Lower Lobe Pulmonary Artery Research Articles

Migrating bullet: A case of a bullet embolism to the pulmonary artery with secondary pulmonary infarction after gunshot wound to the left globe

Bullet embolism is a rare phenomenon following gunshot injuries. We present a case of a 25-year-old male who sustained a gunshot wound to his left globe with the bullet initially lodged in his right transverse sinus. The bullet ultimately embolized to a left lower lobe pulmonary artery resulting in a pulmonary infarct. A discussion of select prior cases, pathophysiology, and management strategies follows.

Pulmonary Resection of Lung Cancer in a Patient With Partial Anomalous Pulmonary Venous Connection

We report a case of a 64-year-old man in whom a partial anomalous pulmonary venous connection (PAPVC) was found before right lower lobectomy for lung cancer. In addition to lung cancer, there was a right superior pulmonary vein that drained into the superior vena cava (SVC). There was a concern of right ventricular heart failure resulting from increased left-to-right shunt flow after lobectomy. Therefore cardiac catheterization was performed to calculate the pulmonary-to-systemic flow rate in the presence of blocked blood flow to the lower lobe pulmonary artery. As a result, we successfully performed lobectomy without correcting the PAPVC.

Endocarditis Due to Cardiobacterium hominis in a 4-Year-Old Boy, Complicated by Right Lower Lobe Pulmonary Artery Mycotic Aneurysm.

The fastidious, slow-growing bacteria of the species designated by the “HACEK” acronym (Haemophilus parainfluenzae, Haemophilus aphrophilus, Haemophilus paraphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens ,a ndKingella kingae) are important causes of gram-negative endocarditis [1]. Haemophilus species account for the largest number of such infections in children, followed by K kingae, then A actinomycetemcomitans [2, 3]. In children, we found no published reports of E corrodens endocarditis and only 2 reports of C hominis endocarditis; 1 in a 17-year-old in the United Kingdom and the other in a 3-year-old in Japan [4, 5]. To our knowledge, we describe here the first reported case of endocarditis due to C hominis in a child in the western hemisphere, and, for this infection, the unique occurrence of a large pulmonary vessel mycotic aneurysm. CASE REPORT The patient was a 4-year-old male with DiGeorge syndrome, developmental delay and complex congenital heart disease. His heart disease consisted of tetralogy of Fallot with pulmonary atresia, small pulmonary arteries, and major aortopulmonary collaterals. He had hypoparathyroidism but had normal T-cell numbers and function. At 3 months of age, he underwent placement of a right ventricle-to-pulmonary artery (RV-PA) non-valved conduit. At 18 months of age he underwent ventricular septal defect (VSD) patch closure, replacement of his RV-PA conduit with a Contegra 16-mm valved conduit, and patch plasty of the left pulmonary artery. His most recent echocardiogram, 1 month before presentation, had revealed an insignificant residual VSD at the patch margin, trivial tricuspid regurgitation, RV pressure equal to ¾ systemic pressure, moderate RV hypertrophy, mild aortic insufficiency, and normal biventricular function. The patient presented to the Mount Sinai Kravis Children’s Hospital emergency department with a 1-week history of fever as high as 102 o F, intermittent cough, irritability, and decreased appetite. Physical findings on presentation included mild irritability, temperature of 38.9 o C, abnormal facies consistent with DiGeorge syndrome, coarse breath sounds bilaterally, and a harsh, grade 3/6 systolic heart murmur, loudest at the base, radiating to the back. Dentition was intact, and there were no mucosal or skin lesions. Pulse oximetry revealed reduced oxygen saturation, and a chest radiograph showed bilateral patchy areas of opacification. Blood was obtained for cultures and other laboratory studies, treatment for presumed pneumonia was begun with intravenous ceftriaxone and oral azithromycin, and the patient was admitted to the inpatient unit for continued management. The peripheral white blood count was 16 900/mm 3 , with 73% neutrophils, and the serum C-reactive protein level was 162 µg/L. The single blood culture drawn at admission was reported positive at 64 hours (Bactec 9240 System; Becton Dickinson, Franklin Lakes, NJ) for small gram-negative bacilli. The isolate was subsequently identified as C hominis and was found to be susceptible to ceftriaxone (VITEK 2; bioMerieux, Durham, NC). Subsequent single blood cultures drawn on hospital days 2, 4, and 5 all were negative. A transthoracic echocardiogram showed a mobile echobright structure consistent with a vegetation near the

Pulseless electrical activity during electroconvulsive therapy: a case report.

