Cases Of Pulmonary Thromboembolism Research Articles

Treatment of recurrent pulmonary thromboembolism with ecosonic endovascular system

Venous thromboembolism is a collective term that describes two diseases, pulmonary thromboembolism (PTE) and deep vein thrombosis, with or without symptoms but often accompanying each other. Pulmonary thromboembolism (PTE) develops in most cases due to thrombus formation in the deep veins of the lower extremities and migrates to the pulmonary artery and/or its branches. It is a preventable disease with high mortality and morbidity and includes diagnostic difficulties. Recurrence may occur despite treatment in 5-23% of PTE cases. Patients may apply to the hospital with symptoms such as unexplained dyspnea, stabbing or atypical chest pain, hemoptysis, and syncope. We aimed to present the patient who had chronic deep vein thrombosis (DVT) and was frequently hospitalized due to recurrent massive PTE. In our case, disease status requires catheter thrombolytic therapies two times in three months.

Pulmonary thromboembolism following organophosphate intoxication: a case report

Various symptoms manifest after organophosphate intoxication due to muscarinic, nicotinic, and central nervous system effects. Complications are common, and morbidity occurs due to respiratory center depression, cardiovascular complications, aspiration pneumonia, general weakness, and neurological symptoms. Some studies have reported a statistically significant association between organophosphate intoxication and deep vein thrombosis. However, cases of pulmonary thromboembolism (PTE) resulting from organophosphate poisoning are very rare. A 45-year-old male patient was transferred to our hospital after ingesting an unknown amount of an insecticide and receiving 6 L of gastric lavage at a local hospital. Other than nausea, no symptoms (e.g., dyspnea) were present, but a hemodynamic test showed an elevated lactic acid level, and metabolic acidosis worsened over time. Accordingly, we conducted initial treatment including continuous renal replacement therapy. After 7 hours, the poisoning analysis result was confirmed, and lambda-cyhalothrin and chlorpyrifos (0.441 µg/mL and 0.401 µg/mL, respectively) were detected. We introduced pralidoxime. Although no increase in pseudocholinesterase was found during hospitalization, continuous renal replacement therapy and pralidoxime were discontinued because the patient did not show symptoms of intermediate syndrome, including dyspnea and altered consciousness. The patient complained of abdominal pain on hospital day 8. Abdominal computed tomography was performed to evaluate the possibility of a corrosive injury to the stomach or esophagus, and we confirmed PTE. The D-dimer level was 1.96 mg/L (normal range, 0–0.55 mg/dL). A radiologic examination showed a PTE in the main pulmonary artery leading to the segmental pulmonary artery. After heparinization, the patient was discharged after being prescribed a vitamin K-independent oral anticoagulant. Through this case, we would like to emphasize the need for a thorough evaluation of clinical symptoms because atypical symptoms can occur after poisoning with organophosphate pesticides.

腹臥位から仰臥位へ体位交換時に肺血栓塞栓症を発症した重症COVID–19肺炎の2例(Two cases of pulmonary embolism after position change from prone position during mechanical ventilation due to severe COVID–19 pneumonia)

