car trip), old age, in real clinical practice should not be neglected laparoscopic surgery and concomitant conditions— obesity, diabetes mellitus, hypertension and varicose veins. At the slightest suspicion of pulmonary embolism, it is important for the physician to consider the above factors. A clear algorithm for diagnosis and timely treatment will ensure the effectiveness of such patients and the process of their recovery. In recent years, obesity at the angle of low-intensity inflammation began to be considered involved in the processes of increased thrombosis. Although certain mechanisms of thrombosis in obesity have been elucidated, the frequent fatal thrombotic consequences of severe COVID-19 remain unclear, mainly in the category of patients with obesity, carbohydrate metabolism disorders, and diabetes. In this clinical case, the authors demonstrate the total stratification of risk factors, even at first glance insignificant effects of obesity of the first degree, but in combination with varicose veins of the lower extremities, which caused massive pulmonary embolism in young men.

First Documented Case of Massive Pulmonary Embolism and Massive Ilio-Femoral Deep Venous Thrombosis Treated Simultaneously

Venous Thromboembolism (VTE) is a spectrum of disease including Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) [1,2] . VTE is a major public health concern, estimated to effect 1 to 2 per 1,000 people in the US each year.

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.

Bowel Obstruction Revealing a Mesenteric Infarct in a SARS COV 2 Infection Area: A Case Report

SARS COV 2 is an RNA virus with pulmonary tropism responsible not only for severe pneumopathy but which can cause major thromboembolic and cardiovascular complications with life-threatening consequences and are more serious with the presence of cardiovascular risk factors, cases of massive pulmonary embolism has been described in several articles as well as occlusion of the superior mesenteric artery.

Surgical pulmonary embolectomy: still a useful technique in sick cases of massive pulmonary embolism.

Surgical pulmonary embolectomy: still a useful technique in sick cases of massive pulmonary embolism.

Technical efficiency, short-term clinical results and safety of a large-bore aspiration catheter in acute pulmonary embolism - A retrospective case study.

Background:Mechanical thrombectomy plays an important role in the management of acute pulmonary embolism (PE), either when rapid clot dissolution is needed or when thrombolytics are contraindicated. We describe our clinical and technical experience with the FlowTriever mechanical thrombectomy device in patients with acute PE.Materials and Methods:A retrospective analysis was performed on all cases of acute PE treated with the FlowTriever device at a single tertiary care hospital system during the trial period (November 2019–January 2020). Technical and clinical results, including complications, are reported.Results:Technical success was achieved in all eight successive cases (seven cases of submassive and 1 case of massive PE). Mean pulmonary artery pressure (MPAP) improved significantly after mechanical thrombectomy (27.8 ± 6.4 mmHg preprocedure; 20.5 ± 3.8 mmHg postprocedure; 7.3 ± 5.2 mmHg decrease after the procedure; P = 0.016). Hemoglobin levels did not change significantly after mechanical thrombectomy (11.8 g/dl ± 3.4 preprocedure; 9.9 g/dl ± 2.1 postprocedure; P = 0.20). Reduction in MPAP was achieved in 88% of cases (7/8) and hypoxia improved in all the nonintubated patients (7/7). Mortality observed in one patient with a massive central PE, was not related to the procedure. No mortality or procedural complications were observed in patients with submassive PE.Conclusions:The positive initial clinical experience and safety profile using the FlowTriever in the treatment of acute PE suggests, it has the potential to fill the unmet needs of a good mechanical thrombectomy device to treat massive and submassive high-risk PE especially when thrombolytics are contraindicated.