BackgroundArrhythmias resulting in cardiac arrest during electroconvulsive therapy have been reported. Most reported cases of cardiac arrest had asystole as the initial rhythm. Pulseless electrical activity as an initial rhythm of cardiac arrest during electroconvulsive therapy has never been reported. Also, thromboembolism after inflation of pneumatic tourniquet during lower limb surgery has been reported but never following tourniquet inflation during an electroconvulsive therapy.Case presentationWe report a case involving an 81- year- old female who presented to us for an electroconvulsive therapy for severe depression and developed pulseless electrical activity immediately after electroconvulsive therapy. She was successfully resuscitated and was later found to have bilateral pulmonary emboli with a complete occlusion of the right lower lobe pulmonary artery. The source of embolus was from her left lower extremity deep venous thrombus, which we believe, got dislodged intraoperatively after inflation of pneumatic tourniquet. Our patient not only survived the massive pulmonary embolus, but also showed significant improvement in her mental status compared to her pre-admission level at the time of discharge to a sub-acute rehabilitation centre.ConclusionWe recommend that patients who are elderly and at high risk of thromboembolism should selectively undergo a preoperative doppler ultrasound for deep venous thrombosis. Also, selective application of tourniquet in the upper limb, to monitor for seizure activity, would reduce the incidence of pulmonary thrombo-embolism as embolic events are significantly less from deep venous thromboses of upper extremities when compared to lower extremities.

Isolated absence of right pulmonary artery: Radiographic and multi-detector CT demonstration

Isolated absence of right pulmonary artery: Radiographic and multi-detector CT demonstration

Ocena gałęzi subsegmentalnych tętnicy płucnej za pomocą ultrasonografii wewnątrznaczyniowej u pacjentów ze stenozą mitralną

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Karapinar H, Kaya Z, Açar G, et al. Original paperThe assessment of subsegmental branches of the pulmonary artery by intravascular ultrasound in patients with mitral stenosis. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2012;8(4):287-292. doi:10.5114/pwki.2012.31909. APA Karapinar, H., Kaya, Z., Açar, G., Batukan Esen, Ő., Bulut, M., & Küçükdurmaz, Z. et al. (2012). Original paperThe assessment of subsegmental branches of the pulmonary artery by intravascular ultrasound in patients with mitral stenosis. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 8(4), 287-292. https://doi.org/10.5114/pwki.2012.31909 Chicago Karapinar, Hekim, Zekeriya Kaya, Göksel Açar, Őzlem Batukan Esen, Mustafa Bulut, Zekeriya Küçükdurmaz, and Ibrahim Gül et al. 2012. "Original paperThe assessment of subsegmental branches of the pulmonary artery by intravascular ultrasound in patients with mitral stenosis". Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej 8 (4): 287-292. doi:10.5114/pwki.2012.31909. Harvard Karapinar, H., Kaya, Z., Açar, G., Batukan Esen, Ő., Bulut, M., Küçükdurmaz, Z., Gül, I., Yazıcıoğlu, M., Esen, A., and Kirma, C. (2012). Original paperThe assessment of subsegmental branches of the pulmonary artery by intravascular ultrasound in patients with mitral stenosis. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 8(4), pp.287-292. https://doi.org/10.5114/pwki.2012.31909 MLA Karapinar, Hekim et al. "Original paperThe assessment of subsegmental branches of the pulmonary artery by intravascular ultrasound in patients with mitral stenosis." Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, vol. 8, no. 4, 2012, pp. 287-292. doi:10.5114/pwki.2012.31909. Vancouver Karapinar H, Kaya Z, Açar G, Batukan Esen Ő, Bulut M, Küçükdurmaz Z et al. Original paperThe assessment of subsegmental branches of the pulmonary artery by intravascular ultrasound in patients with mitral stenosis. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2012;8(4):287-292. doi:10.5114/pwki.2012.31909.

