Fatal Pulmonary Embolism Research Articles

Clinical outcomes of AngioJet pharmacomechanical thrombectomy versus catheter-directed thrombolysis for the treatment of filter-related caval thrombosis.

The inferior vena cava filter is utilized worldwide to intercept thrombi and to reduce the risk of fatal pulmonary embolism (PE). However, filter-related thrombosis is a complication of filter implantation. Endovascular methods such as AngioJet rheolytic thrombectomy (ART) and catheter-directed thrombolysis (CDT) can treat filter-related caval thrombosis, but the clinical outcomes of both treatment modalities have not been determined. To compare the treatment outcomes of AngioJet rheolytic thrombectomy vs catheter-directed thrombolysis in patients with filter-related caval thrombosis. In this single-center retrospective study, 65 patients (34 males and 31 females; mean age: 59.0 ± 13.43 years) with intrafilter and inferior vena cava thrombosis were enrolled between January 2021 and August 2022. These patients were assigned to either the AngioJet group (n = 44) or the CDT group (n = 21). Clinical data and imaging information were collected. Evaluation measures included thrombus clearance rate, periprocedural complications, urokinase dosage, incidence of PE, limb circumference difference, length of stay, and filter removal rate. Technical success rates were 100% in the AngioJet and CDT groups. In the AngioJet group, grade II and grade III thrombus clearance was achieved in 26 (59.09%) and 14 (31.82%) patients, respectively. In the CDT group, grade II and grade III thrombus clearance was accomplished in 11 (52.38%) patients and 8 (38.10%) patients, respectively (P > 0.05).The peridiameter difference of the thigh was significantly reduced in patients from both groups after treatment (P < 0.05). The median dosage of urokinase was 0.08 (0.02, 0.25) million U in the AngioJet group and 1.50 (1.17, 1.83) million U in the CDT group (P < 0.05). Minor bleeding was shown in 4 (19.05%) patients in the CDT group, and when it was compared with that in the AngioJet group, the difference was statistically significant (P < 0.05). No major bleeding occurred. Seven (15.91%) patients in the AngioJet group had hemoglobinuria and 1 (4.76%) patient in the CDT group had bacteremia. There were 8 (18.18%) patients with PE in the AngioJet group and 4 (19.05%) patients in the CDT group before the intervention (P > 0.05). Computed tomography angiopulmonography (CTA) showed that PE was resolved after the intervention. New PE occurred in 4 (9.09%) patients in the AngioJet group and in 2 (9.52%) patients in the CDT group after theintervention (P > 0.05). These cases of PE were asymptomatic. The mean length of stay was longer in the CDT group (11.67 ± 5.34 d) than in the AngioJet group (10.64 ± 3.52 d) (P < 0.05). The filter was successfully retrieved in the first phase in 10 (47.62%) patients in the CDT group and in 15 (34.09%) patients in the AngioJet group (P > 0.05).Cumulative removal was accomplished in 17 (80.95%) out of 21 patients in the CDT group and in 42 (95.45%) out of 44 patients in the ART group (P > 0.05). The median indwelling time for patients with successful retrieval was 16 (13139) d in the CDT group and 59 (12231) d in the ART group (P > 0.05). Compared with catheter-directed thrombolysis, AngioJet rheolytic thrombectomy can achieve similar thrombus clearance effects, improve the filter retrieval rate, reduce the urokinase dosage and lower the risk of bleeding events in patients with filter-related caval thrombosis.

Analysis of echocardiographic criteria for pulmonary embolism

To date, the search for the most informative diagnostic and prognostic echocardiographic criteria for pulmonary embolism is relevant. Aims. To conduct a critical analysis of the generally accepted echocardiographic criteria for pulmonary embolism in order to establish the most significant of them in determining the severity and outcomes of the disease. Materials and methods. The study included 42 patients with fatal pulmonary embolism, 51 patients with hemodynamically unstable and 193 with hemodynamically stable course of the disease. The prevalence of generally accepted echocardiographic criteria for overload of the right heart was assessed, followed by their significance for determining the severity of the disease and predicting its outcomes. Results. It was found that among the generally recognized echocardiographic criteria, the most significant for determining the severity of pulmonary embolism and its outcomes are: an increase in the ratio of basal sizes of the right and left ventricles more than 1.1, an increase in systolic pressure in the pulmonary artery more than 55 mm Hg, dyskinesia of the free wall of the right ventricle, flattening of the interventricular septum, a decrease in systolic excursion the plane of the tricuspid valve is less than 1.6 cm. However, all of them, except the last one, do not have high sensitivity and specificity. The significance of the currently underestimated cardiac stroke volume as a prognostic indicator of echocardiography has been established. It was determined that its decrease of less than 45 ml correlated with hemodynamic instability of the course of the disease, and less than 35 ml was associated with a fatal outcome. This indicator had high diagnostic characteristics. Conclusion. A decrease in the systolic excursion of the tricuspid valve plane of less than 1.6 cm and a decrease in the stroke volume of the heart of less than 45 ml are the most significant indicators of echocardiography in assessing the severity and prognosis of pulmonary embolism.