Predictors for Chronic Thromboembolic Pulmonary Hypertension

Introduction - The most dangerous complication of acute venous thrombosis is pulmonary embolism (PE), which results directly in mortality in most cases. In non-fatal cases of massive pulmonary embolism, when thrombolytic therapy or embolectomy is not possible or ineffective, there is severe chronic thromboembolic pulmonary hypertension (CTEPH). The purpose of our study was to develop clinical, laboratory and instrumental criteria to characterize the development of varying CTEPH intensity after the earlier is PE. Methods - The study is based on a retrospective material comprising 26 patients with the pulmonary embolism arteries and survived it. At different times (1-5 years) after the event and discharge from the hospital, the patients were summoned and examined. All patients were performed to an ultrasonography of the lower limbs, echocardiography, and some patients had pulmonary perfusion scintigraphy and CT angiography. In case of high pulmonary hypertension, which was detected with echocardiography, the right heart catheterization was used for the immediate detection of pulmonary pressure. In the course of our study, we compared the patients' findings received in the initial hospital admissions with the findings of clinical and instrumental methods we had received in the long term after the pulmonary embolism (PE). Results - According to our study, there is a certain trend towards the development of severe CTEPH forms, depending on the following primary clinical and instrumental characteristics. The following factors have been recognized as favorable factors resulting in the incidence of milder CTEPH forms or its total absence in the long term: effective thrombolytic therapy, relative “freshness” of thrombotic masses, distal lesion level of the lower extremity veins (up to the popliteal veins inclusive), young age of patients. It is worth mentioning separately the adequate anticoagulant therapy, which is prescribed following the thrombolysis or in automedication. As a rule, patients followed two regimens of anticoagulant therapy after the thrombolytic therapy: unfractionated heparin during the first 24 hours, with the subsequent transition to warfarin, rivaroxaban immediately at the end of the thrombolysis. Two regimens of anticoagulant therapy: low molecular heparins followed by the transition to warfarin and rivaroxaban from the first days of treatment were also present when the thrombolytic therapy was not possible or not necessary. In the long term, we observed the best pulmonary artery recanalization by combination of the thrombolytic therapy and rivaroxaban, although there were patients who were not treated with the thrombolysis due to the developed allergic reaction in the massive PE, but on the top of administered rivaroxaban there was detected a full pulmonary channel permeability one year after the treatment onset. The effect of the pulmonary artery recanalization in the warfarin treatment was much weaker. Negative factors in the CTEPH development could include the proximal level of deep vein lesions, the elderly age of patients, not "fresh" thrombotic masses. After 10 days of their formation, each consecutive day affected negatively the efficiency forecast of the thrombolytic and anticoagulant therapy in terms of pulmonary artery recanalization. Conclusion - There are certain clinical and instrumental parameters that allow for a certain degree of prediction of the CTEPH development following the earlier PE, but further studies are required to have more reliable statistics.

GUILLAIN-BARRÉ SYNDROME AS A COMPLICATION OF EXTRACORPOREAL MEMBRANE OXYGENATION

SESSION TITLE: Critical Care Devices SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is considered the highest form of life support. Despite its expanded use and improved success, adverse issues including hemostatic, thrombotic and hemolysis still occur at high rates. Guillain-Barre syndrome (GBS), a demyelinating polyneuropathy, is not documented in the literature as an adverse issue. We present a case of massive pulmonary embolism (PE) requiring ECMO complicated by GBS. CASE PRESENTATION: A 54-year-old female with a history of breast cancer in remission, deep vein thrombosis formerly on rivaroxaban, discontinued after cancer remission, presented with acute onset severe chest pain. She was in severe respiratory distress, tachycardic and in shock. She was intubated with cardiac arrest soon after, with successful resuscitation. Computed-tomography angiography (CTA) scan confirmed massive bilateral PE and she was administered tenecteplase. Her hemodynamics worsened necessitating maximal vasopressor support. Labs showed an acute drop in hematocrit from 32% to 14% with increasing abdominal distension, rigidity and decreased bowel sounds alarming for compartment syndrome. Bedside ultrasound revealed signs of retroperitoneal bleed, an adverse effect of tenecteplase. Despite massive transfusion protocol, she continued to worsen necessitating venous-arterial ECMO to support cardiogenic shock. Within 30 minutes of ECMO support, vasopressors were weaned and underwent exploratory laparotomy for abdominal compartment syndrome. She remained on ECMO for 17 days with improvement. While on ECMO, she developed progressive ascending lower extremity weakness. Lumbar puncture was done, with a WBC of 0, Glucose 107 mg/dL and Protein 77 mg/dL with cytoalbumincytologic dissociation. Magnetic resonance imaging showed diffuse nerve root and cord enhancement, findings consistent with GBS. She subsequently received full treatment of intravenous immunoglobulin with improvement in her symptoms. DISCUSSION: GBS has a pathogenesis related to aberrant immune response against the peripheral nervous system. Infections are known to be a cause, but there is literature about surgery as a potential trigger, often spinal surgery. One study cited an attributable risk of 4.1 cases per 100000 surgeries with most attributed to spinal surgery. To our knowledge this is the first case of GBS with ECMO exclusive of preceding infection. Initiation of ECMO is associated with an immediate inflammatory reaction. As blood enters the circuit, levels of pro-inflammatory cytokines increase causing leukocyte activation. Simultaneously, there is antigen release and autoimmunization to antigens, similar to GBS in surgical patients. CONCLUSIONS: As ECMO patients are critically ill, they are more prone to develop critical care neuropathy. It is important that in patients with neuromuscular weakness in the setting of ECMO use, that GBS be amongst the differential of critical care neuropathy. Reference #1: Dowling JR, Dowling TJ. A Rare Axonal Variant of Guillain-Barré Syndrome following Elective Spinal Surgery. Case Rep Orthop. 2018;2018:2384969. Published 2018 Aug 7. https://doi.org/10.1155/2018/2384969 Reference #2: Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care. 2016;20(1):387. https://doi.org/10.1186/s13054-016-1570-4. DISCLOSURES: No relevant relationships by Abhas Khurana, source=Web Response No relevant relationships by Gaurav Manek, source=Web Response No relevant relationships by Varun Tandon, source=Web Response No relevant relationships by Aysha Tandon, source=Web Response