Catheter-Based Reperfusion Treatment of Pulmonary Embolism

Case Presentation: A 76-year-old man with a history of hemicolectomy for colon cancer 10 days previously was admitted because of syncope and severe shortness of breath. On physical examination, the patient was hemodynamically unstable, with a systolic arterial pressure of 80 mm Hg, a heart rate of 124 beats per minute, and distended jugular veins. He was agitated and unable to speak full sentences. His respiratory rate was 28 breaths per minute, and oxygen saturation was 80% on room air. Contrast-enhanced computed tomography showed a filling defect of the left main pulmonary artery, complete occlusion of the left lower lobe pulmonary artery, nonobstructive filling defects of the right lower lobe pulmonary artery, and right ventricular enlargement (right-to-left ventricular dimension ratio of 1.4) (Figure 1). The hemodynamic situation remained unchanged after initiation of treatment with oxygen, intravenous unfractionated heparin, and normal saline. Figure 1. Contrast-enhanced chest computed tomogram from the first case. Left, Complete occlusion of the left lower lobe pulmonary artery (large arrow) and nonobstructive filling defect in the right lower lobe pulmonary artery (small arrow). Right, The subannular right-to-left ventricular dimension ratio was obtained from the reconstructed 4-chamber view.1 Right (47.3 mm) and left (33.9 mm) ventricular dimensions were measured perpendicular to the interventricular septum and 1 cm above the atrioventricular annulus plane. The right-to-left ventricular dimension ratio was calculated as 1.4. Case Presentation: A 55-year-old woman suddenly developed acute shortness of breath 3 weeks after resection of a meningioma. On physical examination, the patient appeared hemodynamically stable, with a systolic arterial pressure of 100 mm Hg, a heart rate of 96 beats per minute, a respiratory rate of 18 breaths per minute, and an oxygen saturation of 89% while receiving 3 L of oxygen via face mask. A contrast-enhanced computed tomography confirmed subtotal filling defects in both main pulmonary …

Pulmonary artery tumour–embolism diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration

To the Editors: A 61-yr-old female was diagnosed with pulmonary embolism. She had a history of poorly differentiated thyroid cancer with follicular cell phenotype, and had first been treated in 2006 by thyroidectomy and radioactive iodine-131. Local relapse (cervical nodes) had occurred within 3 months and required five cycles of chemotherapy, consisting of cisplatin and doxorubicin, followed by cervical radiotherapy and surgical resection of residual nodes. 2 yrs later during follow-up, abnormal 18F-fluorodeoxyglucose (FDG) uptake was described on positron emission tomography (PET)/computed tomography (CT) in the left thoracic hilar regions. CT pulmonary angiography showed a filling defect in the left lower lobe pulmonary artery and at the origin of the lingular artery; no delayed embolism enhancement was observed. It was considered to be a pulmonary embolism, and anticoagulation was initiated. 6 months later, follow-up imaging showed stability of both FDG uptake and CT pulmonary angiography images, and anticoagulation was continued. 10 months later, follow-up showed a right pulmonary upper lobe nodule on CT scan associated with high FDG uptake on PET/CT, and thyroglobulin ascension. This nodule was considered to be a thyroid cancer metastasis and treated by CyberKnife radiotherapy. As FDG uptake and thyroglobulin …

Pulmonary Cement Embolism after Kyphoplasty

An 80-year-old female with a history of osteoporosis was evaluated for sudden onset axial low back pain with bilateral lower extremity weakness, hyperreflexia, pain, urinary retention, and decreased rectal tone. Computed tomography of the lumbar spine revealed L1 compression fracture, retropulsion of bone causing spinal canal compromise with associated severe central canal stenosis. Following cement kyphoplasty of L1 with polymethyl methacrylate, the patient developed tachycardia and dyspnea. Chest radiograph and computed tomographic pulmonary angiogram revealed a large collection of hyperdense material within the right lower lobe pulmonary artery, consistent with pulmonary cement emboli. Management and imaging are discussed.

Nécrose pulmonaire iatrogène due à une chimiothérapie hypersélective

The management of cancer requires regular access to the central venous system. We report here, a case of a central venous access system causing pulmonary necrosis and abscess. A 48 year old woman with a past history of B-cell lymphoma presented with a relapse of her disease. A subcutaneous central venous access port was placed in the right brachiocephalic area with puncture of the subclavian vein. She received three doses of chemotherapy. Eight days later, she consulted the emergency department on account of right-sided chest pain. Examination revealed a right-sided pleural effusion. The chest x-ray showed the tip of the catheter at the right pulmonary hilum. A CT scan confirmed that the tip of the central venous catheter was located in a branch of the right lower lobe pulmonary artery and was surrounded by consolidation in the right middle and lower lobes. The progress was marked by the development of a lung abscess despite removal of the central venous access system. Subsequent surgery led to satisfactory resolution. We report a dramatic case that reminds us that placement of a central venous access system requires a sound technique and regular radiological surveillance.