Imaging Findings in Pulmonary Fat Embolism: Literature Review and Practical Aspects

Imaging Findings in Pulmonary Fat Embolism: Literature Review and Practical Aspects

Early recognition of pulmonary complications of sickle cell disease

Sickle cell disease (SCD) is an inherited hematological disorder with multiple-organ involvement. The pulmonary complications of SCD are associated with significant morbidity and mortality. This article presents an important review of acute and chronic pulmonary complications, including acute chest syndrome, pneumonia, pulmonary thromboembolism, pulmonary fat embolism, chronic sickle cell lung disease, and pulmonary hypertension, in patients with SCD. Bronchial asthma and obstructive sleep apnea in relation to SCD are discussed in this article. Early recognition of pulmonary complications leads to early therapeutic interventions and improvement of the overall treatment outcome.

Research progress of D-dimer in the diagnosis of perioperative lower limb deep vein thrombosis in fracture

Deep vein thrombosis is a disorder of venous return caused by abnormal intravascular coagulation, which has a high perioperative incidence in orthopedic patients and can develop into venous thrombosis syndrome and even fatal pulmonary embolism in severe cases. As a specific marker of thrombosis, D-dimer is widely used in diagnosing perioperative deep vein thrombosis in fractures, but its specificity in clinical diagnosis is low. It is often necessary to combine dynamic monitoring, ultrasound, Wells score, fibrinogen, and homocysteine to improve the accuracy of diagnosis. The authors have searched the literature and compiled a review of the latest research on D-dimer in diagnosing and managing deep vein thrombosis for clinical reference.

Relationship between vascular access and angulation of vena cava filter at placement and retrieval: a multicenter retrospective cohort study.

Inferior vena cava (IVC) filters are commonly used intravascular devices designed to prevent fatal pulmonary embolism (PE), maintaining the IVC filter as centered as possible is fundamental for achieving its filtration function. This study aimed to characterize the tilt angles of IVC filter between the vascular access of internal jugular vein (IJV) and femoral vein (FV), as well as to identify factors associated with increased or decreased tilt angles between placement and retrieval. This is a multicenter retrospective study. A multicenter retrospective study was conducted from October 2017 to March 2019. The primary outcome was the change in filter tilt between placement and retrieval. The secondary outcome was the identifications of factors associated with increased or decreased tilt angle. Relevant variables were analyzed using t-tests, Chi-square tests, Fisher's exact tests, while multivariate logistic regression analysis was used to determine risk factors. A total of 184 eligible patients were included in this study. The IJV group had a lower likelihood of tilt angle over 10° at the time of placement compared to the FVs group (0% versus 12.5%, p = 0.040). Among the 171 patients with a mean dwell time of 22.1 days, the IJV group had a higher likelihood of tilt angle over 10° than the FVs group (10.3% versus 2.3%, p = 0.080). The use of FVs access at placement was associated with a higher difference between placement and retrieval filter tilt angles (p < 0.01). Multivariate logistic regression analysis showed that hypertension [odds ratio (OR) 0.668; 95% confidence interval (CI) 0.328-1.358, p = 0.265], cardiologic artery disease (OR 0.537; 95% CI 0.136-2.130, p = 0.377), cerebral venous disease (OR 0.555; 95% CI 0.186-1.651, p = 0.290), filter types (OR 1.624; 95% CI 0.851-3.096, p = 0.141), and IVC filter thrombosis (OR 1.634; 95% CI 0.804-3.323, p = 0.175) were not associated with increased filter tilt angle. Right side (OR 0.434; 95% CI 0.202-0.930, p = 0.032) or bilateral lower extremity deep vein thrombosis (LEDVT) (OR 0.383; 95% CI 0.148-0.995, p = 0.049) were identified as protective factors. IJV access was associated with a lower filter tilt angle at the time of placement, while FVs access was linked to a higher difference between placement and retrieval tilt angles. Right side or bilateral LEDVT were identified as protective factors against increased IVC filter tilt angle.

