Lobar Arteries Research Articles

Balloon Pulmonary Angioplasty with Stent Implantation as a Treatment of Proximal Chronic Thromboembolic Pulmonary Hypertension

We present a case of a 67-year-old female with proximal chronic thromboembolic pulmonary hypertension (CTEPH), disqualified from pulmonary endarterectomy due to multiple comorbidities and high risk-to-benefit ratio as assessed by multidisciplinary CTEPH team. She was referred for balloon pulmonary angioplasty (BPA) and underwent three sessions with balloon catheters up to 8 mm diameter. During the second procedure, the elastic recoil phenomenon was observed in the treated post-thrombotic lesion of the right lower lobe artery, which made the balloon angioplasty ineffective. It was decided to implant a self-expanding stent for the prevention of restenosis. The procedure resulted in significant improvement of regional perfusion, as confirmed by control angiography. We feel that it contributed to the significant improvement of hemodynamic parameters and exercise capacity, as assessed three months after the last BPA procedure. In conclusion, pulmonary artery stenting may be an option in proximal CTEPH when elastic recoil phenomenon makes balloon angioplasty of a large vessel ineffective.

75-Year-Old Woman With Chest Pain and Shortness of Breath

75-Year-Old Woman With Chest Pain and Shortness of Breath

P1700 Recurrent inflammatory myofibroblastic tumor of the right ventricle and pulmonary artery

Abstract Introduction Inflammatory myofibroblastic tumor (IMT), also known as plasma granuloma, is a very rare tumor with varying biological behavior, from completely benign to malignant. IMT can occur in virtually every organ, but cardiac origin is extremely rare. IMT occurs mainly in children and young people. The mainstay of treatment is complete surgical resection of the tumor. We present a case of 28 year old white woman with no contributory medical and family history, who was admitted to hospital because of dyspnea and cough. The transthoracic echocardiography (TTE) showed elevated pulmonary artery systolic pressure up to 61 mm Hg and mild dilation of right chambers. Further assessment by computed tomography showed thrombosis of the main pulmonary artery (PA), narrowing its lumen by 90%, with spread to the lobar and segmental arteries of the left lung - signs of massive pulmonary embolism. During thromboendarterectomy revealed a mass, about 4,1 x 3,1 x 1,8 cm in size, with thrombotic overlays, locating at the right ventricular outflow tract (RVOT) and the pulmonary trunk. Histological examination and Immunohistochemistry studies was consistent with IMT with an intermediate potential of malignancy. A year after the operation, the patient became pregnant. Routine TTE showed low density mobile mass narrowing the pulmonary trunk. The transvalvular blood flow velocity was 2.4 m/s. Cardiac magnetic resonance (CMR) was consistent with echo findings. The pregnancy has been preserved, and after 36 weeks it was decided to perform the birth of a girl by means of a Cesarian section. After 2 months, due to an increase in the size of the tumor and the dyspnea, a reoperation was performed to remove the tumor lining the RVOT and intimately connected with the PA valve, excision of the PA valve. A bioprosthesis was installed. The tumor had an identical morphological picture. Conclusion This case report describes a rare recurrent cardiac inflammatory myofibroblastic tumor involving RVOT and PA. The prognosis after surgical treatment of IMT is usually favorable, but it is known that some tumors recur, and rarely they can even metastasize. The long-term outcome is not well established due to the rarity of these tumors. Abstract P1700 Figure.

An area ratio of thyroid gland to common carotid artery for evaluating the thyroid gland size.