Massive pulmonary embolism causing large T-wave inversion and QT prolongation.

We present a case of massive pulmonary embolism where the electrocardiogram (ECG) demonstrated transient T-wave inversion and marked QT-prolongation. The pathomechanism and clinical significance of these changes are discussed.

Comparison of Ultrasound-Accelerated versus Pigtail Catheter–Directed Thrombolysis for the Treatment of Acute Massive and Submassive Pulmonary Embolism

PurposeTo compare the technical and clinical effectiveness of ultrasound-accelerated endovascular thrombolysis (USAT) versus pigtail catheter–directed thrombolysis (PCDT) for the treatment of acute pulmonary embolism (PE). Materials and MethodsA single-center retrospective study of patients treated with USAT or PCDT for acute massive or submassive PE between January 2010 and December 2016 was performed by reviewing electronic medical records. Sixty treatments were reviewed (mean patient age, 56.7 y ± 14.6), including 52 cases of submassive PE (21 treated with USAT, 31 with PCDT) and 8 cases of massive PE (3 treated with USAT, 5 with PCDT). Endpoints included pulmonary artery pressure (PAP), Miller PE severity index, tissue plasminogen activator (TPA) dose, infusion duration, procedural variables, and complications. ResultsDemographics, PE severity, and right:left ventricular diameter ratios were similar between groups. USAT and PCDT significantly reduced mean PAP (reductions of 7.4 mm Hg [P = .002] and 8.2 mm Hg [P < .001], respectively) and Miller index scores (reductions of 45.8% [P < .001] and 53% [P < .001], respectively) with similar effectiveness (P = .47 and P = .15, respectively). Procedure (P < .001) and fluoroscopy (P = .001) times were significantly longer in the USAT group. The USAT group underwent fewer sessions (2.2 ± 0.6 vs 2.4 ± 0.6; P = .17) with shorter infusion times (23.9 h ± 8.8 vs 30.4 h ± 12.6; P = .065) and a lower total dose of TPA (27.1 mg ± 11.3 vs 30.4 mg ± 12.6; P = .075) compared with the PCDT group, but the differences were not significant. Complications (P = .07) and 30-day mortality rates (P = .56) were not significantly different between groups. ConclusionsUSAT and PCDT demonstrated comparable effectiveness and safety in the treatment of patients with acute PE.

経皮的心肺補助装置装着後に合併した線溶亢進型播種性血管内凝固のため，抗凝固療法を回避して救命した肺血栓塞栓症の1例(A case of massive pulmonary embolism successfully resuscitated with veno–arterial extracorporeal membrane oxygenation without anticoagulation management due to complication of fibrinolytic phenotype disseminated intravascular coagulation)