One filter may be enough for duplicate inferior vena cava filter implantation in patients with deep venous thrombosis: Two cases report

Duplicate inferior vena cava (IVC) is an uncommon congenital malformation, but should be treated carefully under the circumstances of deep venous thrombosis (DVT). However, there is a paucity of clinical guidance on this situation. Duplicate IVC was diagnosed based on the imaging examination that revealed the dual IVC. Deep venous thrombosis was diagnosed by Compression Doppler ultrasonography of both lower extremities with the high-elevated D-dimer. Retrievable IVC filters were implanted to prevent massive and fatal pulmonary embolism. Appropriate anticoagulation therapy was also performed. Two retrievable filters were successfully implanted and retrieved in two patients with deep venous thrombosis and duplicate inferior vena cava, respectively. During further follow-up, no adverse event was reported. Comprehensive imaging examination might contribute to the diagnosis of duplicate IVC, especially when individual conditions were limited. The position above the confluence of bilateral IVCs might be an appropriate suprarenal retrievable filter insertion location. To deal with different types of dual IVC anatomy, different strategies should be taken into consideration.

4D printing of shape memory inferior vena cava filters based on copolymer of poly(glycerol sebacate) acrylate-co-hydroxyethyl methacrylate (PGSA-HEMA)

Biodegradable shape memory polymers (SMP) with suitable transition temperatures (Tr) and mechanical properties are highly demanded in biomedical field as deployable medical devices. Herein, we report a 4D printing shape memory Inferior Vena Cava Filters (IVCFs), an implantation device, which could prevent the fatal pulmonary embolism, to exemplify the applicability of the biodegradable shape memory polymer in biomedical device field. The IVCF composed of poly(glycerol sebacate) acrylate-co-hydroxyethyl methacrylate (PGSA-co-HEMA) was digital light processing (DLP) 3D printed. The appropriate mechanical property and Tr = 37.8 °C, which is close to human body temperature, was tailored by tuning the ratio of the raw material. PGSA-PHEMA presents an excellent cytocompatibility, hemocompatibility and histocompatibility as implants. Besides, in vitro degradation results indicate the biodegradability but withhold the mechanical properties within the service time. Furthermore, the simulated filter deploying and fully emboli interception verifies the successful realization of the concept of rapid, minimally invasive and controllable implantation of the 4D printing of IVCFs through the SMP transformation process, and the feasibility of the filter as well. Therefore, this work provides a new biocompatible SMP and offers a new strategy for developing deployable medical devices.

Fatal Pulmonary Embolism Resulting From a Popliteal Venous Aneurysm.

Fatal Pulmonary Embolism Resulting From a Popliteal Venous Aneurysm.

Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial

ObjectiveTo compare two different treatment durations of rivaroxaban in patients with symptomatic isolated distal deep vein thrombosis (DVT).DesignRandomised, double blind, placebo controlled clinical trial.Setting28 outpatient clinics specialising in venous thromboembolism.Participants402...

CATHETER-DIRECTED THROMBECTOMY OF A SADDLE PULMONARY EMBOLUS

CATHETER-DIRECTED THROMBECTOMY OF A SADDLE PULMONARY EMBOLUS

Pulmonary embolism and 529 human blood metabolites: genetic correlation and two-sample Mendelian randomization study

