Massive Thrombus Research Articles

Secondary Osteosarcoma Developing 10 Years after Chemoradiotherapy for Non-small-cell Lung Cancer

A 53-year-old female patient was admitted with pain and a progressively enlarging mass in the right upper chest. Chest computed tomography revealed a mass lesion in the region of the right upper ribs. Ten years prior to this admission, the patient had undergone right lobectomy for lung adenocarcinoma. One year after the surgery, follow-up computed tomography had revealed tumor recurrence in the mediastinal and supraclavicular lymph nodes, and the patient had been treated by chemoradiotherapy. Thereafter, regular follow-up had revealed no evidence of recurrence of the non-small-cell lung cancer. Histopathological findings revealed proliferation of spindle-shaped malignant tumor cells in a background of osteoid, consistent with the diagnosis of osteosarcoma. The location of the tumor was consistent with the radiation field. Based on the clinicopathological findings, the patient was diagnosed as having secondary osteosarcoma occurring as a result of the chemoradiotherapy administered previously for the recurrent non-small-cell lung cancer. Unfortunately, the patient died of rapid progression of the osteosarcoma within a week of admission to the hospital. The autopsy revealed contiguous invasion by the tumor of the heart, with massive thrombus formation. The peripheral pulmonary arteries were diffusely occluded by metastatic tumors. Our case serves to highlight the risk of development of secondary sarcoma as a life-threatening late complication after chemoradiotherapy for locally advanced non-small-cell lung cancer, even after complete cure of the primary tumor.

Coronary Artery Embolism Causing Acute Myocardial Infarction in Patients with Mechanical Heart Valve Prosthesis: Which is the Optimal Treatment?

Coronary artery embolism resulting in acute myocardial infarction (AMI) is an infrequent but potentially life-threatening occurrence. To date, there is still no consensus in the literature regarding the optimal therapeutic algorithm for embolic myocardial infarction. We present our experience with three patients who had mechanical valve prosthesis and suffered from AMI due to coronary artery embolism in the setting of sub-therapeutic or interrupted anti-coagulation therapy. Those patients were treated with intracoronary thrombolysis, thrombus aspiration followed by balloon angioplasty and thrombus aspiration alone, respectively. In our case 1, the coronary angiogram demonstrated extensive thrombus within the left circumflex coronary artery and extending into the left anterior descending (LAD). We performed intracoronary thrombolytic therapy, which results in completed thrombus resolution and favourable clinical outcome. In our case 3, coronary angiography revealed massive thrombus within the middle-LAD with a TIMI grade 3 distal flow. The patient underwent a successful thrombus aspiration procedure without stent implantation. In our case 2, the coronary angiography revealed total occlusion of the middle LAD, and thrombus aspiration was initially performed because of the large thrombus burden. However, this approach was unsuccessful and so the patient was then treated with balloon angioplasty, resulting in TIMI 2 flow. Embolic myocardial infarction, although uncommon, can occur in predisposed groups such as those with prosthetic mechanical valves with sub-therapeutic anticoagulation. The treatment for this specific group of patients needs to be tailored individually.

Removal of pacemaker leads in extracorporeal circulation

Results Overall, 6 leads were removed from 4 patients. The commonest indication for extraction was infection (endocarditis) in three patients (75 %). The other patient was operated because of massive thrombus on the leads. Removal was complete and safe for all the patients. All the patients received epicardial lead with pacemaker pocket located in the rectus abdominis muscle. The postoperative period was free of complications in all the patients.

Open mitral comissurothomy in surgery of isolated mitral stenoses

Methods Analyzed group consists of 225 patients (pts) with MVD operated in Institute from 01.01.1081 till 01.01.2008. Average age was 51,3±6,1 yy. 151 (67,1%) pts belonged to IV NYHA class, 69 (30,7%) – to III and 5 (2,2%) pts to II. There were 69 (30,7%) males and 156 (69,3%) females. Mitral stenosis was in 191(84,9%) pts, combined MVD in 34 (15,1%) pts. Isolated OMC was performed In 146 (64,9%) pts, in 79 (35,1%) cases – in combination with other plastic procedures on MV including ring annuloplasty, suture comissuroplasty, resection of posterior leaflet. Thrombectomy of left atrium was performed in 71 (31,6%) pts including 21(9,3%) pts with massive thrombus formation. 9 (4,0%) pts were cerebral cysts after previous episods of thromboemboli. Tricuspid valve correction was occured in 69 (30,7%) pts All operations were performed with cardiopulmonary bypass, moderate hypothermia and crystalloid cardioplegia.