75歳の女性。突然発症した呼吸困難を主訴に，当院に救急搬送された。来院時，循環虚脱および低酸素血症を認め，心臓超音波検査で左室の圧排を伴う右室の著しい拡大を認めた。来院15分後に，心肺停止状態となったため，心肺蘇生術を開始した。約2分後に自己心拍が再開したが，循環虚脱が継続したため，経皮的心肺補助装置（veno–arterial extracorporeal membrane oxygenation: VA–ECMO）を導入した。その後に行った肺動脈造影検査で，肺動脈の塞栓像を認め，肺血栓塞栓症と診断した。しかし，線溶亢進型の播種性血管内凝固（disseminated intravascular coagulation: DIC）を合併し，出血傾向を認めたため，抗凝固療法，血栓溶解療法は施行せず，輸血療法およびVA–ECMOを用いた循環呼吸管理を行った。第2病日に，出血傾向，循環呼吸動態が改善したため，VA–ECMOから離脱した。抗凝固療法は，VA–ECMO抜去部の止血が完了した第3病日から開始した。その後の経過は良好であり，第29病日に，神経学的後遺症もなく独歩退院した。心肺停止に至った重症肺血栓塞栓症に，線溶亢進型DICが合併し，急性期に抗凝固療法や血栓溶解療法が施行できない場合でも，出血傾向が改善するまでVA–ECMOによる循環呼吸管理を継続することで救命できる可能性がある。 A 75–year–old woman was admitted to our hospital because of sudden–onset dyspnea. She was in a state of obstructive shock and hypoxia and echocardiography showed right ventricular dilatation. Approximately 15min after arriving at the hospital, she experienced a cardiac arrest; we performed cardiopulmonary resuscitation, and spontaneous circulation restored in 2min. However, as obstructive shock was not resolved, we performed veno–arterial extracorporeal membrane oxygenation (VA–ECMO). Pulmonary angiography revealed pulmonary artery occlusions. Disseminated intravascular coagulation (DIC) was of the fibrinolytic phenotype; it was complicated with pulmonary embolism, and a bleeding tendency was noted. Therefore, blood transfusions were performed and hemodynamic support was provided with VA–ECMO and catecholamines, without anticoagulation and thrombolysis. The following day, her coagulopathy resolved and hemodynamic status recovered; VA–ECMO support was successfully removed. Anticoagulation was started on the 3rd hospital day, when bleeding at the VA–ECMO puncture site was confirmed to have stopped. The patient recovered and was discharged from the hospital on the 29th hospital day. DIC is sometimes complicated with pulmonary embolism in post–cardiac arrest patients. This case shows the possibility that continued hemodynamic and respiratory support with VA–ECMO until bleeding tendency resolves might aid in recovery of patients for whom anticoagulation and thrombolysis are contraindicated. 心肺停止（cardiopulmonary arrest: CPA）蘇生後は，播種性血管内凝固（disseminated intravascular coagulation: DIC）や 1, 2，胸骨圧迫による胸部外傷など 3, 4，出血性合併症を来す場合がある。今回我々は，線溶亢進型DICを合併した肺血栓塞栓症（pulmonary embolism: PE）症例を経験した。