Effects of a localized high-flow anastomosis between the aorta and left lower lobe pulmonary artery on great vessel flow and pulmonary arterial reactivity in the contralateral lung

We sought to assess the effects of a localized anastomosis between the aorta and left lower lobe pulmonary artery on flows through central vessels and on the vascular reactivity of small pulmonary arteries distal or contralateral to the shunt. Flow rates in major vessels and tensions from small pulmonary arteries from the left and right lower lobes were determined 48 hours after creation of an end-to-side anastomosis of the left lower lobe pulmonary artery to the aorta. Anastomoses increased flow through the left lower lobe pulmonary artery from 194±6 to 452±18 mL/min immediately after anastomosis to 756±19 mL/min by the time of harvest (n=88, P<.05). Flow rates in main pulmonary arteries from hosts with anastomoses were lower (557±26 vs 1033±244 mL/min), whereas aortic root flows were not different from control values (1370±53 vs 1120±111 mL/min; P=.07). Wet/dry weights of both lungs and aortic flow rates were proportional to shunt flow rates. Pulmonary artery rings harvested from the right (unshunted) lobes of high-flow hosts exhibited increased reactivity to the thromboxane agonist U46619 and phenylephrine relative to those of left pulmonary arteries from the same animal or those of control hosts. Our studies are the first to identify enhanced reactivity of pulmonary arteries in a lung contralateral to a localized high-output shunt between an aorta and pulmonary artery. These observations suggest that patients with localized systemic-to-pulmonary shunt could exhibit modified vascular tone in remote pulmonary arteries.

Mechanisms underlying increased reactivity of pulmonary arteries contralateral to a localized high-flow anastomosis

Our model of a systemic-pulmonary shunt exhibits enhanced reactivity of pulmonary arteries contralateral to a localized shunt between the left lower lobe pulmonary artery and aorta relative to those of ipsilateral or control pulmonary arteries 48 hours after anastomosis. We examined the contribution of nitric oxide, cyclooxygenase, lipoxygenase, or cytochrome P450 production to mediating this enhanced reactivity. We created a surgical end-to-side anastomosis of the left lower lobe pulmonary artery to the aorta. Forty-eight hours later, we tested tension of pulmonary artery rings from the right and left lower lobes for contraction to the thromboxane mimetic U46619 in the presence of vehicle or inhibitors of nitric oxide synthase, cyclooxygenase, cytochrome P450, or lipoxygenase. Western blots of pulmonary artery homogenates were probed for endothelial nitric oxide synthase or isoforms metabolizing arachidonic acid. Eicosanoid products from intact pulmonary artery rings were detected using labeled arachidonic acid and high-performance liquid chromatography separation. Enhanced reactivity of unshunted right pulmonary arteries over that of left pulmonary arteries from high-flow hosts was not eliminated by inhibitors of nitric oxide synthase, cyclooxygenase, cytochrome P450. Treatment with 2 different lipoxygenase inhibitors, nordihydroguaiaretic acid and cinnamyl-3,4-dihydroxy-α-cyanocinnamate, closed the difference in contractility of shunted and unshunted pulmonary arteries. Pulmonary arteries contralateral to shunts metabolized arachidonic acid to 12-hydroxyeicosatetraenoic acid in greater quantities than analogous pulmonary arteries from the experimental left or control pulmonary arteries. Forty-eight hours after anastomosis, enhanced reactivity of contralateral pulmonary arteries is attributable in part to increased lipoxygenase products as opposed to nitric oxide or other eicosanoid products.

Pulmonary Artery Aneurysm With False-Positive FDG PET in a Patient With Behcet Disease

A 60-year-old man presented with dyspnea, oral ulcers, systemic symptoms, and biopsy proven erythema nodosum, consistent with Behcet disease. During evaluation of the patient's dyspnea, a new mass lesion (2.2 cm) in the right lower lobe (not present 4 months earlier) was shown on HRCT and demonstrated mildly increased FDG uptake (SUVmax = 2.7) on PET CT, predictive for neoplasm. This lesion was however intensely enhancing on CTPA with direct blood supply from a right lower lobe pulmonary artery and mural thrombus. Pulmonary artery aneurysm was confirmed and successfully embolized.