BackgroundThe incidence of pulmonary embolism complications in the literature ranges from 10 to 50%, with a 0.5–10% risk of fatal pulmonary embolism. However, the biological cause of pulmonary embolism is unknown.MethodsThis study used data from the Genome-Wide Association Study (GWAS) of Pulmonary Embolism and Human Blood Metabolites from the UK Biobank, and the data from subjects of European ancestry were analyzed. We explored the relationship between pulmonary embolism and blood metabolites in three ways. We first analyzed the genetic correlation between pulmonary embolism and human blood metabolites using the linkage disequilibrium score regression (LDSC) and then analyzed the causal relationship between pulmonary embolism and meaningful blood metabolites obtained from the LDSC, a procedure for which we used Mendelian randomization analysis. Finally, we obtained transcriptome sequencing data for patients with a pulmonary embolism from the GEO database, analyzed differentially expressed genes (DEGs) in patients with pulmonary embolism versus healthy populations, and compared the DEGs with the resulting blood metabolite genes to further validate the relationship between pulmonary embolism and blood metabolites.ResultWe found six human blood metabolites genetically associated with pulmonary embolism, stearic acid glycerol phosphate ethanolamine (correlation coefficient = 0.2582, P = 0.0493), hydroxytryptophan (correlation coefficient = 0.2894, P = 0.0435), and N1-methyladenosine (correlation coefficient = 0.0439, P = 0.3728), and a significant causal relationship was discovered between hydroxytryptophan and pulmonary embolism. After screening microarray data from the GEO database, we performed differential gene analysis on the GSE19151 dataset and screened a total of 22,216 genes with P values less than 0.05, including 17,361 upregulated genes and 4854 downregulated genes. By comparing the resulting differentially expressed genes with six genes encoding blood metabolites, LIPC and NAT2 were found to be differentially expressed in association with pulmonary embolism.

Cancer Histology and Natural History of Patients with Lung Cancer and Venous Thromboembolism.

Simple SummaryCancer is a widely heterogeneous disease, and the natural history of patients with cancer-associated thrombosis may differ according to the cancer site. Lung cancer is the most common malignancy, and a leading cause of death. A number of studies in the literature suggest that patients with adenocarcinoma may have a worse outcome than those with squamous or other types of lung cancer. The aim of the current study was to assess the potential impact of lung cancer histology on the incidence rates of VTE recurrences, major bleeding, or death appearing during the course of anticoagulation, in patients with lung cancer and VTE. Our findings, obtained from a large series of consecutive patients with lung cancer and VTE (482 patients), reveal important differences between patients with adenocarcinoma vs. other histologies in their outcomes during anticoagulation. This might likely help to design better therapeutic strategies for patients with lung cancer.Background: In patients with lung cancer and venous thromboembolism (VTE), the influence of cancer histology on outcome has not been consistently evaluated. Methods: We used the RIETE registry (Registro Informatizado Enfermedad TromboEmbólica) to compare the clinical characteristics and outcomes during anticoagulation in patients with lung cancer and VTE, according to the histology of lung cancer. Results: As of April 2022, there were 482 patients with lung cancer and VTE: adenocarcinoma 293 (61%), squamous 98 (20%), small-cell 44 (9.1%), other 47 (9.8%). The index VTE was diagnosed later in patients with squamous cancer than in those with adenocarcinoma (median, 5 vs. 2 months). In 50% of patients with adenocarcinoma, the VTE appeared within the first 90 days since cancer diagnosis. During anticoagulation (median 106 days, IQR: 45–214), 14 patients developed VTE recurrences, 15 suffered major bleeding, and 218 died: fatal pulmonary embolism 10, fatal bleeding 2. The rate of VTE recurrences was higher than the rate of major bleeding in patients with adenocarcinoma (11 vs. 6 events), and lower in those with other cancer types (3 vs. 9 events). On multivariable analysis, patients with adenocarcinoma had a non-significantly higher risk for VTE recurrences (hazard ratio [HR]: 3.79; 95%CI: 0.76–18.8), a lower risk of major bleeding (HR: 0.29; 95%CI: 0.09–0.95), and a similar risk of mortality (HR: 1.02; 95%CI: 0.76–1.36) than patients with other types of lung cancer. Conclusions: In patients with lung adenocarcinoma, the rate of VTE recurrences outweighed the rate of major bleeding. In patients with other lung cancers, it was the opposite.