The feasibility of ultrasonographic measurement of thyroid gland area to common carotid artery (TG:CCA) was investigated. Twenty-one healthy, 12 hypothyroid and 18 non-thyroid illness (NTI) dogs were evaluated. The area of thyroid lobe and common carotid artery in right and left sides were measured using the same ultrasonographic images in transverse plane. The average of the right and left ratio was calculated as TG:CCA. The median TG:CCA of 21 healthy dogs was 1.53, and it did not correlate either body weight or age. The median TG:CCA of 12 hypothyroid dogs was 0.81, which was significantly lower than that of 18 NTI dogs (1.81, P<0.001). If the cut off value <1.12 was used, TG:CCA indicated hypothyroidism with a sensitivity of 100%, specificity of 83%, and accuracy of 90%. Our data indicated that TG:CCA was independent of both body weight, which may contribute to consistent measurement of thyroid size. The results of this study suggest that TG:CCA is a promising tool for diagnosing canine hypothyroidism.

P686 Right atrial, right ventricular and pulmonary cement embolism: a rare complication of percutaneous vertebroplasty

Abstract A 68-year-old man was admitted to the hospital with complaints of pain in the lumbar spine. He had L5 disc herniation, Spinal stenosis of the L5 root canal - S1 on the right in the past medical history. Percutaneous vertebroplasty at the level of L3 and Th8 vertebral bodies was performed six months ago due to painful vertebral hemangioma. The man is suffering from arterial hypertension, receives antihypertensive therapy. During routine transthoracic echocardiography, a hyperechoic structure with a size of 9.5 x 0.9 cm was found in the right atrium and right ventricle. Chest computed tomography with contrast enhancement revealed signs of bone cement in the right atrium and right ventricle, in the right upper lobe artery, in the branches of the upper lobe artery, in the paravertebral venous plexuses. Considering the duration of the disease, the stable condition, the absence of clinical manifestations and disorders of intracardiac hemodynamics, it was decided to refrain from surgical treatment. Antiplatelet therapy and dynamic observation were recommended. Conclusion Percutaneous vertebroplasty is a modern minimally invasive surgical procedure for the treatment of degenerative-dystrophic diseases of the spine. However, the cement can penetrate into the paravertebral veins and migrate to the right chambers of the heart and the pulmonary artery. This clinical case demonstrates asymptomatic cement embolism of the right chambers of the heart and pulmonary artery after percutaneous vertebroplasty, detected incidentally during routine echocardiography. Abstract P686 Figure.

Arterial attenuation in individualized computed tomography pulmonary angiography injection protocol adjusted based on the patient's body mass index

Background:The aim of this study was to optimize computed tomography pulmonary angiography (CTPA) protocols with regard to improve vascular attenuation without increasing contrast media (CM) volumes. Therefore, we compared the standard CTPA protocol to an individualized contrast media injection protocols adjusted for the patient's body mass index (BMI).Materials and Methods:Two groups of 295 patients with suspected pulmonary embolism (PE) have been receiving CTPA. Group 1 received a standard protocol without taking patient's BMI into account. Group 2 received a CTPA scan, where dose and flow rate of CM injections were adjusted for the patient's BMI. Images were retrospectively analyzed by drawing regions of interests in defined positions in the superior vena cava, descending aorta, the pulmonary main trunk as well as the left and right lower lobe arteries. Intravascular attenuation, contrast volumes, and flow rates were compared using unpaired t-tests. Furthermore, a qualitative image analysis was performed by two experienced readers blinded for the protocol used for image acquisition to evaluate the image quality and arterial attenuation.Results:Patient's BMI was similar in both the groups (27.5 ± 1.5 kg/m2 vs. 28.4 ± 2.1 kg/m2; P = 0.67). Contrast volumes were lower (54.2 ± 4.8 ml vs. 55 ml; P < 0.05), and flow rates (4.1 ± 0.3 ml/s vs. 3.5 ml/s; P < 0.05) were significantly higher in the individualized protocol. The qualitative image analysis yielded an agreement on diagnostic interpretability in the individualized and standard group of 49% and 51% (95% Wilson confidence interval for mean), respectively.Conclusion:An individualized CTPA protocol based on the patient's BMI reduced the contrast media volume and led to an increased pulmonary artery enhancement improving image quality, particularly in the evaluation of the peripheral pulmonary arteries. Thus, contrast media volumes in CTPA should be adjusted for the patient's BMI.