COVID–19肺炎では腹臥位呼吸療法の有効性が注目されている。今回，腹臥位から仰臥位への体位交換時に発症した肺血栓塞栓症を2例経験したので報告する。1例目は59歳の男性，発症11日目に人工呼吸を開始し，15日目から腹臥位呼吸療法を開始した。17日目に仰臥位へ体位交換した30分後より，SpO2が94%から85%へと低下し，心拍数も90bpmから120bpmへ上昇した。D–ダイマーが9.2μg/mLから22.5μg/mLへ上昇していたため，肺血栓塞栓症を疑い，造影CTで左肺動脈血栓が判明した。2例目は46歳の男性，発症13日目で人工呼吸を開始し，同日腹臥位呼吸療法を開始した。14日目に仰臥位へ体位交換した10分後より血圧低下，12分後からSpO2が97%から84%へと低下した。D–ダイマーが5.6μg/mLから48.1μg/mLへ上昇していたことと，心臓超音波検査で右心負荷所見がみられたことから肺血栓塞栓症を疑い，造影CTで左内頸静脈血栓と右肺動脈血栓が判明した。今回の2症例は，いずれも腹臥位から仰臥位に体位交換した際に肺血栓塞栓症を発症しており，いずれも中心静脈カテーテル挿入側の内頸静脈に血栓を認めた。長時間の腹臥位から仰臥位への体位交換は，内頸静脈血栓から肺血栓塞栓症を発症させる可能性が示唆され，バイタルサインに留意して行うことが望ましい。 The prone position during mechanical ventilation has been reported to be effective in respiratory failure caused by COVID–19 pneumonia. We report two cases of pulmonary thromboembolism that may have occurred during return to the supine position. A 59–year–old man, with COVID–19 pneumonia, was put on mechanical ventilation in supine position from day 11 to day 15, and prone position from day 15 to day 17. Thirty minutes after returning to the supine position on day 17, he developed hypoxemia and tachycardia. Pulmonary thromboembolism was suspected based upon elevated D–dimer levels. Echo venogram of the right internal jugular vein showed thrombi, and contrast–enhanced computed tomography (CECT) showed thrombi in the left pulmonary artery. A 46–year–old man, with COVID–19 pneumonia, was put on mechanical ventilation in prone position from day 13 to day 14. On day 14, when he was returned to the supine position, he developed hypotension after 10 minutes, and hypoxemia after 12 minutes. CECT showed thrombi in the left internal jugular vein and right pulmonary artery. During mechanical ventilation, a change to the supine position after prolonged prone position may cause pulmonary thromboembolism from thrombi in the internal jugular vein, and should be performed with attention to vital signs. 腹臥位呼吸療法は，acute respiratory distress syndrome（ARDS）の死亡率を低下させる可能性があり 1，COVID–19肺炎にもしばしば実施される。当院でも，集中治療管理を要するCOVID–19肺炎患者に対し，16時から翌日10時の18時間を腹臥位，残りの6時間を仰臥位とする腹臥位呼吸療法を施行した。腹臥位呼吸療法での合併症として，気管チューブ閉塞，事故抜管，静脈路の事故抜去，褥瘡，視力障害，腕神経叢損傷などが報告されている 2。今回，腹臥位から仰臥位への体位交換を契機に発症した肺血栓塞栓症（pulmonary embolism: PE）を2例経験したので報告する。 なお，本症例の報告は倫理委員会の承諾は不要であり，個人情報保護法に基づいて匿名化がなされ，患者・家族の同意を得ている。 患 者：59歳の男性 既往歴：痛風，脂質異常症 現病歴：発熱・頭痛で発症し，同日SARS–CoV–2 PCR陽性と判明した。発症5日目に酸素化不良のため，当院に入院となった。11日目に呼吸状態悪化のため気管挿管し，人工呼吸管理となった。 入院後経過：気管挿管後より，深部静脈血栓症（deep vein venous thrombosis: DVT）予防を目的として，ヘパリンカルシウム5,000単位の皮下注射を1日2回開始した。発症13日目に撮像した体幹部造影CTでは，PE，DVTともに指摘されなかったが，14日目にD–ダイマーが9.8µg/mLと上昇した。超音波検査で，中心静脈カテーテル挿入側である右内頸静脈に血栓を認め（Fig. 1a），リバーロキサバン15mg内服を開始した。また，13日目に撮像したCTでは背側の無気肺が著明であり，人工呼吸器関連肺炎も併発したため，背面開放と体位ドレナージを目的とし，15日目より腹臥位呼吸療法を開始した。17日目に，腹臥位から仰臥位に体位交換した30分後より，SpO2が94%から85%へと低下し，心拍数も90bpmから120bpmへ上昇した（Fig. 2）。 Case 1: Jugular vein echo (a). major and minor axis image showing right internal jugular vein (white arrow). Chest computed tomography (b). Axial view showing left main pulmonary artery thrombus (white triangle). Case 1: Course at onset of pulmonary embolism. ベッドサイドで可能な検査や理学所見では，気胸や痰による閉塞性無気肺を認めなかった。超音波検査では右心拡大を認めなかったが，依然として右内頸静脈に血栓が存在していた。両側大腿静脈，膝窩静脈には，血栓はみられなかった。右内頸静脈血栓があること，D–ダイマーが22.5µg/mLと上昇（前日9.2µg/mL）していること，また長時間の腹臥位から体位交換をした際に起きた酸素化低下と頻脈であることから，PEを強く疑った。既にリバーロキサバン内服が行われていたが，治療量でなかったため30mgに増量し，翌日待機的に造影CTを施行した。造影CTでは，左主肺動脈に血栓塞栓症がみられた（Fig. 1b）。以上の所見より，腹臥位から仰臥位への体位交換を契機に発症したPEと診断した。 その後，COVID–19肺炎後器質化肺炎に対して，プレドニゾロン60mg/day（1mg/kg）を開始した。発症25日目に38度台の発熱があり，膿性痰が出現したため，人工呼吸器関連肺炎としてピペラシリン・タゾバクタム13.5ｇ/日を投与開始した。その後のCTで，左肺に多発空洞影を認め，肺化膿症と診断した。