Case Report: A rare presentation of prostate cancer with peritoneal carcinomatosis and malignant ascites complicated by tumor lysis syndrome

Background: Only 32 cases of prostate cancer with peritoneal carcinomatosis and ascites have currently been reported in the literature. We present the first reported case of prostate cancer with peritoneal carcinomatosis and malignant ascites whose treatment was complicated by tumor lysis syndrome along with a literature review evaluating similar cases. Case: We present a rare case of a 78-year-old retired Caucasian male with recurrent metastatic prostate cancer and malignant ascites. He had previously received definitive radiotherapy for localized prostate cancer but presented with bilateral hydronephrosis and right-sided bladder wall thickening 10 years later. He had imaging evidence of locoregional recurrence with elevated prostate specific antigen (PSA) and was initiated on combined androgen blockade with intramuscular leuprolide and oral bicalutamide. After being transferred to Scripps Clinic, he was found to have a solitary right upper lobe pulmonary lesion for which he completed stereotactic body radiation therapy. Then, 10 months later, he developed new onset malignant ascites and was treated with two cycles of intravenous docetaxel. Treatment resulted in improvement in his ascites and reduction in PSA. Unfortunately, his course was complicated by tumor lysis syndrome, encephalopathy, Escherichia coli bacteremia, and a fatal saddle pulmonary embolism. Conclusions: (1) Occurrence of ascites in prostate cancer patients is associated with worse prognosis than non-ascitic variants. (2) More common etiologies of ascites must be evaluated for. (3) Ascitic fluid prostate specific antigen (PSA) measurement may aid in diagnosis of malignant ascites in cases with diagnostic uncertainty. (4) Patients with advanced disease may benefit from combined hormonal and cytotoxic therapies. (5) Awareness of the occurrence of tumor lysis syndrome (TLS) in patients treated for prostate cancer can help identify patients in whom prophylaxis would be beneficial.

Aspirin and the Hip: Back to the Future? A 70-Year History: Commentary on an article by Leanne Ludwick, BS, et al.: "Aspirin May Be a Suitable Prophylaxis for Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty".

Commentary In their article, Ludwick et al. provide data regarding the suitability of aspirin as prophylaxis against venous thromboembolism (VTE) in selected patients with a history of VTE undergoing total joint arthroplasty. Although observational, non-prospective, and nonrandomized, this study raises many questions about the practice of anticoagulation after arthroplasty during the last 50 years in orthopaedic surgery. In 1951, when Harold Ellis sat for the Fellowship examination of the Royal Colleges of Surgeons1, he was advised that, if questioned by an examiner, “What is the best treatment for osteoarthritis of the hip?” he should reply, “Provide the patient with a walking stick and prescribe aspirin.” In that time period, aspirin was given for pain. Later, when arthroplasty became the treatment for hip osteoarthritis, Charnley (cited by Salzman) and Harris2,3, as early as 1971, began to use aspirin to prevent fatal pulmonary embolism. Between 1970 and 2020, arthroplasties were performed with increasing frequency, and the risk of VTE in total hip arthroplasty (THA) was evaluated to be among the highest among procedures in all surgical specialties. Many drugs were tested and approved by regulatory agencies for the prevention of VTE. Yet, despite the millions of dollars spent on pharmaceutical research to develop new anticoagulants, we cannot answer4 this simple question: Which is the best one? Ludwick et al. confirm that aspirin, a drug known for 4,000 years, is still an actual pharmacologic approach for VTE prevention. Around 4,000 years ago5, herbal medicine used salicylic acid (the natural substance) from willow, myrtle, and meadow sweet. In the Assyrian and Sumerian periods, clay tablets recommended willow leaves for rheumatic disease. The aspirin that we know arrived in 1897 when a stabler form, acetylsalicylic acid, was synthesized by the chemist Felix Hoffmann (at Bayer in Germany), and in 1971 it was proposed to prevent VTE2. Why, for 50 years, have the pharmaceutical industry and orthopaedic surgeons spent so much money (compared with the cost of aspirin) without demonstrating the superiority of new anticoagulants? Nowadays, large-scale data, such as administrative governmental and clinical registries, are a powerful tool to answer questions, but only if there are answers to the questions. There is a difference between a scientific demonstration of effectiveness in the reduction of thrombophlebitis and pulmonary embolism and the scientific evaluation of effectiveness in the prevention of death by fatal pulmonary embolism. For the orthopaedic surgeon, the question remains simple: is it possible to predict and prevent a pulmonary embolism, particularly a fatal one? The prevalence of a fatal pulmonary embolism after hip arthroplasty is around 1.8% without prophylaxis and around 0.1% with any method of prevention4. Surgeons must remember that predicting the future remains difficult (even impossible). It is probably impossible to make a comparative scientific evaluation of the effectiveness of the prevention by 2 different treatments when the phenomenon is prevented. Clinicians use mortality statistics from the natural history of fatal pulmonary embolism and well-designed multicenter prospective studies of prevention using aspirin, anticoagulants, physical methods, or other drugs to change the natural history without increasing hematoma. A fair proportion of patients undergoing primary or revision arthroplasty are older than average. Underlying diseases and medications may contribute to the morbidity and mortality associated with the operation and pulmonary embolism. So, this prevention remains empirically a choice based on 2 assumptions: to use new methods to avoid death is to do good, and to use old methods suggests negligence. For many years, doing good appeared to be giving a new anticoagulation agent, which was more expensive, probably in the same way that doing good had been thought to be performing arthroplasty on young patients after that procedure became available. We know that the results of such thinking can sometimes be paradoxical. In an era of targeted therapy that is increasing health-care costs, aspirin is an old, inexpensive, and well-tolerated drug with a relatively low risk of excessive bleeding that, as proposed by Ludwick et al., may prove to be an effective agent to prevent venous thrombosis.