Clinical analysis of elderly acute pulmonary embolism patients with normal blood pressure and right ventricular dysfunction

Objective To analyze the clinical characteristics of the elderly acute pulmonary embolism(APE)patients with normal blood pressure and right ventricular dysfunction(RVD). Methods A total of 133 elderly APE patients with normal blood pressure and RVD were retrospectively analyzed.According to whether or not to merge RVD, patients were divided into the RVD group(n=42)and the non-RVD group(n=91). The incidence of clinical symptoms and signs, the incidence of pulmonary embolism, clinical indicators after thrombolytic therapy, and the incidence of bleeding were compared and analyzed between RVD and non-RVD groups. Results The incidences of syncope(33.3% or 14/42 vs.7.8% 7/91), P2 accentuation(45.2% or 19/42 vs.25.3% or 23/91), tachycardia(40.5% or 17/42 vs.20.9% or 19/91), cyanosis(26.2% or 11/42 vs.8.8% or 8/91)and jugular vein filling(11.9% or 5/42 vs.1.1% or 1/91)had significant differences between RVD and non-RVD groups(χ2=4.928, 4.644, 5.410, 4.971 and 4.163, all P<0.05). The incidence of proximal pulmonary embolism was higher in RVD group than in non-RVD group[25(59.5%)vs.8(8.8%), χ2=13.636, P<0.01], and the incidence of lobar artery embolism was higher in RVD group than in non-RVD group[32(76.2%)vs.47(51.6%), χ2=9.530, P<0.01]. Thirteen RVD patients received low-molecular-weight heparin anticoagulation combined with thrombolytic therapy, and 29 RVD patients took low-molecular-weight heparin anticoagulant therapy.The pulmonary artery systolic pressure(PASP)and tricuspid regurgitation pressure levels were higher in the thrombolytic therapy group than in the anticoagulant therapy group(t=2.894, 2.518 and 1.957, P=0.004, 0.015 and 0.026). The incidence of bleeding was higher in the thrombolytic therapy group than in the anticoagulant therapy group(23.1% vs.10.3%, χ2= 3.498, P=0.015). Conclusions The right ventricular dysfunction should be confirmed in APE patients with embolism involving proximal pulmonary artery or(and)presenting clinical symptoms or signs such as syncope and tachycardia.The anticoagulation therapy is effective and safe for elderly patients with normal blood pressure and right heart dysfunction without risks for further deterioration. Key words: Pulmonary embolism; Blood pressure; Ventricular function, right; Thrombolysis therapy

Combined shrapnel injury of the inferior vena cava which caused bulletpulmonary artery embolism (case report and review of the literature)

Bullet embolism is a rare and unpredictable complication of gunshot and mine‑explosive injuries. With only few cases described in the literature, bullet embolism may become a diagnostic challenge for emergency and military surgeons. Thus, bullet embolization is a rare phenomenon, the complications can be devastating.A clinical case of bullet embolism is described. 34‑years old man got combined abdominal‑skeletal mine‑explosive injuries with damage to hollow organs (duodenum and transverse colon), inferior vena cava and both low extremities. Internal bleeding was stopped by the inferior vena cava edge wound suturing. Wounds of duodenum and large intestine were sutured; gunshot fractures of both tibial bones were stabilized with external fixation devices. Computer tomography of the entire body showed the presence of embolus in the right middle lobe artery. Clinical manifestations of pulmonary embolism were not observed. The patients had several complications after surgery such as: multiple focal necrosis and perforations of transverse colon caused a fecal peritonitis; duodenum suture failure caused forming of a duodenal fistula; postoperative wound infection. These complications necessitated performing of multiple reoperations. Attempts of endovascular bullet extraction didn’t undertake because of severe concomitant injuries, its complications and asymptomatic clinical course of pulmonary artery projectile embolism. Open surgery removing of embolus was successfully performed in 80 days after injury. The patient was discharged from hospital in good condition in 168 days after gunshot wound. Patients with an explosive‑mine wound and gunshot wound with no exit should to be examined with whole‑body computer tomography for determining possible projectile migration with bloodstream. Patients with asymptomatic pulmonary artery embolism should to be managed non‑operatively in the early posttraumatic period. In case of symptomatic pulmonary artery bullet embolism is reasonable to consider of a possibility of an open thoracic surgery.