抗菌薬治療を60日間継続した後，発症93日目に，リハビリテーション目的に転院となった。 患 者：49歳の男性 既往歴：慢性中耳炎 現病歴：咽頭痛・発熱で発症し，翌日SARS–CoV–2 PCR陽性と判明した。呼吸困難感が出現したため，発症11日目に前医入院となった。呼吸状態悪化のため翌日当院に転院となり，13日目に気管挿管を施行し，人工呼吸管理を開始した。 入院後経過：気管挿管後より，DVT予防を目的として，ヘパリンカルシウム5,000単位の皮下注射を1日2回開始した。気管挿管後も酸素化が改善しなかったため，同日夕方より腹臥位呼吸療法を開始した。翌日，腹臥位から仰臥位に体位交換した10分後から，徐々に血圧が低下し，SpO2も低下した（Fig. 3）。 Case 2: Course at onset of pulmonary embolism. ベッドサイドで可能な検査や理学所見では，気胸や痰による閉塞性無気肺を認めなかった。超音波検査では，両側大腿静脈，膝窩静脈には血栓を認めなかったが，左内頸静脈の中心静脈カテーテル周囲に血栓を認め，右心拡大も認めた。左内頸静脈血栓があること，D–ダイマーが48.1µg/mLと上昇（前日5.6µg/mL）していること，右心負荷所見があり，長時間の腹臥位から体位交換をした際に起きた血圧低下，酸素化低下であることから，PEを強く疑った。APTTの目標を50secとしてヘパリンナトリウム14,000U/dayの持続静脈注射を開始し，同日に造影CTを施行した。造影CTでは左内頸静脈（下顎角から胸鎖関節付近の鎖骨下静脈合流部），および右肺動脈に血栓を認めた（Fig. 4a, b）。 Case 2: Chest computed tomography. Axial view showing right pulmonary artery thrombus in the middle lobe (a. white triangle). Axial view showing left internal jugular vein thrombus (b. white arrow). 以上の所見より，腹臥位から仰臥位へ体位交換した際に発症したPEと診断した。発症第15日目に人工呼吸器関連肺炎を発症したため，セフェピム3g/日を投与開始した。16日目に，P/F ratioが191から289へ改善し，18日目に気管チューブを抜去した。また，19日目にヘパリンからリバーロキサバン30mg/dayへ変更し，22日目に前医に再転院となった。 PEの塞栓源は，約90%が下肢あるいは骨盤内の静脈とされている。しかし，2例とも内頸静脈に血栓があり，超音波検査と造影CTで，両下肢静脈内に明らかな血栓はみられなかった。このことから，内頸静脈血栓からの塞栓子が原因で，PEを発症したと考えられる。集中治療を行う場合，内頸静脈への中心静脈カテーテル留置を行う機会が多いが，中心静脈カテーテルの挿入は内頸静脈血栓形成のリスクとして知られている 3。また，2例ともヘパリンの予防投与を行っていたが，中心静脈カテーテル挿入側の内頸静脈に血栓を認めた。COVID–19では，血管内皮細胞にもSARS–CoV–2感染が成立する。ウイルス感染により障害された血管内皮細胞からの凝固第VIII因子とvon Willebrand factorの放出や，サイトカインストームが血栓傾向の誘引となり，深部静脈血栓症の発症率が上昇するとされている 4。 なお，今回の2症例目では，中心静脈カテーテルを挿入した同日16時ごろから翌日10時ごろまで腹臥位呼吸療法を行い，仰臥位に体位交換をした際にPEを生じている。中心静脈カテーテル挿入時の超音波検査では血栓を認めておらず，腹臥位呼吸療法を行っている18時間の間に，血栓が形成された可能性が高い。鎖骨による鎖骨下静脈合流部への圧迫で内頸静脈の血流うっ滞が生じ，内頸静脈血栓の形成に腹臥位が寄与していた可能性が考えられる。1例目においても，長時間の腹臥位が，既存の内頸静脈血栓の伸展を助長した可能性がある。このような血栓形成のリスクが重なり，ヘパリン予防投与を行っていたにもかかわらず血栓が形成されたと考えられる。 DVTは，通常発生部位から中枢へ成長する過程で，血栓中枢端や伸展血栓が遊離，もしくは血栓の静脈壁接着面が剥離して塞栓子となる。関節周囲や下腿筋ポンプ内のような特殊な状況では，起立，歩行などの際に下肢の筋肉が収縮し，伸展血栓が容易に塞栓化しやすいとされている 5。腹臥位呼吸療法において，腹臥位から仰臥位へ体位交換したことを契機としてPEを発症したという報告は，我々の渉猟する限りみられなかったが，脊椎手術では数例報告されている 6, 7。腹臥位中は，鎖骨による圧迫や胸腔内圧上昇に伴い，内頸静脈や下大静脈のうっ滞が起こることが示唆されている。腹臥位から仰臥位への体位交換で，これらが解除されることにより，血行動態が一時的に変化しうる。それにより，体位交換という受動的な運動であっても，長時間の腹臥位の間に伸展，形成された内頸静脈血栓が遊離した可能性が考えられる。 腹臥位から仰臥位に体位交換した際の酸素化低下はしばしば経験され，原病が重篤，あるいは背側無気肺が著明である場合は，対症療法を行うのみで見過ごされてしまう可能性もある。しかし，今回1例目は頻脈，2例目では血圧低下と，SpO2の低下以外にもバイタルサインの変化を認めていた。COVID–19の血栓症発症リスクが高いことも踏まえ 8, 9，PEを鑑別にあげて対応し，治療介入することができた。さらに2例目は，1例目の経験から，仰臥位への体位交換が内頸静脈血栓を塞栓子としたPE発症の契機となる可能性があることを認識していた。そのため，ベッドサイドでの超音波検査で，両側大腿静脈に加え内頸静脈も観察を行い，内頸静脈血栓を認知することができ，PEを鑑別疾患の上位に挙げることができた。なお，両症例ともPE発症日の採血でD–ダイマーの上昇がみられていた。腹臥位呼吸療法施行中のD–ダイマー上昇は，血栓形成もしくは伸展を示唆している可能性があり，仰臥位に復帰した際にバイタルサイン変動がみられた場合には，PEの発症を疑う必要があると考える。なお，ARDS患者の腹臥位では健常人と異なり，換気血流比不均等の改善による右心負荷の軽減や，左心前負荷増大により，心拍出量が増加する 10。仰臥位への体位交換時には，これらの血行動態の変化は速やかに元に戻り，心拍出量は低下する。これは，PEを発症した際の重症度を高める可能性がある。 当院では，腹臥位からの体位交換時はSpO2，心電図，end–tidal CO2などの観血的動脈圧以外の一部モニターを外していた。同様にモニターを外しており初期症状であるバイタルサインの変化を察知できずに 11，心停止まで至った脊椎手術症例の報告もある 6。今回2例とも，モニターは仰臥位復帰後早急に再装着され，バイタルサインの変化に早期に気づくことができた。モニター未装着となる時間を短縮することが，早期にPEの兆候を察知するために重要である。なお，PE発症時にSpO2低下はよくみられるが，より劇的な症例では急激にend–tidal CO2が低下することが知られており，脊椎手術中end–tidal CO2低下がPE発症覚知の一助となった報告もある 12。当院では腹臥位から仰臥位への体位交換時，end–tidal CO2モニターを外していることがほとんどであった。end–tidal CO2モニターは，頭側で回路混線せずに装着したまま安全に体位交換できるため，今後の腹臥位療法では，装着を継続して体位交換することも，検討の余地がある。 腹臥位呼吸療法時は，内頸静脈還流のうっ滞などにより形成・伸展した内頸静脈血栓が，仰臥位への体位交換で遊離しPEを発症する恐れがあるため，注意して体位交換を行う必要がある。また，腹臥位からの体位復帰時に生じる循環虚脱や肺酸素化能の低下にはPEが関与している可能性があり，これらのバイタルサインの変化を早期に察知するために，装着可能なモニターはできる限り装着を継続し，困難な場合にもモニター未装着時間を可能な限り短縮して迅速な体位交換を行うことが望ましい。 著者全員に本論文に関する利益相反はない。

