Emergency Surgical Embolectomy Research Articles

Successful emergency surgical pulmonary embolectomy for massive pulmonary embolism after urgent cesarean delivery.

Successful emergency surgical pulmonary embolectomy for massive pulmonary embolism after urgent cesarean delivery.

Systemic thrombolytic and ultrasound-assisted catheter-directed thrombolysis for treatment of acute pulmonary embolism: a 7-year, multicenter experience.

Treatment of acute pulmonary embolism (PE) varies based upon risk stratification and ranges from outpatient oral anticoagulation to emergency surgical embolectomy. Patients with high-risk PE can be considered for systemic thrombolytic (ST) based upon guideline recommendations, but intermediate-risk PE does not currently have strong evidence to guide primary reperfusion strategies via thrombolytic administration. Ultrasound-assisted catheter-directed thrombolysis (USAT) is an alternative reperfusion option to ST but is not currently recommended as first line in any key guidelines due to limited available evidence. This retrospective, multicenter, observational study compares 210 patients treated with USAT (n = 105) or ST (n = 105) for acute high- or intermediate-risk PE in three hospitals. Baseline characteristics were significant in that severity of illness was higher in those that received ST, which limited comparisons of outcomes. The primary outcome of major bleeding in patients receiving USAT was 15.2% and 22.9% in those that received ST. Efficacy of reperfusion strategy was observed to be 86.7% of patients in USAT group and 65.7% in ST group. Reperfusion strategies had no difference in in-hospital death, intensive care length of stay, or hospital length of stay. Predefined subgroup analysis found that high-risk PE had higher mortality (14.7%) than intermediate-risk PE (0%) regardless of reperfusion strategy. Upon multivariate analysis, high-risk PE was the only independent risk factor for major bleeding while USAT therapy and intermediate-risk PE were independent predictors of efficacy. Due to the difference in baseline severity of illness, direct comparisons in primary outcomes to each group was not performed. We have described real world usage of both USAT and ST and which patients were likely to receive each therapy at these institutions.

Emergent surgical embolectomy for middle cerebral artery occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm in the anterior communicating artery

Background: Intracranial embolism related to cerebral angiography is rare but one of the complications of the procedure. However, the standard management of acute intracranial embolism for this etiology has not been established, and there have been very few reports in the past.Case Description: A 68-year-old male was incidentally found to have an unruptured aneurysm of anterior communicating artery (ACoA). Immediately after the cerebral angiography for the purpose of detailed examination of the aneurysm, the right partial hemiparalysis and mild aphasia developed. Magnetic resonance imaging/angiography (MRI/A) revealed an occlusion in the peripheral part of the left middle cerebral artery (MCA). Due to the existence of magnetic resonance angiography-diffusion mismatch, emergent craniotomy was immediately performed to remove intra-arterial thrombus. We also performed clipping for an unruptured ACoA aneurysm with this approach. Postoperative MRI/A showed that the occluded artery was recanalized and a slight infarction was observed in the left cerebral hemisphere. The patient was discharged on foot and followed at outpatient clinic over 4 years without no neurological deficit.Conclusion: Emergent surgical embolectomy for distal MCA occlusion related to cerebral angiography followed by neck clipping for an unruptured aneurysm of the ACoA was successful in treating acute occlusion of the peripheral part of the MCA in a patient with an unruptured aneurysm. As there are few similar cases, there is controversy about the best management, but this surgical method can be a safe and effective treatment.

P1701 Biatrial thrombus detection in a patient with atrial paroxysmal fibrillation and asymptomatic massive pulmonary embolism