Prospective Study of Pulmonary Embolism Presenting as Syncope.

Syncope represents a common condition among the general population. It is also a frequent complaint of patients in the emergency department (ED). Pulmonary embolism (PE) considers a differential diagnosis, particularly in a case of syncope without chest pain. What is the prevalence of PE among patients who presented an episode of syncope to the ED and among those hospitalized for syncope in a tertiary care hospital? From January 2012 to December 2017, we conducted a prospective observational study among adult patients presenting themselves to the ED consecutively or admitted for syncope. Syncope and PE were defined by professional guidelines. PE was ruled out in patients who had a low pretest clinical probability, as per Wells score and a negative D-dimer assay. In other patients, computed tomography pulmonary angiography was performed. Seventeen thousand eight-two patients (mean age 71.3 ± 13.24 years) visited the ED for syncope. PE was detected in 45 patients (mean age 65.75 ± 9.45 years): 4 with low risk, 26 with intermediate risk, and 15 with high risk. The prevalence of PE in those hospitalized with syncope was 11.47%, which is 45 of 392 (confidence interval 95% 8.48-15.04), and was 2.52%, 45 of 1782 (confidence interval 95% 1.8-3.3), in patients presenting with syncope to the ED. The location of the embolus was bilateral in 24 patients (53.33%), in a main pulmonary artery in 10 (22.22%), in a lobar artery in 10 (22.22%), and in a segmental artery in 1 (2.22%). The occurrence of syncope, if not explained otherwise, should alert one to consider PE as a differential diagnosis. PE rate, presenting as syncope, is the highest in patients with large thrombi, which is responsible for bilateral or proximal obstruction in a main or lobar pulmonary artery.

Chronic low alcohol intake during pregnancy programs sex-specific cardiovascular deficits in rats

BackgroundExposure to an adverse environment in early life can have lifelong consequences for risk of cardiovascular disease. Maternal alcohol (ethanol) intake is common and associated with a variety of harmful effects to the fetus. However, examining the effects on the cardiovascular system in adult offspring has largely been neglected. The objectives of this study were to investigate the influence of chronic, low ethanol consumption throughout pregnancy on blood pressure, vascular reactivity and wall stiffness, all key determinants of cardiovascular health, in both male and female rat offspring.MethodsFemale Sprague-Dawley rats were fed an ad libitum liquid diet ± 6% vol/vol ethanol throughout pregnancy. Male and female offspring were studied at 12 months of age. Arterial pressure, heart rate and locomotor activity were measured over 7 days via radiotelemetry. Renal lobar arteries were isolated and studied using wire and pressure myography.ResultsBasal mean arterial pressure in female ethanol-exposed rats was reduced by ~ 5–6 mmHg compared to control female offspring, whereas arterial pressure was unaffected in male offspring. Ethanol-exposed offspring had an attenuated pressor response to an acute restraint stress, with this effect most evident in females. Renal artery function was not affected by prenatal ethanol exposure.ConclusionsWe show for the first time that low level chronic maternal alcohol intake during pregnancy influences arterial pressure in adult offspring in the absence of fetal growth restriction.