Diagnostic Accuracy in Quantitative Evaluation of Attenuation of Pulmonary Thrombus on Noncontrast Computed Tomography Scan

Abstract Objectives: The objective is to assess the role of noncontrast computed tomography (NCCT) in the identification of pulmonary thromboembolism (PTE) using the difference in attenuation value between thrombus and blood pool and to establish its diagnostic accuracy. Methods: A single-center retrospective analysis was carried out for 1 year among the patients of all age groups who were referred for imaging workup with clinical suspicion of pulmonary embolism (PE). A standard protocol was followed for all the patients undergoing computed tomography pulmonary angiography (CTPA). The diagnosis of PE was based on the direct visualization of the intraluminal thrombus as complete/partial filling defect on CTPA. The average attenuation value of the thrombus on NCCT was measured retrospectively after referring to its position on the corresponding enhanced scans. The difference in attenuation of the pulmonary vessels with and without the thrombus was calculated on NCCT. The data was utilized in the generation of receiver operator characteristic curve to obtain the best cut off level for attenuation differences of the vessels and its accuracy in detecting PTE was determined. Results: Among the study population of 50 subjects, the mean age was found to be 42 years in our study with male sex (72%) having more preponderance to PTE than female sex (28%). The average blood pool range was between 20 and 60 Hounsfield unit (HU). The mean of differences in attenuation between thrombus and blood pool was 34.07 HU. The optimal cut off level for PE affection proved to be difference in attenuation of the pulmonary arteries of more than 20 HU. The sensitivity and specificity were 89.47% and 83.33%, respectively. Conclusion: In clinically suspected cases of PTE, CTPA is the most reliable diagnostic tool. However, with plain computed tomography itself, considering the difference in attenuation values, the thrombus can be identified in majority of the cases thereby reducing the exposure to radiation and contrast to the patients.

Pulmonary thromboembolism and obesity in forensic pathologic case work

328 autopsy cases of fatal pulmonary thromboembolism (PE) were compared to 984 age- and sex-matched controls to evaluate the association between obesity and PE in a forensic context. Both PE and control cases had a mean age of 67,8 years (male 62,9 years, females 71,7 years). The percentage of morbidly obese persons with a body mass index (BMI) of above 40 or abdominal subcutaneous adipose tissue of above 4 cm was higher in the PE group (8,39% vs. 4,67% and 29.45% vs. 23.40%, respectively). On the other side, that of very slim persons (BMI below 18.5 or adipose tissue below 3 cm) was significantly smaller (4,27% vs. 7,52% and 47.55% vs. 56,60%). We thus found a strong association between being overweight and death from PE, while slim persons seem to be at an advantage. As the group of underweight persons includes those suffering from chronic diseases with reduced mobility or hypercoagulability (e.g. tumor kachexia or sarkopenia due to immobilisation), this finding is to some extent unexpected.

Forensic Pathological Analysis of Death Due to Pulmonary Thromboembolism: A Retrospective Study Based on 145 Cases.