Statin use and 30‐day mortality in patients with acute symptomatic pulmonary embolism

BackgroundStatins possess antithrombotic and profibrinolytic properties. The association between statin use and short‐term outcomes in patients with acute pulmonary embolism (PE) remains unknown. MethodsWe used the data from the Registro Informatizado de Pacientes con Enfermedad TromboEmbólica registry to compare the 30‐day all‐cause mortality in patients with acute PE according to the use of statins. Secondary outcome was fatal PE. We used cancer‐related mortality as a falsification endpoint. ResultsFrom January 2009 to April 2021, 31 169 patients with PE were recruited. Of these, 5520 (18%) were using statins at baseline: low intensity: 829, moderate: 3636, high intensity: 1055. Statin users were older and had a higher frequency of diabetes, hypertension, or atherosclerotic disease than non‐users (P <0.001 for all comparisons). During the first 30 days, 1475 patients died (fatal PE, 255). On multivariable analysis, statin users had a lower risk of all‐cause death (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.56–0.76) and fatal PE (OR: 0.42; 95% CI: 0.28–0.62) than non‐users. The risk for death was lower in patients using either low‐ (OR: 0.51; 95% CI: 0.34–0.77), moderate‐ (OR: 0.68; 95% CI: 0.57–0.81), or high‐intensity statins (OR: 0.68; 95% CI: 0.51–0.92). Results did not change in mixed effects logistic regression models with hospitals as a random effect. Statins were not associated with a significant chance in cancer mortality (falsification endpoint). ConclusionsPE patients using statins at baseline had a significantly lower risk of dying within the first 30 days than non‐users. Randomized trials are needed to confirm these data.

Fatal pulmonary embolism in patients on antipsychotics: case series, systematic review and meta-analysis.

Since the 1950s, several studies have reported that patients using first generation and/or second-generation antipsychotics had increased risk of venous thromboembolism events. These events include deep vein thrombosis and/or pulmonary embolism (PE). However, data about fatal PE in patients on antipsychotics (APs) remain scarce. Thus, the current study aimed to investigate sociodemographic, clinical and pharmacological characteristics related to psychiatric patients on APs and who died from a fatal PE. We reported a case-series, then conducted a literature review of relevant studies and performed a meta-analysis of studies with usable data. The main outcome of the study suggested a significantly high risk of fatal PE in patients using APs compared to nonusers (Odds Ratio=6.68, with 95% confidence interval 1.43-31.11). Clozapine was the most incriminated drug. Low potency first generation APs were the second most exhibited medication. Studies about the topic remain scarce with a high heterogeneity and a high probability of bias. Further studies are needed to ascertain this risk and to establish target preventive measures in this particularly vulnerable population.

Thromboembolic Complications in COVID-19 Patients Hospitalized in Italian Ordinary Wards: Data from the Multicenter Observational START-COVID Register.