The multiple systemic artery to pulmonary artery fistulas resulting in severe irreversible pulmonary arterial hypertension in patient with previous history of pneumothorax

BackgroundSystemic artery to pulmonary artery fistulas (SA-PAFs), are extremely rare in people without congenital heart disease. In this group of patients pulmonary arterial hypertension was reported in the single case. Then, we describe a case of multiple SA-PAFs, which were the cause of severe nonreversible arterial pulmonary hypertension in a patient who had a right-sided pneumothorax 35 years earlier.Case presentation52-year-old male Caucasian patient with echocardiographically confirmed pulmonary hypertension (PH) was admitted to cardiology department due to exertional dyspnea and signs of right ventricle failure. Routine screening for causes of secondary PH was negative. Right heart catheterization (RHC) confirmed a high degree arterial PH [mean pulmonary artery pressure (mPAP); 50,6 mmHg, pulmonary wedge pressure (PWP); 11,3 mmHg, pulmonary vascular resistance (PVR); 11,9 Wood’s units (WU)] irreversible in the test with inhaled nitric oxide. Oxygen saturation (SaO2) of blood samples obtained during the first RHC ranged from 69.3 to 73.2%. Idiopathic pulmonary arterial hypertension was diagnosed. Treatment with inhaled iloprost and sildenafil was initiated.Control RHC, performed 5 months later showed values of mPAP (59,7 mmHg) and PVR (13,4 WU) higher in comparison to the initial measurement, SaO2 of blood obtained during RHC from upper lobe artery of the right lung was elevated and amounted 89.7%.Then, pulmonary arteriography was performed. Lack of contrast in the right upper lobe artery with the evidence of retrograde blood flow visible as a negative contrast in the right pulmonary artery was found. Afterwards, right subclavian artery arteriography detected a huge vascular malformation communicating with right upper lobe artery. Following computed tomography angiogram (angio-CT) additionally revealed the enlargement of bronchial arteries originated fistulas to pulmonary artery of right upper lobe.In spite of intensive pharmacological treatment, including the therapy of pulmonary hypertension and percutaneous embolisation of the fistulas, the patient’s condition continued to deteriorate further. He died three months after embolisation due to severe heart failure complicated by pneumonia.ConclusionNon-congenital SA-PAFs are extremely rare, however, they should be excluded in patients with pulmonary arterial hypertension and history of inflammatory or infectious disease of the lung and pleura, pneumothorax, cancer or Takayashu’s disease and after chest trauma.

Change in hepatic hemodynamics assessed by hepatic arterial blood pressure and computed tomography during hepatic angiography with the double balloon technique.

To assess the change in hepatic arterial blood pressure (HABP) and computed tomography during hepatic arteriography (CTHA) using the double balloon technique. Nine patients with hepatocellular carcinoma (HCC) were enrolled. We inserted a 5.2-Fr balloon catheter into the common or proper hepatic artery and a 1.8-Fr microballoon catheter into the lobar or segmental artery feeding the HCC. HABPs were measured with the 1.8-Fr microballoon catheter (usual-HABP), with the 1.8-Fr balloon inflated (B-HABP), and with both the 5.2-Fr and 1.8-Fr balloons inflated (BB-HABP). CTHAs were performed via a 1.8-Fr microcatheter (usual-CTHA), with the 1.8-Fr balloon inflated (B-CTHA selective), with both the 5.2-Fr and 1.8-Fr balloons inflated (BB-CTHA selective), and via the 5.2-Fr catheter with the 1.8-Fr balloon inflated (B-CTHA whole) and with both the 5.2-Fr and 1.8-Fr balloons inflated (BB-CTHA whole). In all cases, B-HABP was lower than usual-HABP. There was a decrease in BB-HABP in comparison with B-HABP in cases with occlusion of the proper hepatic artery. The contrast effect of B-CTHA selective increased in four cases. The contrast effect on B-CTHA whole remained in all cases. This technique can be useful in decreasing HABP and collateral blood flow from the adjacent hepatic segment.

Prevalence of Pulmonary Embolism in Patients Presenting With Syncope.

Prevalence of Pulmonary Embolism in Patients Presenting With Syncope.