Abstract Introduction Computed tomography (CT) is a noninvasive test for detection of LA and LAA thrombus.Although the transesophageal echocardiogram is the gold standart method, it can have rare but potential life threatening complications.Case report:A 62 y.o woman presented to the ER complaining of palpitations started less then 12h ago with no chest pain or dispnea.She was diagnosed with high rate paroxysmal atrial fibrillation (HR∼120/min).The ECG showed AF with no specific changes,the troponin I (TPI) level was negative and a TTE revealed a dilated left atria.The other lab results were within normal range(TBC and blood chemistry).Her past medical history included hypertension and diabetes type 2 for 10 years and 6 months respectively both on regular treatment and obesity.Also 2 months ago she was diagnosed with Hashimoto thyroiditis and close monitoring of TSH was recommended but no treatment.Subsequently,LMWH (enoxaparin) and amiodarone loading dose for cardioversion were started.After 24h the pt was still in AF,with a controlled heart rate and no complains.However ECG changes were noticed (evolutive T negative waves in leads D1,D2,aVL,V3-V6).A D-Dimer was requested and came back negative,O2 saturation was 97%.The asymptomatic pt was transferred to the Cardiology ward for further evaluation.TPI remained negative.Due to the cardiac risk factors and the ECG changes it was decided to perfom a coronary angiography which resulted normal.An electrical cardioversion was considered.Both TEE and pulmonary angio CT were requested prior.Because of the ECG changes the CT was performed first and showed central and peripheric bilateral pulmonary artery clots present also in both the left and right atrial auricles.Due to the massive thromboembolism(PE) unfractioned heparin was immediately started (aPTT 50-70s).A new TTE showed a PAP of 50 mmHg.Approximately 10h after the heparin infusion,the pt became hypotensive and started complaining of dyspnea,tachypnea,cough,pleuritic pain and fever(high temperature 39.5-40ᵒC).Considering the deteriorating conditions she was consulted by a cardiac surgery team and it was decided to perform an emergency surgical pulmonary embolectomy despite the high risk.Within 24h,the pt underwent a surgical embolectomy of the right and left pulmonary branches after incision of the pulmonary artery, as well as a clot embolectomy of the right and left atria auricles (confirmed by intraoperatory TEE).She was put on an iv heparin regimen and recovered well.She was discharged 2 weeks later in good condition,with a PAP of 40 mmHg,on acenocoumarol with persistent AF.1.5 years later she is in NYHA class I,in sinus rhythm taking rivaroxaban 20 mg/d.Discussion: Biatrial thrombus detection in both atrial auricles is rare as well as in this case a massive PE without a stroke.CT can be used as an alternative modality for detecting thrombus in selected high risk patients because it shows a good diagnostic accuracy with high sensitivity and specificity. Abstract P1701 Figure. Biatrial clots on CT and removed ones

