Massive Pulmonary Thromboembolism Research Articles

Does the Incidence and Mortality of Pulmonary Thromboembolism Change Over the Years?

In the last 20 years, with the use of computed tomography (CT) angiography, the number of patients diagnosed with pulmonary thromboembolism (PTE) has increased. At the same time, data show that pulmonary embolism mortality has also reduced in this duration. In this study, we analyzed records of patients with PTE (using ICD's) in the hospital automation system from 2001 to 2013. Data regarding age, sex, date of diagnosis, diagnosis of cancer, hemodynamic status, initial and maintenance treatment, hospital length of stay, and hospital mortality were recorded. Primary endpoints of the study were hospital length of stay and all-cause hospital mortality. The total number of patients included in the study was 1185. The median age was 61 years in 2001 and 71 years in 2013. The number of patients who were diagnosed using CT increased from 10% to 92.8%. Between 2001 and 2013, the number of patients diagnosed with PTE increased, and of all patients with PTE, 13.7% was diagnosed in 2009. The hospital length of stay of 13 days declined to 9 days. The use of a vena cava filter in 2007 was 1.1% and that in 2013 was 4.6%. Mortality rate was 15%, however hospital mortality did not significantly differ over the years but varied between 9.4% and 18.8%. Increased use of thrombolytics in patients with massive PTE has been observed over the years. Massive PTE ratio in 2006 was 8.5% and thrombolytic use was 5.8%, however in 2013, these ratios were 2.6%, 6% respectively (p=0.017). Finally, despite the increased number of patients diagnosed with PTE over the years, the mortality rate was not observed to have changed from 2001 to 2013.

A case of mobile right ventricular thrombus with massive pulmonary thromboembolism

In patients with pulmonary thromboembolism, right heart thrombi are uncommon or underdiagnosed. They may form in situ or arise due to migration from the peripheral venous system. Their presence in pulmonary embolism indicates a grave prognosis and complicates treatment decisions. We report a case of mobile right ventricular thrombus with massive pulmonary thromboembolism who had a rapid fatal course despite early treatment.

Embolic Myocardial Infarction in a Patient with Massive Pulmonary Thromboembolism.

Embolic Myocardial Infarction in a Patient with Massive Pulmonary Thromboembolism.

Extraction of Atrial and Pulmonary Thrombi Using Angiovac Aspiration System with Transesophageal Echocardiography and Fluoroscopic Guidance

Surgical embolectomy is widely used to treat massive or submassive pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension. [1]-[3] However, recently a new minimally invasive transvenous approach to clot evacuation using the AngioVac aspiration system (Vortex Medical, Norwell, Massachusetts) such as AngioVac aspiration system has been successfully used for retrieval of right atrial clot [4]-[6]. This is the first case report describing evacuation of trans-septal thrombus using an AngioVac aspiration system utilizing transesophageal echocardiograph (TEE) and fluoroscopic guidance. This case report also highlights the potential complications involved in AngioVac system which were readily diagnosed using TEE. We present a 66-year-old Caucasian female with a right atrial thrombus extending into left atrium through a patent for ovale (PFO) defect and a pulmonary artery thrombus. She underwent suction evacuation with an AngioVac aspiration system under TEE and fluoroscopic guidance. The right atrial thrombus extending into left atrium through a PFO was successfully evacuated through the PFO. However, the evacuation of the clot in the pulmonary artery was complicated by a rupture of the right ventricle requiring emergent sternotomy, cardiopulmonary bypass (CPB) and transient extracorporeal mechanical oxygenation (ECMO) support. The patient rapidly improved post-operatively and was discharged from hospital. Echocardiographic documentation of right heart thrombus and pulmonary emboli has poor prognostic implications. This report delineates the utility of TEE for visualization of cannula placement and real time aspiration of clots through the cannula. Potential complications associated with this technique are mechanical dislodge of thrombus from its attachment with subsequent embolization and rupture of cardiac chambers. Accessing the thrombus in the PA can be challenging and actual visualization of the cannula in the PA is often difficult and available only through TEE. This report highlights the utility of TEE for demonstrating trans-septal clot and the importance of precise positioning of cannula in avoiding complications. In spite of complications, AngioVac aspiration system under TEE and fluoroscopic guidance may become a safe alternative for surgical removal of intracardiac thrombi.