Pulmonary embolism in young age

Introduction. One of the risk factors for pulmonary embolism is age &gt; 40 years. Lately, more and more cases of thromboembolism occur at a young age, that requires special attention in diagnosis and treatment. Objectives. The purpose of this article was to analyze the clinical case of thromboembolism at a young age. Material and methods. Our patient B., 33- year-old male was urgently hospitalized with the chest pain when breathing in, shortness of breath, blood-streaked sputum cough and body temperature up to 37-38.5 °С. 17.12.18 the bone immobilization of the right fibula due to a fracture was performed. 30.12.18 - the patient felt compressive pain in the right side of the chest, shortness of breath, blood-streaked sputum cough. An ambulance was called, but the patient was not hospitalized. Since 31.12.2018 till 05.01.2019 – body temperature rose to 38°C. 06.01.19 - a recurrence of initial symptoms. 07.01.19 - the chest pain intensified, patient was transported by ambulance to a hospital. During the examination: vesicular breathing, weakened in the lower sections, mostly on the right, respiratory rate -20/min, heart rate 100 beats/min, blood pressure 120/70 mm Hg. The main diagnosis: thromboembolism of the lobar arteries of the right lung. Class I, very low risk (43 points by PESI scale – Pulmonary Embolism Severity Index, 5 points by the Padua prediction score). Complication: right-sided inferior infarction-pneumonia. Concomitant diagnosis: fracture of the right fibula. Recommended treatment: rivaroxaban 12 mg; eplerenone 50 mg, ceftriaxone 1 g bid intravenous injection (IV), levofloxacin 500 mg IV, oxygen therapy. Results. Laboratory and instrumental studies were carried out. Laboratory tests revealed an increased in leukocytes, erythrocyte sedimentation rate, ALT, troponin І. ECG: right axis deviation. Computed tomography (CT) of the chest: CT signs of thromboembolism of the arteries of the right lung, right-sided inferior infarction-pneumonia, changes are more typical for an inflammatory process in the initial stage. Ultrasound examination of the abdominal organs and kidneys: diffuse changes of the liver parenchyma, traces of fluid in the right pleural cavity. Conclusions. Prolonged immobilization in young patients can be only one risk factor for the formation of pulmonary embolism. In order to predict possible complications in patients with pulmonary thromboembolism, it is necessary to take into account the initial state of the patient and associated diseases in each case.

Application of a Functional3-dimensional Perfusion Model in Laparoscopic Partial Nephrectomy With Precise Segmental Renal Artery Clamping

ObjectivesTo assess the feasibility of a novel functional perfusion model based on enhanced computed tomography (CT) for the evaluation of split renal function and orientation of segmental renal artery clamping during laparoscopic partial nephrectomy (LPN). Materials and MethodsFrom December 2016 to November 2017, functional perfusion model was applied in 91 patients with T1a renal tumors who had undergone LPN with segmental renal artery clamping. Split computed tomographic-glomerular filtration rate (CT-GFR) was calculated using the 2-point Patlak plot technique. Parenchymal perfusion areas of segmental renal arteries were marked, and target segmental arteries were determined by the perfusion areas wherein tumors were confined. LPN with precise segmental renal artery clamping was performed based on the novel model. Correlations between CT-GFR and estimated GFR and radioisotope GFR were analyzed using Pearson's method. Intraoperative ischemic status and surgical outcomes were assessed. ResultsMean tumor size was 2.9cm. Large tumors were accompanied by more feeding lobar arteries than segmental arteries. CT-GFR was strongly correlated with estimated GFR (r = 0.70) and radioisotope GFR (r = 0.88). All LPNs were successful without converting to main renal artery clamping. Mean operation time was 81.8 minutes; median estimated blood loss was 120mL. The actual parenchymal ischemic region observed during the operation was consistent with the prediction of the perfusion model in all patients. No arterial bleeding or other uncontrollable defect bleeding occurred during tumor resection. ConclusionThis model is a reliable method for the determination of split renal function and orientation of segmental artery clamping during LPN.