出血傾向のため，急性期に抗凝固療法や血栓溶解療法が施行できなかったが，DICが改善するまで経皮的心肺補助装置（veno–arterial extracorporeal membrane oxygenation: VA–ECMO）による循環呼吸管理を継続することで，救命できたため報告する。本症例報告の作成にあたり，個人情報保護法に基づき匿名化し，患者本人の同意を得た。 患 者：75歳の女性，身長145cm，体重42.7kg，body mass index 20.3 現病歴：未治療の下肢静脈瘤の既往はあるが，他の特記すべき既往歴，家族歴，常用薬はない。また，長期臥床や，安静を強いられる長距離移動などの病歴もない。来院当日の起床後，屋外で散歩中に突然，呼吸困難を自覚した後に転倒し，顔面を打撲した。その後，独歩で帰宅したが，患者が呼吸困難を訴えたため，家族が救急要請し当院に搬送された。 来院後経過：来院時，JCS 3–R，血圧94/60mmHg，心拍数104/分，呼吸数30/分，体温35.8℃，SpO2 92%（酸素リザーバーマスク10L/分 投与下）であった。胸部レントゲン写真では肺野に明らかな異常は認めなかったが，12誘導心電図検査ではV1–3誘導で，陰性T波を伴う完全右脚ブロックを（Fig. 1），心臓超音波検査では左室の圧排を伴う右室の著しい拡大を認めた。身体所見上は，呼吸音，心音に明らかな異常を認めなかったが，頸静脈の怒張を認めた。また，転倒時に受傷したと考えられる非活動性の出血を伴う口唇，口腔内の挫創，鼻出血を認めた。両側下肢には網目状静脈瘤を認めた。来院時の血液検査結果は，WBC 8,900/μL，Hb 9.6g/dL，PLT 8.2×104/μL，CK 48U/L，CKMB 18U/L，トロポニンI 0.090ng/mL，BNP 31.3pg/mL，APTT 62sec，PT–INR 1.43，fibrinogen 81mg/dL，D–dimer 114.9μg/mL，AT III 82%であった。 Electrocardiogram on admission. Electrocardiogram showing complete right branch block and a negative T wave in leads V1–3. 来院後，徐々に血圧が低下し，来院15分後にCPA状態（無脈性電気活動）となったため，心肺蘇生術を開始した。気管挿管し，アドレナリン1mgを投与したところ，約2分後に自己心拍が再開したが，循環虚脱が継続した。広範型PEを疑い，来院から43分後に透視下に右大腿動静脈からVA–ECMOを導入した（カテーテルサイズは脱血19.5Fr，送血13.5Fr，テルモ社キャピオックス®システムを使用，2,000回転で駆動開始）。その後，左大腿静脈アプローチで肺動脈造影を施行すると，右上葉動脈，中葉動脈，左肺尖動脈，肺舌動脈などが閉塞しており，PEと診断した（Fig. 2）。左右の肺動脈主幹部には血栓を認めず，VA–ECMO挿入後，循環動態が安定したため，直視下肺動脈血栓摘出術や，カテーテル的治療は不要と判断し，右内頸静脈から肺動脈カテーテルを留置し手技を終了した。しかし，来院から約2時間後より，顔面外傷部およびVA–ECMO，肺動脈カテーテル刺入部から止血困難な出血を認めるようになった。血液検査を再検したところ，Hb 5.6g/dLと貧血の進行およびD–dimer 264.5μg/dL，fibrinogen 50mg/dL未満，PT–INR 2.44，PLT 11.3×104/μLと凝固障害の悪化を認めた。線溶亢進型DICと診断し，顔面外傷部の縫合，鼻腔内へのガーゼタンポン挿入，カテーテル刺入部の圧迫および輸血療法を開始した。経過中，出血性合併症のため，VA–ECMO導入時を含め，抗凝固薬や血栓溶解薬は使用しなかった。VA–ECMO導入後に撮影したCT検査では，肋骨骨折，気胸，胸腹腔内出血などの胸骨圧迫による合併症は認めなかった。 Pulmonary artery angiography. Right upper lobe, middle segmental, left apical segmental, and lingular pulmonary artery branches are occluded with thrombi (arrowheads). Fig. 3aにD–dimer，fibrinogen，PLTの経時的変化および輸血療法の時間経過を示す。来院後16時間までに，赤血球濃厚液14単位，新鮮凍結血漿30単位，濃厚血小板20単位の輸血を行い，凝固障害は改善し，Hbは9.2g/dLまで上昇した。Fig. 3bにVA–ECMOの血液流量，肺動脈カテーテルで測定した心拍出量の経時的推移を示す。最大量ドブタミン5μg/kg/min，ノルアドレナリン0.1μg/kg/minを使用したが，抗凝固療法や血栓溶解療法を施行しなかったにも関わらず，心拍出量は徐々に上昇し，導入23時間後にVA–ECMOを離脱した。集中治療室に入室後に施行した超音波検査で，両側下肢深部静脈内に浮遊血栓を多数認めたため，下肢深部静脈血栓症がPEの原因と考え，VA–ECMO抜去後，回収可能型下大静脈フィルターを留置した。抗凝固療法は，出血傾向が消失し，VA–ECMO抜去部の止血が完了した第3病日から，未分画ヘパリンの持続投与を500単位/hrで開始し，APTTがコントロール値の1.5～2.5倍になるように調節した。 