Pulmonary thromboembolism (PTE) is a common cause of sudden unexpected death in forensic and clinical practice. Although the prevention of thrombosis has been paid more attention in clinical practice in recent years, the number of deaths due to PTE remains extensive. In the present study, 145 cases of fatal PTE were collected and retrospectively analyzed from 2001 to 2020 at the School of Forensic Medicine, China Medical University in Liaoning Province, northeast of China. The demographic characteristics, risk factors of PTE, origins of thrombi, and time interval from the occurrence of main risk factors to PTE were retrospectively analyzed. The 40 to 59 age group accounted for the 51.0% of the total cases. Immobilization, trauma (especially fracture of the pelvis, femur, tibia, or fibula), surgery, cesarean section, and mental disorders were the top 5 high-risk factors. Among the involved cases, 92.9% of the PTE (130/140) occurred within 60 days and peak at 8 to 15 days after the exposure of main risk factors. According to the autopsy findings, 87.6% of the thrombi blocked the bilateral pulmonary arteries at pulmonary hilus, with a maximum diameter of 1.6 cm and a maximum length of 21.9 cm, which were mainly derived from lower limb (65.5%) or pelvic veins (10.3%). Although the embolus limited the pulmonary circulation, there is no difference on the ratio of lung-to-heart weight between PTE and the disease-free accident victims. Overall, our present retrospective study provides important information for the forensic analysis on the cause of death and potential guidance on clinical prevention of PTE.

Clinicopathological Characteristics of Cancer-Associated Venous Thromboembolism (CAT-VTE) from a Medicolegal Autopsy.

Objective: This study aimed to determine the clinicopathological characteristics of cancer-associated venous thromboembolism (CAT-VTE).Methods: A total of 47 cases of lethal pulmonary thromboembolism (PTE) with active cancer were investigated by autopsy records.Results: We studied 22 men and 25 women who were deceased at a mean age of 66±11 years. Nine (19%) patients had recently undergone cancer resection, 14 (30%) were undergoing clinical treatment for cancer, and 24 (51%) were autopsy-proven CAT-VTE. The colon (eight cases), lungs (seven cases), and ovaries (six cases) were frequent sites of a tumor. There were 29 (62%) cases of acute PTE and 18 (38%) of recurrent PTE. The embolic source was detected in 36/39 (92%) cases. Among them, 33 cases were leg deep vein thrombosis (DVT) and 31 were calf-type DVT. Three cases were isolated vena cava thrombi that were present near the tumor. Twenty-three (64%) cases were recurrent DVT.Conclusion: Most of the lethal CAT-VTE cases were induced by the same mechanism as non-CAT-VTE that originated from calf-type DVT with proximal propagation. However, the finding that patients had tumor-related vena cava thrombi suggested that prevention of CAT-VTE requires individualized treatment of patients according to their pathological condition. (This is secondary publication from Jpn J Phlebol 2020; 31(3): 123–129.)

A Novel Diagnostic Marker in Pulmonary Thromboembolism? Platelet-Derived Growth Factor –β

Objective: Pulmonary thromboembolism (PTE) is a condition characterized by severe cardiopulmonary injury. There is a need for a cheap and reliable biochemical marker, which is also easily and rapidly accessible, with high specificity and sensitivity in the diagnosis of PTE. The PDGF ligand receptor system plays a role in the development of pulmonary hypertension and contributes to thickening of the vascular wall and increasing the wall tension. In the present study, we aimed to investigate whether plasma PDGF-B levels increase in patients with PTE and the diagnostic value of PDGF-B in PTE along with its relationship with mortality.
 Methods: This prospective clinical study was conducted in the emergency department of a tertiary university hospital between March 1st, 2020 and March 1st, 2021. A total of 44 patients diagnosed as having PTE in the emergency department (patient group) and 34 healthy volunteers without any chronic disease (control group) were included in our study.
 Results: The PDGF-β levels of the patients diagnosed as having PTE in the ED were found to be significantly higher than those of patients in the control group (Z=-2.015, p=0.044). There was no significant linear relationship between PDGF-β levels and age, gender, presence of chronic disease, systolic and diastolic blood pressure as well as peak heart rate, respiratory rate, and axillary body temperature values at the time of admission to the emergency department, Geneva, Wells and PESI scores. In our study, no significant linear relationship was found between PDGF-β and D-Dimer levels in patients with PTE and mortality.
 Conclusion: The results obtained from this study, which investigated whether PDGF-B was a new prognostic biomarker for PTE, suggest that plasma PDGF-B levels are significantly higher in PTE cases and can aid in the diagnosis of PTE. However, PDGF-B cannot be used as a marker to predict prognosis.

High incidence of pulmonary thromboembolism in hospitalized SARS-CoV-2 infected patients despite thrombo-prophylaxis

BackgroundSARS-CoV-2 infected patients present thrombotic complications caused by direct endothelial cells injury of the microvessels. Pulmonary thromboembolism (PE) has been reported by Computed Tomography pulmonary angiogram (CTPA) in patients with COVID-19 pneumonia with high D-dimer levels. ObjectivesWe present the characteristics of SARS-CoV-2 infected patients diagnosed of PE by CTPA in our hospital. We also present the comparison of these findings with non-infected patients with PE data. MethodsRetrospective observational cohort study that included patients over 18 years of age hospitalised consecutively between 26th February and 20th May 2020 in an European Hospital with SARS-CoV2 virus infection, and with suspected infection at beginning of admission but with negative PCR, who were studied with CTPA for suspicion of VTE, during their hospitalization. ResultsDuring the study period, 52 CTPA were performed in our hospital, sixteen in SARS-CoV-2 infected patients, with 4 cases (33%) of PE in the infected group, and 11 (44%) in the non-infected group. No significant differences in age (p = 0.43) and sex (p = 0.31) were found between the two groups, infected and non-infected patients. In the infected group, the patients who had PE had a much lower median age (47.8 years) than those without PE (73.3 years). No differences between infected and non-infected patients were detected in the diagnosis of PE with CTPA, 28.6% versus 27.8% (p = 1.00). Overall patient mortality was 1.9%; one patient died (6.3%) in the infected group, and none in the non-infected group (p = 0.31). ConclusionA considerable incidence of PE diagnosed by CTPA in SARS-CoV-2 infected patients has been observed, despite thrombo-prophylaxis.