FREE FLOATING RIGHT HEART THROMBI AND PULMONARY EMBOLI: A CASE SERIES

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Free floating right heart thrombi (FFRHT) often portend imminent pulmonary embolism (PE) and warrant immediate intervention given their association with high mortality rates - ranging from 27% to 44% with up to 20% mortality within the first day of admission by some reports. Management remains controversial without specific society guidelines, and multiple surgical and pharmacologic treatments have previously been described. Here we present three cases of patients with FFRHT with markedly different management and outcomes. CASE PRESENTATION: Case 1: A 70-year-old man with recent ankle fracture presented with dyspnea and dizziness and was found to have a femoral vein thrombus. Transthoracic echo (TTE) showed right ventricular dilatation and a FFRHT (Fig. 1). He underwent emergent surgical embolectomy with extraction of multiple extensive clots and temporary placement of a right ventricular assist device (RVAD). The patient was later discharged from the hospital with no functional impairment. Case 2: A 74-year-old male dialysis patient presented with fever and pain at his fistula site and received empiric treatment for sepsis. The following day, he developed respiratory failure which progressed to cardiac arrest and underwent six minutes of CPR with ROSC. TTE showed biventricular failure with minimal cardiac activity and a visible RHT (Fig. 2). He received tissue plasminogen activator (tPA) with some improvement on repeat TTE, but soon succumbed to his illness. Case 3: A 49-year-old woman with Hodgkin’s lymphoma and recent left hip replacement presented with dyspnea and calf pain, and was found to have femoral vein thrombosis as well as large bilateral central submassive PE (Fig. 3). Therapeutic anticoagulation was started and TTE showed a large mobile thrombus in the right atrium, which appeared to traverse the inter-atrial septum with a mobile component in the left atrium. She was given tPA and serial repeat TTE showed resolution of RHT and right heart strain. The patient was discharged from the hospital in good condition on oral anticoagulation. DISCUSSION: RHT can be type A "clot in transit” (originating in the periphery) or type B (originating in the right heart). Type A RHT are strongly associated with PE. The existing literature on their management is controversial - while association with PE and high mortality is clear, few reports compare outcomes from anticoagulation alone to thrombolysis or surgical embolectomy (with or without RVAD placement). Incidence of FFRHT is likely drastically underestimated, and is expected to continue rising as bedside cardiac ultrasound becomes more prevalent in the initial assessment of patients with PE. CONCLUSIONS: Bedside cardiac ultrasonography is vital in assessing patients with PE to improve detection of FFRHT. Management of these patients with either thrombolysis or surgical embolectomy should be considered in addition to anticoagulation. Reference #1: Barrios D, Chavant J, Jimenez D, Bertoletti L, Rosa-Salazar V, Muriel A, et al. Treatment of right heart thrombi associated with acute pulmonary embolism. Am J Med. 2017;130:588-595 Reference #2: Koc M, Kostrubiec M, Elikowski W, Meneveau N, Lankeit M, Grifoni S, et al. Outcome of patients in right heart thrombi: the right heart thrombi european registry. Eur Respir J. 2016; 47:869-875 Reference #3: Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thrombo-emboli. Chest. 2002;121:806-814 DISCLOSURES: Speaker/Speaker's Bureau relationship with pfizer Please note: $5001 - $20000 Added 03/20/2019 by ron goldenberg, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Janssen Please note: $5001 - $20000 Added 03/20/2019 by ron goldenberg, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with BMS Please note: $5001 - $20000 Added 03/20/2019 by ron goldenberg, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with melinta Please note: $1001 - $5000 Added 03/20/2019 by ron goldenberg, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with allergan Please note: $5001 - $20000 Added 03/20/2019 by ron goldenberg, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with merck Please note: $5001 - $20000 Added 03/20/2019 by ron goldenberg, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with achaogen Please note: $5001 - $20000 Added 03/20/2019 by ron goldenberg, source=Web Response, value=Honoraria No relevant relationships by Ingrid Gunther, source=Web Response No relevant relationships by Ali Hafiz, source=Web Response No relevant relationships by Susan Mirabal, source=Web Response My spouse/partner as a Advisory Committee Member relationship with CORECEPT Please note: $1001 - $5000 Added 03/15/2019 by Vikramjit Mukherjee, source=Web Response, value=Consulting fee No relevant relationships by Odai Sinokrot, source=Web Response No relevant relationships by James Tsay, source=Web Response No relevant relationships by Winnie Yan, source=Web Response

A hybrid operating room for combined surgical and endovascular procedures for cerebrovascular diseases: a clinical experience at a single centre

Purpose: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).Material and methods: A single-plane DSA system with 3-dimensional rotational angiography (3DRA), cone-beam computed tomography, and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of neurovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorised into five subcategorical procedures according to the dominance of surgical and/or endovascular procedures: intraoperative angiographic evaluation, combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, surgical approach for interventional procedure, and frameless stereotaxic operation.Results: Intraoperative angiography revealed unsatisfactory clipping of intracranial aneurysms in 6 (13.6%) patients and remnant AVMs in 1 (16.7%) patient, which were determined as complete surgical outcome via indocyanine green videoangiography. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial haemorrhage (ICH) were treated by partial embolisation and surgical clipping. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolisation. In 1 (0.8%) complicated case of 103 intra-arterial (IA) thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. Direct puncture of the common carotid artery or vertebral artery was performed to achieve interventional access to treat aneurysm or recanalise vessel occlusions in 7 cases. In 27 cases of ICH, frameless stereotaxic haematoma aspiration was performed using XperGuide® system. All procedures were performed in single sessions without any procedural complications.Conclusion: Hybrid OR with a fully equipped DSA system could provide safe and precise treatment for neurovascular diseases. Hybrid procedures for neurovascular diseases in hybrid OR are a promising new trend.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease.