Migration of covered stents from hemodialysis A‐V access to the pulmonary artery: Percutaneous stent retrieval and procedural trends

Details are presented of two patients with end-stage renal disease (ESRD) who recently experienced migration of a Viabahn covered stent from a peripheral hemodialysis A-V access to the right lower lobe pulmonary artery. Successful percutaneous retrieval was achieved in one patient using a dual snare approach, facilitated by ex vivo product testing. The second patient was managed conservatively. A review of the institution's A-V access salvage procedures, indicated a concomitant trend toward greater use of stent-assisted procedures, and a higher utilization of covered versus uncovered stents.

Transcatheter treatment of pulmonary artery pseudoaneurysm using pda closure device

Aneurysm of the branch pulmonary arteries are rare. The treatment options vary from case to case and include either surgery or percutaneous transcatheter treatment. The authors report a case of a 13-year-old boy who presented with a large pseudoaneurysm arising from the left lower lobe pulmonary artery. It was treated successfully by occluding the neck of the pseudoaneurysm by endovascular deployment of a patent ductus arteriosus closure device across it. There were no complications and the repeat computed tomography angiography of the patient at 3 weeks followup revealed no flow inside the thrombosed smaller aneurysm.

A 29-year-old male with chest pain and haemoptysis

A 29-yr-old African male was admitted with a 1-week history of chest pain, shortness of breath and haemoptysis. He had returned from Africa by plane 2 weeks previously. The patient denied fever, sweats or weight loss. He had no significant past medical history, was not taking any regular medication, and was a lifelong nonsmoker. He lived in the UK and was in full-time education. Physical examination did not reveal any abnormalities. Laboratory investigations showed elevated inflammatory markers, including an erythrocyte sedimentation rate level of 59 mm·h−1 and a C-reactive protein level of 53 mg·L−1, normal haemoglobin at 139 g·L−1 and leukocytosis of 14.6×109·L−1 with a predominance of neutrophils. Chest radiograph was normal. Computed tomography (CT) pulmonary angiography confirmed the presence of filling defects within branches of the right lower lobe, left lingular and left lower lobe pulmonary arteries, with no radiological evidence of right heart strain. Small nodules of ≤7 mm were identified in both lungs (fig. 1⇓). Several small mediastinal nodes were also identified. The patient was anti-coagulated with warfarin for bilateral pulmonary thromboembolism. Fig. 1— Computed tomography pulmonary angiography. Arrows show small pulmonary nodules. The patient had further episodes of atypical chest pain and haemoptysis over the following month. He was readmitted with signs of right heart failure and normocytic …

Hyperhomocysteinemia Due to Pernicious Anemia Leading to Pulmonary Thromboembolism in a Heterozygous Mutation Carrier

Pulmonary thromboembolism is a life-threatening condition resulting mostly from lower extremity deep-vein or pelvic-vein thrombosis. A 46-year-old woman was admitted to hospital with pain on the right side of the chest and hemoptysis. On laboratory analysis, D-dimer level was elevated. Computed tomographic pulmonary angiography revealed intravascular filling defects due to thrombi in right lower lobe pulmonary segmental arteries. Screening for thrombophilic states was normal except for heterozygous mutations of both prothrombin and methylene tetrahydrofolate reductase (MTHFR 677) genes. Homocysteine level was high, and vitamin B12 level and serum ferritin level were reduced. Serum antiparietal antibody was positive, and therefore, pernicious anemia was diagnosed along with iron-deficiency anemia. After the diagnoses were established, enoxaparin followed by warfarin was started in addition to oral vitamin B12, pyridoxine, thiamine, folic acid, and ferroglycine sulfate supplementation. At the end of 8 weeks of the replacement therapy, vitamin B12, folate, and homocysteine levels and red cell volume were found to be normal, with complete resolution of the thrombus confirmed by repeat computed tomographic pulmonary angiography. We conclude that hyperhomocysteinemia due to vitamin B12 deficiency associated with pernicious anemia might have decreased the threshold for thrombosis. In addition, the presence of heterozygous prothrombin and methylene tetrahydrofolate reductase mutations might serve as synergistic cofactors triggering pulmonary thromboembolism.