Endovenous Treatment for Acute Massive Pulmonary Thromboembolism.

Treatment for venous thromboembolic conditions differs significantly depending on whether the condition is acute or chronic. Endovenous treatment is now available for treating the most severe cases of acute massive pulmonary thromboembolism, and the goal is rapid central clot removal to relieve life-threatening pulmonary circulation. Endovenous catheter interventions include catheter-directed thrombolysis and catheter-assisted thrombus removal. The latter is divided into aspiration thrombectomy, fragmentation, and rheolytic thrombectomy. Data from cohort studies indicate that the clinical outcome and safety after open surgical treatment and endovenous treatment may be comparable. This paper reviews the current approaches to endovenous treatment for acute massive pulmonary thromboembolism, and presents our study of hybrid treatment using a combination of local fibrinolysis, mechanical fragmentation, and clot aspiration.

Associating liver partition and portal vein ligation for staged hepatectomy: A surgical technique for liver resections.

Background:Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel surgical technique liver resection in traditionally nonresectable primary intrahepatic tumors or colorectal liver metastases.Materials and Methods:From June 2013 to March 2014, patients with primary tumor of liver or colorectal tumors with liver metastasis were selected to evaluate whether they met the initial criteria for ALPPS procedure.Results:Nine patients enrolled in the study with primary diagnoses of colon and rectosigmoid cancer, carcinoid tumor, gastrointestinal stromal tumor of small intestine, hepatocellular carcinoma, and pancreatic neuroendocrine tumor (PNET). Four candidates excluded from the study prior or during the first step operation due to fatty liver, hepatic fibrosis, peritoneal seeding, and multiple small intestine metastases. Five patients underwent two stages of ALPPS with the interval of about 1 week. Liver hypertrophy was 100% among our candidates after the initial step. One postoperative death happened because of massive pulmonary thromboembolism Recurrence of liver metastasis was seen in one patient. Hepatic failure Class B and A were observed in two patients which did not progress during follow-up period. One patient developed an enterocutaneous fistula.Discussion:We recommend to use 2 organ bags, one for wrapping right lobe and the other one for covering visceral organs and also do liver biopsy in suspicious cases of damaged liver parenchyma and laparoscopic exploration of abdomen for seeding and multiple metastases prior to laparotomy.Conclusion:As the procedure has not been well established and verified by oncologists yet, further studies are required to define the exact indications of ALPPS.

Acute pulmonary thromboembolism: Epidemiology, predictors, and long-term outcome – A single center experience

IntroductionAcute pulmonary thromboembolism (PTE) is a life-threatening disease. Mortality in PTE still remains very high in spite of progress in diagnostic tools. Mortality rate is about 30% in patients with unrecognized acute PTE. MethodsIt is a single center observational study of 31 consecutive patients who were hospitalized in the Department of Cardiology at MS Ramaiah Memorial hospital between January 1, 2010 and June 2015. All the patients confirmed with diagnosis of acute PTE by CT scan (either HRCT or CTPA) were included in the study. Following relevant investigations chosen patients were risk stratified as per standard guidelines into massive, sub massive or low risk and treated accordingly. The included patients were followed up for a period of 1 year with 2D-echocardiogram and other relevant investigations for comparison to assess improvement. Mortality due to either acute PTE or other causes was noted in the study. ResultsOf the 31 patients enrolled in our study, 71% (n=22) of the patients belonged to the age range 20–50 years with those in the age group 31–40 years comprising 39% (n=12) of the total. Elderly people over 65 years of age comprised only 19% (n=6) of the total number of patients. Dyslipidemia, prolonged immobilization, deep vein thrombosis, post-operative state, malignancy and post-partum period were the commonly reported risk factors. We thrombolysed a total of 18 (58%) patients with massive and submassive PTE, of which 12 (39%) received tenecteplase and 6 patients received streptokinase (19%). Three (9%) patients required repeat thrombolysis with streptokinase due to failed thrombolytic therapy with tenecteplase. ConclusionsOur study reported higher incidence of acute PTE in the middle age group population. Prevalence of dyslipidemia was high in this cohort of patients studied although the exact association of it in APE could not be determined. Thrombolytic therapy can be considered for patients with both massive and submassive pulmonary thromboembolism. Repeat thrombolysis can be considered in case one thrombolytic agent failed to give the desirable results.