Clinical course of the patient. Fig. 3a shows the results of blood tests. Two–way arrow indicates the duration of blood transfusions. –●– D–dimer, –▲– Fibrinogen, –■– PLT Fig. 3b shows the hemodynamic status, and the two–way arrow shows the duration of catecholamine use. –●– CO, –▲– ECMO flow PLT: platelet count, CO: cardiac output, VA–ECMO: veno–arterial extracorporeal membrane oxygenation 第5病日に，人工呼吸器から離脱した。食事摂取量が安定した後，第12病日よりワルファリンの内服を3mg/日で開始した。下肢静脈血栓の消失した第14病日に，下大静脈フィルターを抜去した。未分画ヘパリンは，ワルファリンによる抗凝固効果が得られた第20病日まで継続した。その後の経過は良好であり，第29病日に独歩退院した。退院時のワルファリン服用量は3.5mg/日であり，PT–INRは1.61だった。 後日測定した，プロテインC活性はワルファリン3.5mg服用下で95%，プロテインS活性は90%，ループスアンチコアグラントは蛇毒法で1.29，抗カルジオリピン抗体（IgG）8U/mL以下，抗カルジオリピンβ2グリコプロテインI複合体抗体1.2U/mL以下，と正常範囲であり，先天的な血液凝固能亢進素因は認めなかった。本症例における下肢深部静脈血栓症の原因は，下肢静脈瘤による下肢血流停滞が原因と考え，永続的な抗凝固療法の継続を指示した。 「肺血栓塞栓症および深部静脈血栓症の診断，治療，予防に関するガイドライン」 5では，心肺蘇生を要する，あるいは高度なショックが遷延する広範型PEには，VA–ECMOによる循環呼吸補助を行ったうえで，血栓溶解療法，カテーテル的治療，外科的血栓摘出術などを行うことを推奨している。血栓溶解療法は，迅速な血栓溶解作用や血行動態改善作用に優れており，循環破綻を伴う重症PEの予後改善につながるとの報告 6があるが，出血性合併症のリスクがある 5, 6。 CPA蘇生後症例は，その心停止原因に関わらず，線溶亢進型DIC 1, 2や，胸骨圧迫による肋骨骨折，気胸，内胸動脈損傷などの合併報告 3, 4があり，出血性合併症のリスクが高い。とくに，extracorporeal cardiopulmonary resuscitation（ECPR）症例での出血性合併症の報告は多く，Iwashitaら 7は未分画ヘパリン3,000単位を投与したECPR 32症例のうち，3例（9%）に外科的処置や血管塞栓術を要する出血が合併したと報告している。また，Hashibaら 8は，ECPRを施行したPEによるCPA症例12例のうち，5例に血栓溶解療法を行ったところ，6例（50%）に出血性合併症を認めたと報告している。 CPA蘇生後症例に合併する線溶亢進型DICは，組織低灌流や虚血に伴い産生される内因性線溶物質が引き起こすと考えられており 1，心停止時間が長いほどその合併頻度は高くなる 2。本症例は心停止時間が約2分間と短時間であったにも関わらず，DICを合併した。広範型PEは心停止の有無に関わらず消耗性の凝固障害を合併することが知られている 9。本症例の来院時血液検査から算出した急性期DICスコアは6点であり，本症例は，来院時すでに，PEに伴う組織低灌流や虚血，あるいは凝固因子の消耗により，線溶亢進型DICが合併しており，VA–ECMO導入後も遷延したと考えた。 出血を伴う線溶亢進型DICに対しては，未分画ヘパリンの投与は禁忌であり，濃厚血小板，新鮮凍結血漿の補充が必要となる 10。しかしながら，DIC治療の根幹は基礎疾患，本症例でいえばPEの治療である 10。本症例は，出血性合併症のため抗凝固療法や血栓溶解療法などのPEの特異的治療が施行できず，VA–ECMOを用いた循環呼吸補助および合併したDICに対する輸血療法のみを施行したにも関わらず，入院翌日にはVA–ECMOから離脱できた。野村ら 11は，肺動脈近位部の血栓は，胸骨圧迫により破砕される可能性を報告している。本症例でも，肺動脈造影時に，肺動脈主幹部には血栓を認めず，上記機序による有効肺血管床の回復が血行動態の改善につながった可能性が考えられた。また，線溶亢進型DIC合併の過程で産生された内因性線溶物質が，自ら肺動脈内の血栓溶解に働きかけた可能性も示唆された。 VA–ECMO使用時には，ACTを180–200sec前後に維持するように抗凝固を行うことが推奨されている 12。本症例では，抗凝固薬を使用せずVA–ECMOを使用したが，回路トラブルは起こらなかった。今回用いたECMOは，テルモ社のキャピオックス®であり，血液流路面には，血液適合性ポリマーコーティングが施されている。同コーティングおよび患者が線溶亢進状態であったため，回路トラブルが起こらなかったと考えた。 なお，本症例では測定していないが，凝固活性化の指標となるTATや，線溶活性化の指標となるPICの測定は，DICの病態把握に有用であり 10，測定を考慮すべきであった。 線溶亢進型DICを合併した重症PE症例を経験した。CPAを合併したPEの診療の際には，胸骨圧迫に伴う胸部外傷や，線溶亢進型DICなどの出血性合併症に注意し，抗凝固療法や抗凝固療法の適応は，慎重に評価する必要がある。 本論文における利益相反はない。