Bidirectional cavopulmonary connection without additional pulmonary blood flow as an ideal staging for functional univentricular hearts☆

Our institutional policy differs from others substantially, as we never leave any additional blood flow at the time of performing bidirectional cavopulmonary connection (BCPC). The aim was to evaluate the influence of this strategy on hemodynamics and pulmonary artery development. Between 2001 and 2006 a total of 124 patients had completion to a total cavopulmonary connection (TCPC). Review of 84 angiograms before BCPC and TCPC allowed for analysis of hemodynamic findings and measurement of the pulmonary arteries (PA). Mean age at BCPC was 12.6+/-15.3 months. Mean age at time of TCPC was 31.3+/-18.7 months, with an interval of 18.6+/-11.8 months between BCPC and completion to extracardiac TCPC. There was no postoperative mortality after BCPC, one patient died after TCPC (1.2%). The mean oxygen saturation increased after BCPC from 74.4% to 79.6% (p<0.01). The mean PA pressures decreased after BCPC from 15.1 to 13.5mmHg (n.s.). The mean left atrial pressure decreased from 5.8 to 4.9mmHg prior to TCPC (p=0.06). The pulmonary/systemic blood flow ratio was 1.4 prior to BCPC and decreased to 0.67 prior to TCPC (p=0.04). The pulmonary/systemic resistance ratio decreased also from 0.19 to 0.07 prior to TCPC (p<0.01). The right PA, as well as the right lower lobe PA, showed a significant increase in diameter after BCPC (p<0.01). The left PA also increased in size, although this was not statistically significant. After BCPC without additional blood flow, hemodynamic findings are favorable for completion of TCPC. Our findings support our institutional policy not only for an early staging to a BCPC, but likewise a swift completion towards a TCPC.

Picture quiz: Pitting oedema and recurrent pulmonary embolism

A 37 year old man presented with sudden onset, sharp pain across the left side of his chest. The pain was worse on deep inspiration and associated with shortness of breath. He had no history of recent surgery, no long journeys, and he had not been immobile. He reported a previous pulmonary embolism, two years ago. Examination findings include pitting oedema of the ankles and ascites. He said that his parents noticed he looked “puffy” at the age of 4. This problem worsened, until his face became swollen, and resolved after a course of prednisolone. The swelling returned months later. Further steroids were prescribed, and the problem abated. The patient had experienced relapse throughout his life, each one characterised by generalised oedema, lethargy, and frothy urine. Routine investigations (box 1) showed that he was hypoproteinaemic, with raised D-dimers. Computed tomography angiography showed a large filling defect in the left lower lobe pulmonary artery—that is, pulmonary embolism (fig 1). Could this man's pulmonary embolism be related to his protein status? Fig 1 Computed …

Large septic pulmonary embolism complicating extraction of an infected transvenous defibrillator lead

1 A-53-year-old man with known coronary artery disease and a istory of sustained monomorphic ventricular tachycardia underent placement of a dual-chamber implantable cardioverter-defirillator (ICD) in 2003. He presented to an outside facility with ever. His blood cultures were positive for Staphylococcus epiermidis, and the patient subsequently was transferred to our acility for further treatment. On physical examination he apeared well. He was afebrile, and his left infraclavicular ICD ocket was benign. A transthoracic echocardiogram (Figure 1A) evealed a large mobile vegetation (1.5 cm 1.5 cm) localized to he ICD lead within the right ventricle as it coursed through the ricuspid valve. Mild tricuspid regurgitation was present. A transenous endocardial lead extraction was performed using a comination of locking stylet and electrocautery dissection. All imlanted hardware was extracted without evidence of retained lead ragments. Immediately after the procedure, a transthoracic echoardiogram showed no evidence of vegetation within the heart and o change in valvular regurgitation. After the procedure, the paient developed left-sided pleuritic chest pain associated with feer. Computed tomographic scan of the chest confirmed a large ulmonary embolus (Figure 1B, filling defect) confined to the eft lower lobe pulmonary artery with evidence of pulmonary nfarction and consolidation (arrowhead). Intraoperative cultures f the pocket and lead tips were negative for bacterial growth; the atient had been receiving intravenous (IV) antibiotics for a few ays prior to the procedure. The patient was treated with 6 weeks f IV antibiotics and recovered without sequelae. He subsequently nderwent repeat ICD placement. With the ever-increasing number of cardiac pacemaker and CD placement procedures, physicians are likely to encounter ore patients with infected intravascular device hardware. he risk of pulmonary embolism complicating extraction of acemaker and ICD leads associated with vegetations 1 cm n size has been highlighted in the literature. The original bservation regarding the risk of embolization and larger vegtations was reported by Mugge et al, who demonstrated that 2 (47%) of 47 patients with vegetations 1 cm had evidence