Failure of Therapy at Premortem Diagnosed Pulmonary Thromboembolism

Objectives: We analyzed patients diagnosed premortem with pulmonary thromboembolism (PTE), focusing on causes of failure of therapy together with clinical characteristics. Methods: This was a retrospective study of 25 cases. We classified PTE as massive, submassive and nonmassive. Results: Of the 25 cases, 76% (19/25) had two or more risk factors for PTE. The point of origin of PE could be determined in only 44% of 25 cases. In 20 % (5/25) of cases diagnosed with PTE a maximum 3 months prior to death, the main cause of death was unknown. Of 10/20 (50%) massive and 8/20 (40%) submassive PTE cases, 5 and 3 underwent thrombolysis therapy, respectively. Both of 2/20 (10%) non-massive PTE cases underwent LMWH; in 1 of these cases, autopsy showed thrombus of a large pulmonary artery at 25 days after therapy. Submassive PTE cases were older and had a greater number of risk factors than did massive PTE cases. The point of origin of PTE was a right heart thrombus in six (24%) cases. Surgeries were performed in 3/6 (50 %) cases with right atrial thrombus. The survival duration after therapy in those who underwent surgery was longer than those who received thrombolysis and LMWH therapies. Conclusions: Physicians may provide appropriate information to patients who have certain risk factors (trauma, surgery, pregnancy, etc.) to predict acute PE at a preventable stage. If risk factors are present for a prolonged period, or if new risk factors for PTE are identified, patients should be followed up carefully because of the risk of progression of thrombosis.

Trombólisis sistémica exitosa en un paciente con tromboembolismo pulmonar masivo, luego de reanimación cardiocerebropulmonar prolongada. Informe de caso

Massive pulmonary thromboembolism is an entity with significant morbidity and mortality if not treated early. We describe the case of a young man with a history of knee trauma who was admitted to the emergency room complaining of sudden onset of dyspnea and syncope. During clinical evaluation, he had 5 episodes of cardiac arrest and required prolonged cardio pulmonary and cerebral resuscitation, the diagnosis of massive pulmonary thromboembolism was confirmed by echocardiography and computed tomographic pulmonary angiography. Despite prolonged cardio pulmonary and cerebral resuscitation is considered a relative contraindication to systemic thrombolysis, latter was performed, with remarkable clinical improvement without sequelae at discharge.

Successful systemic thrombolysis in a patient with massive pulmonary thromboembolism after prolonged cardio pulmonary and cerebral resuscitation. Case report

Massive pulmonary thromboembolism is a condition with high morbidity and mortality if not treated early. A case of a young man with a history of knee trauma that was admitted to the emergency department with sudden dyspnea and syncope is discussed. During the clinical evaluation the patient experienced 5 episodes of cardiac arrest that required prolonged cardiopulmonary-cerebral resuscitation. The diagnosis of massive pulmonary thromboembolism was confirmed by echocardiography and thoracic CT angiography. Although prolonged cardiopulmonary-cerebral resuscitation is a relative contraindication for systemic thrombolysis, the patient experienced remarkable clinical improvement with no sequelae upon hospital discharge.

Surgical technique for the treatment of renal cell carcinoma with inferior vena cava tumor thrombus: tips, tricks and oncological results.

Renal cell carcinoma represents 3 % of all cancers. Around 4–10 % of cases present with inferior vena cava involvement, generally with tumor thrombus. Clinical and preoperative stage will be classified depending of the thrombus extension. A high quality preoperative workup is essential to properly plan surgical approach. Complete surgical resection of the tumor is potentially the only curative treatment, although it supposes a real challenge due to operative difficulty, potential for massive bleeding or tumor pulmonary thromboembolism. Surgery includes techniques derived from transplantation surgery and, in some cases, cardiovascular intervention with cardiopulmonary bypass. Long-term oncological outcomes after complete removal of the entire tumor burden are acceptable. In this report we describe step-by-step surgical maneuvers depending on the thrombus lever, and focusing in complete abdominal approach for the complete excision of the tumor. Moreover, a recent literature review about oncological results is reported.