Thrombectomy and Lung Resection for Massive Left Pulmonary Embolism in a 30 Years Old Man in Yaounde, Cameroon

Pulmonary embolism is a well-recognized clinical entity with significant morbidity and mortality. It is called massive when it extends over more than half of the vascular bed. In the past, surgical treatment was the last therapeutic option but more and more surgical treatments are performed in several centers with few side effects and a lower mortality rate. Pulmonary embolectomy has never been attempted in Cameroon. We are reporting herein the first case of massive pulmonary embolism in a 30 years old man complicated by lung gangrene treated by thrombectomy and lung resection.

A cases reported of cases of massive pulmonary embolism after cesarean section

A cases reported of cases of massive pulmonary embolism after cesarean section

PCPSからV-V ECMOへ切り替えることで救命することができた広範型急性肺血栓塞栓症の1例

PCPSからV-V ECMOへ切り替えることで救命することができた広範型急性肺血栓塞栓症の1例

Massive Pulmonary Embolism with Hemodynamic Compromise Successfully Treated with Veno-Arterial Extracorporeal Membrane Oxygenation

Introduction: Cardiogenic shock that results from pulmonary embolus has a high mortality rate. Systemic thrombolysis is frequently used in submassive and massive pulmonary embolus and has been shown to restore circulation. However, in the event of impending or ongoing cardiac arrest, systemic thrombolysis or anticoagulation alone has not been always shown to be effective. Case reports have previously established that extracorporeal membrane oxygenation can effectively be used as an effective rescue strategy in cases of cardiac arrest as a result from massive pulmonary embolus. We report six cases of massive pulmonary embolism (PE), in which veno-arterial extracorporeal membrane oxygenation (VA ECMO) was utilized or used as a backup strategy with excellent outcomes. We highly recommend using this strategy at the bedside in a tertiary care facility where VA ECMO support is available.&#x0D; Methods: This is a retrospective study of all patients that underwent VA ECMO or utilized VA ECMO at the bedside as a rescue strategy in the setting of massive PE. We abstracted relevant clinical information from patient charts for this review.&#x0D; Results and analysis: Out of the 107 VA ECMO runs performed at our facility between 1 September 2013 and 31 December 2014, four patients utilized this strategy in the setting of massive PE with impending cardiac arrest; in two cases it was available to use as a backup strategy. All six patients (Table 1) had successful recovery with complete restoration of cognitive status, functional status, and without any clinical signs of right ventricular (RV) dysfunction on discharge.

Two Cases of Treatment with Thrombolysis and an Extracorporeal Membrane Oxygenator in Patients with Pulmonary Embolism and Cardiac Arrest

광범위 íìƒ‰ì „ì¦ì€ ì‚¬ë§ë¥ ì´ 높은 위험한 질환이다. 이러한 경우 í˜ˆì „ ìš©í•´ì œ 치료를 하게 되는데 이에 반응이 없는 경우 ì‚¬ë§ë¥ ì€ 매우 높은 편이다. 최근에 이러한 치료에 반응이 없는 광범위 íìƒ‰ì „ì¦ 환자에서 ECMO를 ì ìš©í•˜ëŠ” 것이 ë³´ê³ ë˜ê³ ìžˆë‹¤. 이에 ì €ìžë“¤ì€ ì‹¬íì •ì§€ë¥¼ 동반한 광범위 íìƒ‰ì „ì¦ 환자에서 í˜ˆì „ ìš©í•´ì œ 치료 후에도 ì‹¬íì •ì§€ê°€ ë°œìƒí•˜ì˜€ê³ ECMO를 이용한 구조요법을 시행하여 치료한 증례를 경험하였기에 ë¬¸í—Œê³ ì°°ê³¼ 함께 ë³´ê³ í•˜ëŠ” 바이다. 중심 단어: íìƒ‰ì „ì¦; 체외막 산소화 장치; í˜ˆì „ìš©í•´; ì‹¬íì •ì§€

A Case of Massive Pulmonary Embolism Masked by a Ventricular Septal Defect

A Case of Massive Pulmonary Embolism Masked by a Ventricular Septal Defect