ObjectiveTo describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).MethodsA single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.ResultsForty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.ConclusionHybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

Nitinol clip distal migration and resultant popliteo-tibial artery occlusion complicating access closure by the StarClose SE vascular closure system

Lower extremity ischemia following deployment of a vascular closure device for access site closure after a transfemoral endovascular procedure rarely occurs. A 68-year-old woman diagnosed with subarachnoid hemorrhage due to...

Direct Microsurgical Embolectomy for Acute Occlusion of the Internal Carotid Artery and Middle Cerebral Artery

Surgical embolectomy is the most promising therapy for physically removing emboli from major cerebral arteries. However, it requires an experienced surgical team, time-consuming steps, and is not incorporated into acute stroke therapy. We established seamless collaboration between services, refined surgical techniques, and conducted a prospective trial of emergency surgical embolectomy. Surgical indications included the presence of acute hemispheric symptoms, absence of low-density area on computed tomography, evidence of internal carotid artery terminus or proximal middle cerebral artery occlusion, and availability of resources to start surgery within 3 hours of symptom onset. The indications were confirmed by an interdisciplinary team. We assessed revascularization rates, time from admission to surgery and from surgery to recanalization, procedural complications, and clinical outcomes. Between 2005 and 2014, 14 consecutive patients with acute proximal middle cerebral artery or internal carotid artery terminus occlusion underwent emergency surgical embolectomy. All patients showed complete recanalization. Twelve patients survived and 7 had fair functional outcome (Rankin Scale score, ≤3). No significant procedural adverse events occurred. The mean times from admission to start of surgery, from surgery to recanalization, and from onset to recanalization were 14 minutes, 79 minutes, and 223 minutes, respectively. Our results suggest that microsurgical embolectomy can rapidly, safely, and effectively retrieve clots and deserves reappraisal, although the choice largely depends on local institutional expertise.

Emergent cervical surgical embolectomy for extracranial internal carotid artery occlusion.

Acute extracranial internal carotid artery (ICA) occlusion by a huge cardiogenic embolus is rare, but can be catastrophic. Seven patients with acute ischemic stroke due to embolic occlusion of extracranial ICA who underwent emergent cervical surgical embolectomy were retrospectively reviewed. Diagnosis was made in six patients with magnetic resonance imaging (MRI) with optional digital subtraction angiography (DSA), while computed tomography (CT) and DSA were used in one patient with an implanted pacemaker. Clinical outcomes, including recanalization rate, recanalization time, complications, modified Rankin scale (mRS) at 3 months, and National Institute of Health Stroke Scale (NIHSS) score improvement at 1 month were evaluated. Complete recanalization was obtained in seven patients (100 %). Median recanalization time from symptom onset and from start of surgery was 402 and 40 min, respectively. All seven patients showed severe left ventricular hypertrophy (LVH) according to an increased cardiothoracic ratio (CTR) ≥50 %. Complications included recurrence of cardioembolic stroke with the right middle cerebral artery occlusion, minimal expansion of infarction, and aggravation of heart failure, each in one patient, respectively. Four (57.1 %) patients had a history or postoperative recurrence of cardioembolic stroke. Median NIHSS at 1 month was 2 (range, 0-30). Median mRS at 3 months was 2 (range, 0-5). Five patients (71.4 %) had a favorable outcome (mRS2). Cervical surgical embolectomy for acute extracranial ICA occlusion resulted in a high complete recanalization rate with an acceptable safety profile. A possible association between severe cardiac illness and huge embolus occluding proximal large artery was suggested.

Aortic and right ventricular rupture in a patient after transcatheter aortic valve implantation; The direction of the calcification predicts aortic annulus rupture