One case of pulmonary embolectomy in acute massive pulmonary thromboembolism by cardiopulmonary bypass by color ultrasound technique

One case of pulmonary embolectomy in acute massive pulmonary thromboembolism by cardiopulmonary bypass by color ultrasound technique

Primitive neuroectodermal tumors of kidney: Our experience in a tertiary care center.

Primitive neuroectodermal tumors (PNET) are rare highly aggressive neoplasms. The diagnosis is made by histopathology with the support of immunohistochemistry (IHC) and cytogenetics. The aggressive multimodality treatment is recommended for the management of these tumors. The purpose of our study is to review our experiences in the diagnoses and treatment of PNET of the kidneys. We retrospectively reviewed the data of all the patients, who were treated for the PNET of the kidneys at our institute between April and March 2011 and compared with the available literature. A total of eight patients were treated for PNET of the kidney. Out of the eight patients, four were males and four females. Nearly 50% of our patients had inferior vena caval thrombus at the time of presentation. The diagnosis was made on histopathology supported by IHC. Out of the eight patients, one patient had intraoperative death due to massive pulmonary thromboembolism and another died on the 7th post-operative day due to disseminated intravascular coagulation and multiorgan failure. Rest six patients were treated with post-operative chemotherapy or a combination of chemotherapy and radiotherapy. For these six patients, overall median survival was 45 months with a 3 year disease-free survival of 66% and 5 year survival of 44%. PNET of the kidneys are rare peripheral neuroectodermal tumors with an aggressive clinical course. These tumors carry a very poor prognosis. An aggressive treatment approach using a combination of surgery, chemotherapy and radiotherapy is recommended for a reasonable survival in these tumors.

Clinical Significance of the Soleal Vein and Related Drainage Veins, in Calf Vein Thrombosis in Autopsy Cases with Massive Pulmonary Thromboembolism.

To clarify the histopathological characteristics of deep vein thrombosis (DVT) resulting in lethal pulmonary thromboembolism (PE). We investigated 100 autopsy cases of PE from limb DVT. The distribution and chronology of DVT in each deep venous segment were examined. Venous segments were classified into three groups: iliofemoral vein, popliteal vein and calf vein (CV). The CV was subdivided into two subgroups, drainage veins of the soleal vein (SV) and non drainage veins of SV. Eighty-nine patients had bilateral limb DVTs. CV was involved in all limbs with DVT with isolated calf DVTs were seen in 47% of patients. Fresh and organized thrombi were detected in 84% of patients. SV showed the highest incidence of DVTs in eight venous segments. The incidence of DVT gradually decreased according to the drainage route of the central SV. Proximal tips of fresh thrombi were mainly located in the popliteal vein and tibioperoneal trunk, occurring in these locations in 63% of limbs. SV is considered to be the primary site of DVT; the DVT then propagated to proximal veins through the drainage veins. Lethal thromboemboli would occur at proximal veins as a result of proximal propagation from calf DVTs.

Massive Pulmonary and Coronary Artery Thromboembolism in the Setting of Undetected Patent Foramen Ovale

Invasive surgery brings with it a unique set of post-surgical risks that are directly dependent on various factors including the specific surgical approach used, pre-existing comorbidities and features such as gender and age. Pulmonary thromboembolism is one of the most feared complications following surgery, and diagnosis and treatment of this entity is a challenging task for the clinician. Here we describe a case of massive pulmonary thromboembolism and associated coronary artery thromboemboli status post spinal fusion surgery in a 68 year-old man with an undetected patent foramen ovale (PFO). Although the decedent was managed clinically with proper deep venous thrombosis prophylaxis protocols and physical rehabilitation, he went into cardiorespiratory arrest after experiencing acute oxygen desaturation and newly detected right bundle branch block. PFO can be incidentally found in 25% of the adult population. Several clinical syndromes including stroke, migraine headaches and obstructive sleep apnea have been associated in patients with PFO, the last two from which the decedent suffered. The pathology of this unique case of massive pulmonary thromboembolism resulting in coronary artery thromboemboli in the setting of an undetected PFO is discussed. The discovery of PFO in patients prior to surgery, if detected early, may improve post-surgical outcomes. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Elderly Woman Presenting After a Collapse