An affordable approach for the extraction of migrated foreign devices into pulmonary arteries

Percutaneous embolization of the hypogastric and gonadal veins represents an effective treatment of pelvic venous congestion syndrome. In rare cases, coil migration may occur. We are presenting the case of a 57-year-old female patient diagnosed in 2013 with pelvic congestion syndrome, treated by a transcatheter coil embolization technique of the gonadal and hypogastric veins. During the procedure, one coil migrated to the right inferior pulmonary lobe artery leading to localized thromboembolism. Four years after the intervention, the patient addressed our Cardiology Department for an attempt of coil extraction. A minimally invasive percutaneous endovascular technique through the right subclavian vein was performed. The reason for the few cases reported regarding the percutaneous extraction and the limited experience in this field is assumed to be due to the absence of clinical expression induced by the migrated coils, most patients being asymptomatic. The management of coil migration in asymptomatic cases is a controversial issue. In the presented case, our patient had two thrombotic events induced by the migrated coil. So, a percutaneous attempt was performed for its extraction since our patient needed long-term oral anticoagulation therapy. The procedure didn’t succeed but showed the fact that percutaneous extraction of pulmonary artery migrated coil could be feasible in those symptomatic cases with recent occurred migration using affordable devices.

A comparison of the data computed tomographic angiography and&#x0D; echocardiography with classic electrocardiographic signs of pulmonary embolism the low risk of death.

A study of the correlation of the ECG symptoms to echocardiographic and CT-angiographic of the symptoms of overload of the right heart in 87 patients with pulmonary embolism (PE) is not a high risk of death. All patients were hospitalized on the first day of development of pulmonary embolism. 35.6% of patients had ECG symptoms overload right heart: deep teeth S and Q negative T in V-V, signs of blockade of right bundle branch block. Most of these patients had occlusion of the lobar artery. And in patients without ECG symptoms ofpulmonary embolism were more often obstruction of the segmental arteries (p&lt;0,01). ECG symptoms overload right heart was with the obstruction of two or more of the lobar artery or more than ten segmental arteries. Most patients with pulmonary embolism with ECG signs of overload of right departments of heart, source of embolism was veins of femoral-popliteal segment, and pulmonary embolism in patients without ECG symptoms source was sureline vein (p=0,03). A high correlation between ECG symptoms and amount of damage to the pulmonary system in CT-angiographic, ECG and EchoCG symptoms overload right heart. The same high correlation between the ECG signs of overload of the right heart and clinical symptoms: shortness of breath and presyncopal states.

Three-Dimensional Quantitative Color-Coding Analysis of Hepatic Arterial Flow Change during Chemoembolization of Hepatocellular Carcinoma

PurposeTo evaluate feasibility of using three-dimensional (3D) quantitative color-coding analysis (QCA) to quantify substasis endpoints after transcatheter arterial chemoembolization of hepatocellular carcinoma (HCC). Materials and MethodsThis single-institution prospective study included 20 patients with HCC who had undergone segmental or subsegmental transcatheter arterial chemoembolization between December 2015 and March 2017. The chemoembolization endpoint was a sluggish anterograde tumor-feeding arterial flow without residual tumor stains. Contrast medium bolus arrival time (BAT) was used as an indicator of arterial flow. BAT of the proper hepatic artery was obtained as a reference point. BATs of the proximal right lobar artery, proximal left lobar artery, and segmental artery that received embolization were analyzed before and after chemoembolization. Wilcoxon signed rank test was used to evaluate the difference between BATs before and after chemoembolization. ResultsBATs before and after chemoembolization of the segmental artery that received embolization were 0.47 seconds (interquartile range [IQR], 0.31–0.70 s) and 1.04 seconds (IQR, 0.78–2.01 s; P < .001), respectively. BATs before and after chemoembolization of the proximal left lobar hepatic artery (0.35 s [IQR, 0.11–0.55] and 0.13 s [IQR, 0.05–0.32], P = .025) and right lobar hepatic artery (0.23 s [IQR, 0.13–0.65] and 0.22 s [IQR, 0.08–0.39], P = .027) exhibited no significant change. Conclusions3D QCA is a feasible method for quantifying sluggish segmental arterial flow after transcatheter arterial chemoembolization in patients with HCC.

D-dimer in Adolescent Pulmonary Embolism.