Background Coronavirus disease 2019 (COVID-19) infection causes acute respiratory insufficiency with severe interstitial pneumonia and extrapulmonary complications; in particular, it may predispose to thromboembolic disease. The reported incidence of thromboembolic complications varies from 5 to 30% of cases. Aim We conducted a multicenter, Italian, retrospective, observational study on COVID-19 patients admitted to ordinary wards, to describe the clinical characteristics of patients at admission and bleeding and thrombotic events occurring during the hospital stay. Results The number of hospitalized patients included in the START-COVID-19 Register was 1,135, and the number of hospitalized patients in ordinary wards included in the study was 1,091, with 653 (59.9%) being males and 71 years (interquartile range 59–82 years) being the median age. During the observation, two (0.2%) patients had acute coronary syndrome episodes and one patient (0.1%) had an ischemic stroke; no other arterial thrombotic events were recorded. Fifty-nine patients had symptomatic venous thromboembolism (VTE) (5.4%) events, 18 (30.5%) deep vein thrombosis (DVT), 39 (66.1%) pulmonary embolism (PE), and 2 (3.4%) DVT+PE. Among patients with DVT, eight (44.4%) were isolated distal DVT and two cases were jugular thrombosis. Among patients with PE, seven (17.9%) events were limited to subsegmental arteries. No fatal PE was recorded. Major bleeding events occurred in nine (1.2%) patients and clinically relevant nonmajor bleeding events in nine (1.2%) patients. All bleeding events occurred among patients receiving thromboprophylaxis, more frequently when treated with subtherapeutic or therapeutic dosages. Conclusion Our findings confirm that patients admitted to ordinary wards for COVID-19 infection are at high risk for thromboembolic events. VTE recorded among these patients is mainly isolated PE, suggesting a peculiar characteristic of VTE in these patients.

Indications and prognostic outcome of inferior vena cava filter

Abstract Background An inferior vena cava (IVC) filter is useful in patients with venous thromboembolism (VTE) who have any of the following conditions: contraindications to anticoagulants, recurrent pulmonary embolism (PE) despite anticoagulants or complications related to anticoagulants, and low cardiopulmonary reserve. This study aimed to assess indications, efficacy, and outcome of IVC filter insertion for patients with VTE. Patients and methods A retrospective study was conducted at Almoosa Hospital, Al Alhsa, Kingdom of Saudi Arabia, in the period between August 2017 and September 2020. All adult patients who underwent IVC filter were included. Results The study included 1350 cases. The patients were divided into two groups: group 1 included 1310 patients who had VTE without the need for an IVC filter, and group 2 included 40 patients, 39 of whom had VTE and required an IVC filter, and one patient with polytrauma (cerebral hemorrhage, pelvic hematoma) in whom an IVC filter was used prophylactically. A total of 40 IVC filters were used. Thirty (75%) patients had submassive PE with pulmonary hypertension and low pulmonary vascular reserve, nine (22.5%) patients had VTE with contraindications for an anticoagulant (due to gastrointestinal bleeding, cerebral hemorrhage, or major trauma), while one (2.5%) patient had an IVC filter inserted prophylactically although no VTE was present. The rate of IVC removal was 30% (12 cases), with no reported complications of IVC insertion or removal, except in one case where the filter was removed in two separate sessions. Conclusion IVC filter insertion, when used correctly, is a safe and effective method of preventing a potentially fatal PE by blocking the passage of thrombi from the lower extremities and pelvis to the lungs when used correctly.

Fat embolism after intraosseous catheters in pediatric forensic autopsies

In our center, we performed the autopsy of a child who died from drowning and presented, at autopsy, a major pulmonary fat embolism (PFE). A cardiopulmonary resuscitation (CPR) was performed, including infusion by intraosseous catheter (IIC). No other traumatic lesions and diseases classically related to a risk of PFE were detected. According to some animal studies, we considered the IIC as the only possible cause for PFE. However, we could not find literature to confirm this hypothesis in humans, especially in a pediatric population. To verify the occurrence of PFE after IIC in a pediatric population, we retrospectively selected 20 cases of pediatric deaths autopsied in our center, in which a CPR was performed, without bone fractures or other possible causes of PFE: 13 cases with IIC (group A) and 7 cases without IIC (group B). Several exclusion criteria were considered. The histology slides of the pulmonary tissue were stained by Oil Red O. PFE was classified according to the Falzi scoring system. In group A, 8 cases showed PFE: 4 cases with a score 1 of Falzi and 4 cases with a score 2 of Falzi. In group B, no case showed PFE. The difference between the two groups was statistically significant. The results of our study seem to confirm that IIC can lead to PFE in a pediatric population and show that the PFE after IIC can be important (up to score 2 of Falzi). To the best of our knowledge, our study is the first specifically focused on the occurrence of PFE after IIC in a pediatric population by using autoptic data.