Risk Stratification of Pulmonary Thromboembolism using Brain Natriuretic Peptide and Troponin I; a Brief Report.

Introduction:Pulmonary thromboembolism (PTE) is one of the most prevalent medical disorders, with a notable annual fatality rate. This study aimed to evaluated the accuracy of serum pro-BNP and troponin I levels in PTE diagnosis. Methods:This cross-sectional study was implemented on 267 patients with suspected PTE (sudden chest pain or sudden dyspnea) in Imam Reza Hospital in Mashhad, Iran. All patients underwent pulmonary computed tomography (CT) angiography (as the gold standard test) and their serum levels of troponin I and pro-BNP were measured. The screening performance characteristics of pro-BNP in detection of PTE cases were measured and reported using receiver operating characteristic (ROC) curve analysis. Results:Two-hundred-sixty-seven patients with a mean age of 67.7 ±11.5 years were evaluated (60.1% male). PTE was confirmed via CT angiography in 121 patients. The area under the ROC curve of troponin I and pro-BNP in detection of PTE was 0.501 ng/mL and 0.972 pg/mL, respectively. The sensitivity and specificity of proBNP at the best cut-off point (100 pg/ml) were 85.4% and 80.2%, respectively. The sensitivity and specificity of troponin I at the best cut-off point (0.005 ng/ml) were 65.5% and 42%, respectively.Conclusion:Due to the comparatively good sensitivity and specificity of proBNP in diagnosis of pulmonary thromboembolism, it can be employed as a diagnostic determinant in patients with suspected pulmonary thromboembolism along with other laboratory tests.

A Study of Three Cases of Pulmonary Thromboembolism after Spinal Cord Injury

A Study of Three Cases of Pulmonary Thromboembolism after Spinal Cord Injury

Clinical Significance and Prognosis of Right Heart Thrombi Associated With Acute Pulmonary Thromboembolism - Results of a Multicenter Registry of Thrombolysis in Japan.

Thrombolytic therapy is standard treatment in acute pulmonary thromboembolism (PTE) with hemodynamic instability. Although right heart thrombi (RHT) appear to increase mortality in acute PTE, large-scale studies of acute PTE with RHT are scarce.Methods and Results:Patient data (from August 2005 to May 2014) obtained from post-marketing surveillance of thrombolytic therapy using a tissue-type plasminogen activator were analyzed retrospectively. Of the 2,698 confirmed cases of acute PTE who underwent echocardiographic assessment, 166 (6.2%) were diagnosed with RHT. PTE patients with RHT, compared with those without RHT, had higher rates of mortality (20.2% vs. 10.4%, P<0.001), hemodynamic instability (53.0% vs. 37.7%, P<0.001), and PTE recurrence (6.6% vs. 2.3%, P=0.003). When considering PTE-related hemodynamic severity (cardiopulmonary arrest/collapse, massive, submassive, and non-massive), mortality was significantly higher in patients with RHT in the massive (19.8% vs. 7.7%, P=0.002) and submassive (8.0% vs. 2.8%, P=0.018) groups, whereas no significant differences was found between those with and without RHT in the cardiopulmonary arrest/collapse (51.7% vs. 52.1%, P=0.960) and non-massive (1.6% vs. 0%, P=0.596) groups. PTE patients with RHT had higher mortality, severity, and PTE recurrence rates. RHT was particularly associated with worse outcomes in patients with massive or submassive PTE.

Pulmonary thromboembolism during pregnancy and puerperium: Comparison of survival and death cases.

In Japan, the frequency of maternal deaths due to obstetric hemorrhage has been decreasing in the last decade, while that resulting from other causes such as pulmonary thromboembolism (PTE) was consistent. To help reduce maternal deaths due to PTE, we investigated PTE during pregnancy and puerperium and compared the survival and death cases, and aimed to find out life and death factors. This study was a retrospective analysis based on a clinical chart review in 407 maternal and perinatal centers. We compared the survival and death cases of PTE during pregnancy and puerperium from 2013 to 2017. In PTE during pregnancy, the survival cases underwent significantly earlier diagnoses than the death cases, and thromboprophylaxis was performed in most of both the survival and death cases of PTE during puerperium according to the existing Japanese guidelines; however, only one fourth of the total cases underwent anticoagulation to prevent venous thromboembolism (VTE). Early diagnosis of PTE in suspected cases was associated with better survival during pregnancy.