D-dimer is used to aid in diagnosing adult pulmonary embolism (PE). D-dimer has not been validated in adolescents. Clinicians must balance the risk of overtesting with that of a missed PE. D-dimer may be useful in this context. This study evaluates D-dimer in PE-positive and PE-negative adolescents. PE-positive patients<22 years were diagnosed with PE by computed tomography (CT) or high-probability ventilation/perfusion, seen at emergency departments (EDs)/hospitals within a 16-hospital system across two states, January 1998 through December 2016. Of the 189 PE-positive patients, 88 (46.5%) had a D-dimer and were matched 1:1 by age, sex, and race to patients suspected of PE but confirmed negative by CT angiogram. Ages of PE-positive patients ranged from 13 to 21 years, 64 (73%) were female, and 52 (60%) were Caucasian. Mean D-dimer was significantly higher (3,256 ng/mL, 95% confidence interval [CI]= 2,505-4,006 ng/mL) in PE-positive versus PE-negative patients (1,244 ng/mL, 95% CI= 493-1,995 ng/mL; p<0.001). Mean D-dimer was higher in patients with massive or submassive PE (8,742 ng/mL, 95% CI= 5,994-11,491 ng/mL), followed by PE in central (4,795 ng/mL [95% CI= 3,465-6,125 ng/mL), lobar (3,758 ng/mL [95% CI= 1,841-5,676), and distal (2,327 ng/mL [95% CI= 1,273-3,381 ng/mL]) arteries. When comparing thresholds of positive D-dimer (≥500, ≥750, and ≥1,000 ng/mL), D-dimer had sensitivities of 90, 82, and 67% and specificities of 16, 53, and 67%, respectively. Negative predictive values were 61, 75, and 71% while positive likelihood ratios were 1.1, 1.8, and 2.2, respectively. This study represents the largest available cohort of adolescent patients examining the diagnostic value of D-dimer for PE. Our results indicate that depending on the threshold selected, D-dimer can be a sensitive test for PE in adolescents and that discriminative value is higher for a cutoff of 750 ng/mL than that for 500 ng/mL. Prospective studies investigating the diagnostic value of D-dimer and a clinical decision rule for PE in pediatrics are needed.

Treatment of high- and intermediate-risk pulmonary embolism using the AngioJet percutaneous mechanical thrombectomy system in patients with contraindications for thrombolytic treatment - a pilot study.

IntroductionIntravenous thrombolysis is the treatment of choice in patients presenting with high- and intermediate-risk pulmonary embolism. The role of percutaneous mechanical pulmonary thrombectomy (PMPT) is not fully established, although selected patients can be managed with this method.AimThis open-label single-centre prospective pilot study was aimed at assessing the feasibility of PMPT for the treatment of severe pulmonary embolism in a Polish hospital. We also evaluated the safety and efficacy of such management.Material and methodsWe managed 7 patients, aged 52.7 ±16.6 years, presenting with high- and intermediate-risk pulmonary embolism (4 patients with class 5 and one patient with class 4 of the Pulmonary Embolism Severity Index), with occlusion of at least 2 lobar arteries and contraindications for thrombolysis. Percutaneous mechanical pulmonary thrombectomy was performed using the AngioJet system.ResultsIt was possible to introduce the thrombectomy system to the pulmonary arteries in all patients. The procedure was successful in 6 patients (technical success rate: 85.7%). Two (28.6%) patients died during the hospital stay, one patient with unsuccessful thrombectomy and the other due to pneumonia. In all survivors control echocardiography demonstrated normalised function of the right ventricle. Also, dyspnoea disappeared and blood gas parameters normalised. There was no recurrent thromboembolism during 3–14 months of follow-up.ConclusionsIn the Polish setting, in selected patients, management of high- and intermediate-risk pulmonary embolism with PMPT is technically feasible. Such treatment is relatively safe and effective. It can be an alternative to standard management, especially in patients with contraindications for fibrinolysis or surgical embolectomy.