Severe aortic valve stenosis (AS) is related significantly to morbidity and mortality, if untreated. The recent reports showed that TAVI for severe AS is feasible, associated with similar rate of major adverse events with surgery, and results in improved functional status in these patients. Transcatheter aortic valve implantation (TAVI) procedure has been applied in increasing amounts as a novel alternative choice of treatment in patients with aortic valve disease in case of high risk of cardiac surgery. But, there are possible dangerous and life-threatening complications at any moment during the TAVI procedure [ 1 Seiffert M. Conradi L. Baldus S. Schirmer J. Blankenberg S. Reichenspurner H. Diemert P. Treede H. Severe intraprocedural complications after transcatheter aortic valve implantation: calling for a heart team approach. Eur. J. Cardiothorac. Surg. Sep 2013; 44: 478-484 Crossref PubMed Scopus (37) Google Scholar , 2 Sgroi C. Gulino S. Attizzani G.F. Immè S. Patanè M. Ohno Y. Cannata S. Giarratana A. Aruta P. Bottari V. Barbanti M. Deste W. Giannazzo D. Tamburino C. Valve rupture after balloon aortic valvuloplasty successfully managed with emergency transcatheter aortic valve implantation. Int. J. Cardiol. Sep 20 2013; 168: e13-e14 Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar , 3 Griese D.P. Reents W. Kerber S. Diegeler A. Babin-Ebell J. Emergency cardiac surgery during transfemoral and transapical transcatheter aortic valve implantation: incidence, reasons, management, and outcome of 411 patients from a single center. Catheter. Cardiovasc. Interv. Nov 1 2013; 82: E726-E733 Crossref PubMed Scopus (27) Google Scholar , 4 Pavicevic J. Nguyen T.D. Caliskan E. Reser D. Frauenfelder T. Plass A. Stähli B.E. Maier W. Seifert B. Maisano F. Falk V. Corti R. Grünenfelder J. Emmert M.Y. Aortic valve calcium score is a significant predictor for the occurrence of post-interventional paravalvular leakage after transcatheter aortic valve implantation — results from a single center analysis of 260 consecutive patients. Int. J. Cardiol. Feb 15 2015; 181: 185-187 Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar , 5 Montarello N. Copus B. Prakash R. Worthley S.G. Peripheral embolization of aortic valve calcium following trans-femoral Sapien XT valve implantation requiring emergency surgical embolectomy. Int. J. Cardiol. Feb 15 2015; 181: 17-18 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar ]. The aortic annulus and other structures of the aortic root may be damaged iatrogenically at various levels during the balloon inflation and valve implantation. Rupture of the aortic root during and after percutaneous valve implantation is a rare and potentially lethal complication. So, the landing zone of the valve and the direction of the annular calcification are very important to predict the aortic annulus rupture. Although there is enough time to repair of the aortic annulus during standard surgical procedure, it is very difficult to control this complication during TAVİ procedure. For this reason, it is very important to recognize and be aware of this event and take all preventive actions to prevent the complications on time. The treatment of the aortic annulus rupture is difficult or even mostly untreatable and the only treatment option for this complication is surgical replacement of the aortic root. Herein, we report a case of a 74-year-old woman with aortic annulus and right ventricular rupture after successful TAVI procedure.

Peripheral embolization of aortic valve calcium following trans-femoral Sapien XT valve implantation requiring emergency surgical embolectomy

Trans-catheter Aortic Valve Implantation (TAVI) is a well-established, alternative, standard of care treatment option for inoperable and high risk patients with severe, symptomatic aortic stenosis (AS) [1]. Peri-procedural cerebrovascular events are a known complication of TAVI and comprise more than half of TAVI related strokes with a 30day incidence of 2–5% [2]. In the acute (<24hours) and sub-acute (1–30day) setting, post-TAVI stroke may be due to embolization of atherosclerotic or calcific material from the aortic valve, the risk of which is increased when valve embolization occurs or post-dilatation is carried out [3].

肺血栓塞栓症に対し, 外科的血栓除去術を施行し軽快した一例

症例は39歳女性. 突然の呼吸困難とめまいを主訴に発症し, 緊急搬送となった. 造影CTで, 肺血栓塞栓症 (PTE : Pulmonary thromboembolism) および深部静脈血栓症 (DVT : Deep vessel thrombosis) と診断した. 血栓症の危険因子として肥満, 高血圧症, 経口避妊薬内服歴があげられた. 入院後循環動態が安定していたため, PTEに対しては抗凝固療法を開始し, DVTに対しては血栓の大きさを考慮し下大静脈フィルターの適応はないと判断された. しかし第3病日の造影CTでの再評価では肺血栓は増大しており心臓超音波検査でも肺高血圧所見を認めたため, 外科的血栓除去術を緊急的に行った. 血栓除去後すぐに心機能は回復せず, 体外循環下にICU帰室したが, その後経過は良好で術後22日に独歩退院した. 呼吸・循環動態の安定している肺血栓塞栓症の基本的治療は抗凝固療法だが, 奏功しない症例においては外科的血栓除去術を考慮すべきである.