Mid-term lifetime survivals of octogenarians following primary and revision total knee arthroplasties were satisfactory: a retrospective single center study in contemporary period

BackgroundAs life expectancy increases, the number of octogenarians requiring primary and revision total knee arthroplasty (TKA) is increasing. Recently, primary TKA has become a common treatment option in octogenarians. However, surgeons may still be hesitant about performing revision TKA on octogenarians because of concern about risk and cost benefit. The purpose of this study was to investigate clinical outcomes, postoperative complications, and mid-term lifetime survival in octogenarians after primary and revision TKA.Materials and methodsWe retrospectively reviewed 231 primary TKAs and 41 revision TKAs performed on octogenarians between 2000 and 2016. The mean age of patients undergoing primary TKA was 81.9 years and that of patients undergoing revision TKA was 82.3 years (p = 0.310). The age-adjusted Charlson comorbidity index was higher in revision TKA (4.4 vs. 4.8, p = 0.003). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and range of motion (ROM) were evaluated. The incidence of postoperative complications (TKA-related, specific or systemic) and lifetime survival rate (endpoint death determined by telephone or mail communication with patient or family) were investigated.ResultsThe WOMAC and ROM improved significantly after primary and revision TKA, although postoperative results were worse in the revision group (33.1 vs. 47.2; 128.9° vs. 113.6°; p < 0.001, respectively). There were no cases of aseptic or septic component failure in either group. One case of periprosthetic fracture was observed in the revision group (0% vs. 2.4%, p = 0.151), and three cases of deep vein thrombosis (DVT)/pulmonary thromboembolism (PTE) (one case of DVT and two cases of PTE) were observed in the primary group (1.3% vs. 0%, p = 1.000). The most common systemic complication in both groups was delirium (7.4% vs. 14.6%, p = 0.131). There were no differences between the two groups in the other systemic complication rates. The 5-year and 10-year lifetime survival rates were 87.2% and 62.9%, respectively, in primary TKA and 82.1% and 42.2%, respectively, in revision TKA (p = 0.017).ConclusionsBoth primary and revision TKA are viable options for octogenarians, based on the satisfactory clinical outcomes, TKA-related complication rates, and mid-term lifetime survival. Delirium needs to be managed appropriately as the most common systemic complication in both primary and revision TKA in octogenarians.Level of evidenceIV

Utilidade clínica de analisadores de ensaio D- dímero Point-of-Care para exclusão de tromboembolismo pulmonar em pacientes com COVID-19

The aim was to evaluate the clinical utility of D-dimer POC assay analyzers to rule out the diagnosis of PTE in adult patients diagnosed with COVID-19. Systematic review and meta-analysis. The evaluated technology was the Point-of-Care D-dimer assay analyzer. To combine the effect estimates whose measure was the difference between the means, the random effect model was used. We included 10 studies that evaluated 14 Point-of-Care analyzers compared to the Enzyme Linked Immunosorbent Assay assay. All Point-of-Care analyzers evaluated showed sensitivity and NPV greater than 95 and 97%, respectively, with an average return time of 95 minutes. Evidence suggests that the use of Point-of-Care analyzers for D-dimer is clinically useful to rule out cases of pulmonary thromboembolism and other thromboembolic complications in patients with COVID-19 treated in the emergency room or in primary care units.

Clinical and Laboratory Aspects of the Severity of Pulmonary Embolism in Elderly Patients versus Adult Patients A single centre study

Pulmonary thromboembolism is currently one of the leading causes of disease burden and mortality in Europe, also known as the great masquerader, for its ability to mimic other diseases or to present itself with few symptoms, especially when the pulmonary embolism is very small. With aging population, increased survival of cancer patients and the addition of multiple debilitating diseases such as dementia, heart failure, chronic kidney disease the rate of pulmonary embolism is spiking, with more and more small pulmonary embolism being diagnosed, that may have no immediate impact on mortality, but which may contribute to an increase in morbidity. We have examined retrospectively 108 consecutively cases of pulmonary thromboembolism that have presented in the Emergency Department of Municipal Hospital in Timisoara, Romania over the course of twenty-one months from September 2016 to May 2018 and we evaluated the clinical and laboratory findings in studying the influence of age over the severity of pulmonary embolism.

Value of 18F-FDG PET/CT in differentiating malignancy of pulmonary artery from pulmonary thromboembolism: a cohort study and literature review.

To determine the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in differentiating malignancy of pulmonary artery (PA) from pulmonary thromboembolism (PTE) based on a larger number of cases by pooling our cases and those from the literature. Consecutive patients with a PA lesion who had undergone 18F-FDG PET/CT in our hospital were retrospectively reviewed. Moreover, PubMed, Embase, and Medline were searched for literature reporting individual maximum standardised uptake value (SUVmax) of the malignant PA lesion and/or PTE. 18F-FDG activity was compared between PA malignancy and PTE by pooling the data from literature and our patients. Receiver operating characteristic curve analysis was performed to determine the ability of SUVmax to differentiate PA malignancy from PTE. From our database, we identified 11 patients with pulmonary artery sarcoma (PAS), and nine cases of PTE. Fifty patients with a malignant PA lesion (40 cases of PAS and 10 cases of tumor embolism) and 22 subjects with PTE were extracted from the literature. In our cases, the SUVmax of PAS (11.1 ± 4.9, range: 5.5-19.9) was significantly higher than that of PTE (1.9 ± 0.6, range: 1.1-3.2; P < 0.001). There was no significant difference in the SUVmax between the literature data and our cases in malignant lesions or in PTE. Based on the pooled analysis of the literature data and our cases (61 cases of malignant lesions and 31 cases of PTE), the area under the curve for SUVmax to differentiate PA malignancy from PTE was 0.996 (95% CI: 0.989-1.000). At a cutoff value of 3.3, the sensitivity, specificity, and accuracy were 98.4%, 96.8%, and 97.8%, respectively. The 18F-FDG uptake value is an accurate index for determining PA malignancy.