An 81-year-old woman with myeloma and a recent fractured femoral neck presented after a collapse. On arrival, she was tachycardic, hypotensive, and hypoxic. ECG showed incomplete right bundle branch block, prominent S waves in lead I, Q waves and T-wave inversion in lead III (FigureA, black arrows). Echocardiography, performed by a cardiologist in the emergency department (ED), revealed classic features of massive pulmonary thromboembolism, with right ventricle enlargement and regional impairment of the right ventricle free wall (McConnell’s sign) ( FigureB; Video E1, available online at http://www.annemergmed.com), 1 compression of the left ventricle, and a large serpentine thrombus in the right atrium, which extends into the right ventricle ( FigureB, white arrow; Video E1, available online at http://www.annemergmed.com).

Efficacy and safety of delayed thrombolytic therapy for acute massive pulmonary throboembolism

To observe the efficacy and safety of delayed thrombolytic therapy on acute massive pulmonary thromboembolism (PTE) and discuss the influence factors. From 2009 to 2013, the clinical data of patients with acute massive pulmonary thromboembolism were analyzed retrospectively. Patients with over 14-day duration and treated with thrombolytic therapy (delayed thrombolytic group) were compared with those within 14-day duration and treated with thrombolytic therapy (normal thrombolytic group) in the same period. General conditions before treatment, case history, efficacy and the incidence of bleeding after one-week treatment were collected. The influence factors of delayed thrombolytic therapy were analyzed. Sixty two cases were collected and divided into the normal thrombolytic group with 32 cases and the delayed thrombolytic group with 30 cases. Compared with the normal thrombolytic group, the delayed thrombolytic group had a longer duration [(24.8 ± 0.9) vs.(7.2 ± 0.6)d, P<0.001], an aggravation time of (5.3 ± 0.8) d, and higher systolic pulmonary arterial pressure (SPAP) [(69 ± 4)vs. (55 ± 4)mmHg, 1 mmHg= 0.133 kPa, P= 0.016]. Ages, genders, D-Dimmer, CT subpulmonic obstruction index (CTI), brain natriuretic peptide (BNP), cardiactroponinI (TnI), PaCO₂values and PaO₂values had no statistical difference between two groups. After one-week treatment, the efficacy and the incidence of bleeding was 78% and 25% respectively in normal thrombolytic group, while they were 77% and 30% respectively in delayed thrombolytic group, and there was no significant difference between two groups (P>0.05). The single factor analysis showed that the delayed thrombolytic group had more patients with hypertension, were older and had a lower PaO₂(P<0.05 or 0.01). Multivariate logistic regression analysis did not find the predictors of delayed thrombolytic therapy (P>0.05). For acute massive PTE patients with duration over 14 days, increased D-D and new exacerbation of symptoms,delayed thrombolytic therapy had the same efficacy with the normal thrombolytic therapy. The factors for predicting efficacy need further research.

Successful operation for uncontrollable bleeding associated with gastric cancer under the percutaneous cardiopulmonary support in a case of massive pulmonary thromboembolism

Successful operation for uncontrollable bleeding associated with gastric cancer under the percutaneous cardiopulmonary support in a case of massive pulmonary thromboembolism

Low-dose tissue plasminogen activator in the treatment of a massive pulmonary thromboembolism in a colon cancer patient treated with bevacizumab: A case report.

The current study describes the fibrinolytic treatment of a patient exhibiting an acute massive pulmonary thromboembolism, who was also receiving a bevacizumab-based combination regimen for metastatic colon cancer. The administration of bevacizumab has been associated with an increased risk of venous thromboembolic events and bleeding in cancer patients. However, there is insufficient data regarding the safety and activity of thrombolytic agents in cancer patients receiving bevacizumab-based therapy. In the present case, despite the increased risk of bleeding, low-dose and prolonged tissue plasminogen activator infusion was effectively and reliably applied to treat a massive pulmonary embolism, which resulted in hemodynamic instability in the patient.

TCT-518 Is The Retrieval Of IVC Filter Safe?

We wanted to study the feasibility and safety of IVC filters retrieval in patients with DVT with pulmonary thromboembolism (PTE) with IVC filter. We retrospectively analyzed the data of patients who presented with DVT with massive or sub-massive PTE and were treated with catheter thrombolysis and