Mobile left ventricular thrombus in left ventricular dysfunction: case report and review of literature

Left ventricular (LV) thrombi carry a high risk of embolization. Therapeutic recommendations like treatment with low molecular heparin and intravenous unfractionated heparin (UFH), thrombolysis or surgical thrombectomy have failed to reach a consensus. A 56-year-old female patient presented in cardiogenic shock to the emergency department. Echocardiography demonstrated a dilated LV with a severely depressed global systolic function and a large LV apical thrombus. Treatment with UFH was initiated as well as a treatment with catecholamines for stabilizing the patient's hemodynamic situation. On the follow-up echocardiographic examination, extensive free-floating parts of the thrombus could be documented. Given the high risk of embolization in a now hemodynamically stable situation, emergency surgical embolectomy was performed. A conservative procedure might be useful for bridging till surgical treatment is available and/or the risk due to surgery is acceptable. In absence of evidence-based guidelines for the treatment of LV thrombi, individualized management options concerning surgical, embolization and bleeding risk must be taken into account.

Life-Threatening Pulmonary Embolism: A Multidisciplinary Approach to Diagnosis and Management

Current treatment of life threatening venous thrombo-embolism (VTE) has been based on general concepts dating to the early 1900s. In this manuscript a general overview of current diagnostic and therapeutic methods of VTE is presented along with the Emory University Affiliated Hospitals’ experience of the surgical treatment of life threatening VTE. We retrospectively analyzed the data of twenty-seven consecutive patients who underwent pulmonary embolectomy on cardiopulmonary bypass from January 1998 through April 2010. Our results showed successful outcomes after urgent or emergent surgical pulmonary embolectomy. It encourages the choice of an early and aggressive surgical approach for large pulmonary emboli in hemodynamically unstable patients.

Aggressive Surgical Treatment of Acute Pulmonary Embolism With Circulatory Collapse

Acute high-risk pulmonary embolism is a life-threatening condition with high early mortality rates resulting from acute right ventricular failure and cardiogenic shock. We retrospectively analyzed the outcomes of surgical embolectomy among patients with circulatory collapse. Between July 2000 and September 2011, 24 consecutive patients (17 women and 7 men; mean age, 59.9±17.2 years) underwent emergency surgical embolectomy to treat acute pulmonary embolism with circulatory collapse. Nineteen (79.2%) patients were in cardiogenic shock, and 16 (66.7%) patients received preoperative percutaneous cardiopulmonary support. Eleven (45.8%) patients were in cardiac arrest. The preoperative pulmonary artery obstruction index was 76.9%±16.4% (median, 88.9%; range, 44.4%-88.9%). The indications for surgical intervention were cardiogenic shock (n=16 [66.7%]), failed medical therapy or catheter embolectomy (n=4 [16.7%]), or contraindication for thrombolysis (n=4 [16.7%]). Follow-up was 100% complete with a mean of 6.8±3.9 years (median, 5.6 years). The in-hospital mortality rate was 12.5% (n=3). One patient underwent a repeated embolectomy on postoperative day 6. The postoperative course was complicated by cerebral infarction and by mediastinitis in 1 patient each. The 5-year cumulative survival rate was 87.5%±6.8%. Mean right ventricular pressure significantly decreased from 66.9 to 28.5 mm Hg among the survivors. Surgical pulmonary embolectomy is an excellent approach to treating acute pulmonary embolism with circulatory collapse. Providing immediate percutaneous cardiopulmonary support to patients with cardiogenic shock could help to resuscitate and stabilize cardiopulmonary function and allow for a good outcome of pulmonary embolectomy.