Repeated Thrombolytic Treatment for Recurrent Pulmonary Thromboembolism: A Report of 2 Cases and a Literature Review.

We present 2 cases of pulmonary thromboembolism (PTE). The first case, a 50-year-old man, was admitted to the emergency department because of sudden onset dyspnea and left side chest pain. He was diagnosed with intermediate-risk (submassive) PTE, and thrombolytic treatment was commenced. The patient fully recovered, but 5 days later, he was diagnosed with a new, high-risk PTE. The second patient, a 23-year-old woman, presented with syncope, dyspnea, and chest pain for 2 days. She was diagnosed with high-risk (massive) PTE. Thrombolytic treatment was commenced, and the patient fully recovered, too. But the later patient was also diagnosed with a new PTE 4 days later. We applied repeated thrombolytic treatment in the patients due to repeated PTE. The first patient fully recovered and was discharged from the hospital, but the second patient died because of gastrointestinal bleeding and renal insufficiency. A repeated thrombolytic treatment could be an alternative treatment for these patients, considering treatment's risks.

Incidencia de tromboembolismo venoso en cirugía ortognática

Introduction: Venous thromboembolism (VTE) is an important cause of morbidity and mortality in surgical patients. This entity has well defined and described pathophysiological mechanisms, in addition to risk factors that allow a classification of patients according to different assessment models, which allow to adopt prophylactic measures. In maxillofacial surgery, low levels of incidence have been described. However, there is quite limited evidence and represents a health problem that has received little attention in the literature. Objective: To determine the incidence of venous thromboembolism in patients undergoing orthognathic surgery. Material and Method: Retrospectively, 86 patients who underwent orthognathic surgery was evaluated between October 2006 and January 2016 at the Hospital Clinico de la Pontificia Universidad Catolica de Chile. Two cases of pulmonary thromboembolism were identified, which corresponds to an incidence of 2.6%. Despite the low incidence of VTE in patients undergoing maxillofacial surgery, it is essential to consider the individual risk of the patient and the risk involved in surgery. The prolongation of surgical time, the hospital stay and prolonged immobilization can determine a greater risk of developing this type of complication, therefore it is necessary to consider it and know how to prevent it in an adequate way.

Pulmonary thromboembolism in an emergency hospital: Are our patients different?

Pulmonary thromboembolism (PTE) represents a medical emergency and is the third most common cause of mortality after myocardial infarction and stroke. The purpose of this study was to describe the characteristics and management of patients with PTE admitted in a referral emergency hospital in Romania. We retrospectively reviewed all cases of PTE diagnosed in one of the largest emergency hospitals in Bucharest during a 2-year period (January 2014 - December 2016). Patients with acute PTE were identified by a database search of the diagnostic codes of all discharge diagnoses. Demographic, clinical and paraclinical tests data was retrieved from medical records. 221 patients (48.87% male, mean age 61.76 years (range 21-94 years)) were diagnosed with PTE in our hospital (0.31% of all hospitalizations). Dyspnea was the most frequent symptom reported (78.9%), followed by pleuritic chest pain (23.9%) and unilateral leg pain (15.8%). Upon presentation, 12.6% of patients had high-risk PTE. Up to 72.8% of patients had at least one thrombotic risk factor, while cancer (14%) was the most frequent amongst them. The mean length of hospitalization was 10.3 ± 4.6 days. Unfractioned heparin (UFH) was the preferred anticoagulant during hospital stay (73.7%, p < 0.001). Vitamin K antagonists (AVK) were the preferred anticoagulant (71.7%, p < 0.001) after discharge, whereas non-antivitamin K oral anticoagulants (NOAC) were recommended in 26.3% of patients. Thrombolysis was used in 18 (8.4%) cases. Mortality was 0.9%. Younger patients more frequently associated thrombophilia or a previous thromboembolic event and clinical signs of DVT at presentation. Older patients associated more frequently a history of hospitalization for heart failure or atrial fibrillation during the previous 3 months and a history of cancer. The clinical presentation in older patients was more severe, with higher PESI scores (103.6 ± 33.4 vs. 55.5 ± 17.9, p<0.001) and a longer hospital stay (10.7 ± 4.7 vs. 9.2 ± 3.9, p = 0.03). The type of anticoagulant treatment did not differ depending on age. In our emergency hospital, PTE is a relatively rare cause of hospitalization; the rate is, however, comparable with other major hospitals. Dyspnea and pleuritic chest pain was the clinical presentation dyad. UFH was the preferred anticoagulant for in-hospital treatment while AVK was the preferred option for long term treatment and recurrence prophylaxis; however an increasing number of patients are prescribed NOAC. In older patients clinical severity was higher upon presentation, hospitalization duration was increased and cancer was more frequently associated. Younger patients associated more frequently a primary hypercoagulable state and recurrent thromboembolism. Mortality rate was low during hospitalization, comparable with that seen in other studied populations.