Delayed intracardial shunting and hypoxemia after massive pulmonary embolism in a patient with a biventricular assist device

We describe the interdisciplinary management of a 34-year-old woman with dilated cardiomyopathy three months postpartum on a cardiac biventricular assist device (BVAD) as bridge to heart transplantation with delayed onset of intracardial shunting and subsequent hypoxemia due to massive pulmonary embolism. After emergency surgical embolectomy pulmonary function was highly compromised (PaO2/FiO2 54) requiring bifemoral veno-venous extracorporeal membrane oxygenation. Transesophageal echocardiography detected atrial level hypoxemic right-to-left shunting through a patent foramen ovale (PFO). Percutaneous closure of the PFO was achieved with a PFO occluder device. After placing the PFO occluder device oxygenation increased significantly (Δ paO2 119 Torr). The patient received heart transplantation 20 weeks after BVAD implantation and was discharged from ICU 3 weeks after transplantation.An increase in pulmonary vascular resistance in patients on BVAD can reopen a PFO resulting in atrial right-to-left shunting and subsequent hypoxemia. The case demonstrates the usefulness of transesophageal echocardiography examinations in the detection of this unexpected event. Percutaneous placement of a PFO occluder device is an appropriate strategy to stop intracardiac shunting through PFO in fixed elevation of pulmonary vascular resistance.

Emergency Surgical Embolectomy for Pulmonary Emboli after Failed Thrombolysis

A 34-year-old man presented in cardiogenic shock secondary to massive pulmonary embolism. Surgical embolectomy was performed after failed thrombolysis. Intraoperatively, a right atrial lesion and pulmonary emboli were removed. Histopathology revealed myxoma complicated by pulmonary emboli. The patient made a good recovery. This case suggests that surgical embolectomy should be considered as first-line treatment for all patients with acute massive pulmonary embolism, and not reserved for those with severe hemodynamic compromise or failed conservative management.

Intra-atrial embolus trapped in patent foramen ovale before systemic embolization

CLINICAL SUMMARY A 67-year-old woman presented to the emergency department with a subacute onset of exertional dyspnea that was not associated with angina. Her medical history was positive for hypertension and dyslipidemia. Vital signs were stable except for pulse oxymetry of 89% on room air. Physical examination was positive for mild tachypnea, tachycardia, and a faint systolic murmur. Cardiac enzymes were normal. A subacute valvular pathology was suspected, and an urgent transthoracic echocardiography was performed, which demonstrated an embolus extending from the right atrium to the left atrium across a PFO (Figure 1). The embolus also protruded into the ventricles. In addition, pulmonary hypertension of 70 mm Hg systolic pressure was noted. A computed tomography pulmonary angiography was thus obtained to assess the pulmonary arterial tree for possible embolism, revealing the extension of the embolus from the right atrium into the left atrium (Figure 2, A) and bilateral pulmonary emboli (Figure 2, B). The patient underwent emergency surgical embolectomy under cardiopulmonary bypass. A 12-cm–long transseptal intraatrial embolus traversing the PFO and floating freely into the ventricles and an extensive bilateral pulmonary embolism were found intraoperatively. Both the emboli in the atria and the main pulmonary arteries were removed via a right atriotomy and pulmonary arteriotomy, respectively, and the PFO was closed with primary suturing. The patient made a good postoperative recovery. Postoperative Doppler ultrasound of the lower limbs revealed deep venous thrombosis in the right thigh, most likely the origin of the thrombus.

Pulmonary thromboembolism with thrombus trapped in a patent foramen ovale — the “floating thrombus sign” on CTPA

We present two patients investigated using computed tomography (CT) and found to have a thrombus lodged within a patent foramen ovale (PFO) in association with pulmonary embolism. One patient was managed with emergency surgical embolectomy because of the risk of fragmentation and systemic embolization, and the other was managed conservatively because of significant pulmonary hypertension and inferred high surgical risk. Free-floating thrombus straddling a PFO has been previously reported using transoesophageal echocardiography (TOE); however, the CT appearance of this entity has not been previously documented. The detection of thrombus trapped within a PFO is an important finding with significant management implications for the patient. These cases highlight the importance of reviewing the interatrial septum on CT examinations of the thorax.