Massive thrombus originating from the interatrial septum and prolapsing into the left ventricle

Massive thrombus originating from the interatrial septum and prolapsing into the left ventricle

Differentiation of thrombus from pannus as the cause of acquired mechanical prosthetic heart valve obstruction by non-invasive imaging: a review of the literature

For acquired mechanical prosthetic heart valve (PHV) obstruction and suspicion on thrombosis, recently updated European Society of Cardiology guidelines advocate the confirmation of thrombus by transthoracic echocardiography, transesophageal echocardiography (TEE), and fluoroscopy. However, no evidence-based diagnostic algorithm is available for correct thrombus detection, although this is clinically important as fibrinolysis is contraindicated in non-thrombotic obstruction (isolated pannus). Here, we performed a review of the literature in order to propose a diagnostic algorithm. We performed a systematic search in Pubmed and Embase. Included publications were assessed on methodological quality based on the validated Quality Assessment of Diagnostic Accuracy Studies (QUADAS) II checklist. Studies were scarce (n = 15) and the majority were of moderate methodological quality. In total, 238 mechanical PHV's with acquired obstruction and a reliable reference standard were included for the evaluation of the role of fluoroscopy, echocardiography, or multidetector-row computed tomography (MDCT). In acquired PHV obstruction caused by thrombosis, mass detection by TEE and leaflet restriction detected by fluoroscopy were observed in the majority of cases (96 and 100%, respectively). In contrast, in acquired PHV obstruction free of thrombosis (pannus), leaflet restriction detected by fluoroscopy was absent in some cases (17%) and mass detection by TEE was absent in the majority of cases (66%). In case of mass detection by TEE, predictors for obstructive thrombus masses (compared with pannus masses) were leaflet restriction, soft echo density, and increased mass length. In situations of inconclusive echocardiography, MDCT may correctly detect pannus/thrombus based on the morphological aspects and localization. In acquired mechanical PHV obstruction without leaflet restriction and absent mass on TEE, obstructive PHV thrombosis cannot be confirmed and consequently, fibrinolysis is not advised. Based on the literature search and our opinion, a diagnostic algorithm is provided to correctly identify non-thrombotic PHV obstruction, which is highly relevant in daily clinical practice.

Is no‐no‐reflow following PCI in AMI due to distal embolization of plaque and thrombus?

Catheterization and Cardiovascular Interventions 82:210–211 (2013) Editorial Comment Is no-no-reflow following PCI in AMI due to distal embolization of plaque and thrombus? Jonathan Tobis,* MD Director of Interventional Cardiology, Prof. of Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California Of 3400 patients enrolled in the Horizons-AMI (acute myocardial infarction) trial that assessed the use of bivalirudin versus heparin plus routine GP IIb/IIIa inhibition, 402 patients had intravascular ultrasound (IVUS) imaging poststenting, and of these, 43 patients had IVUS imaging before any intervention as well as post stenting. The accompanying paper [1] describes the observations in this final select group of patients. The authors conclude: 1. In addition to the artery lumen enlarging from the stent, there was a decrease in lesion segment plaque volume. The decrease in plaque volume was greater than the shift of plaque longitudinally from the lesion to the proximal and distal references. 2. The decrease in lesion plaque volume was greater in patients with angiographic thrombus compared to those with no angiographic thrombus. 3. The post-intervention CK-MB correlated with the reduction in plaque volume. This article represents a large amount of meticulous work, measurements and analysis, not only on this subset of patients but also for the larger IVUS cohort and for the multicenter Horizons- AMI trial. The authors should be congratulated because it is difficult to obtain these data. Of the 43 patients who had an acute MI and had IVUS imaging prestenting and poststenting, 20 had thrombus identified by angiography and 23 did not. None of the patients with thrombus received thrombectomy. There was more loss of plaque volume in pts with thrombus versus those without thrombus. five patients with thrombus had no-reflow but none of the patients without thrombus had no-reflow. It is a bit difficult to draw emphatic conclusions with such small numbers of patients, but it certainly is consistent with the hypothesis that percutaneous coronary intervention (PCI) with stenting breaks up thrombus which then heads downstream and causes no-reflow. The periprocedural increase in CK-MB correlated with the reduction in plaque volume which also is suggestive that PCI can release material downstream and cause myocardial necrosis, especially if thrombus is present. So why are there such ambiguous results with thrombectomy in AMI? The authors conclude: “The current findings may also explain why thrombus aspiration or distal protection is not universally beneficial since not all patients with AMI have thrombus,” as documented in this study with IVUS. Perhaps the identification of thrombus would be more sensitive with OCT imaging, but I believe that IVUS is accurate for quantifying a large intralumenal mass of thrombus.

Therapeutic strategies of iatrogenic portal vein injury after cholecystectomy

BackgroundThe incidence of vascular injury after a cholecystectomy is often underestimated. Although injuries to the portal vein are rare, they are devastating. The aim of the present study was to analyze suitable therapeutic strategies regarding portal vein injury in the absence of biliary injury. Materials and methodsEleven patients with portal vein injuries after laparoscopic or open cholecystectomy were referred to our hospital between 2004 and 2010. The clinical presentation, diagnosis, and management of patients with severe portal vein injuries were reviewed. All the patients were discharged without outstanding clinical conditions. During retrospective analysis, these patients were divided into early, middle, and late stages. ResultsAll the 11 patients had a portal vein and/or right hepatic artery injury, but no biliary injuries were observed. Among these patients, different management strategies were managed according to the stage of the injury. Eight patients received a direct suture at the time of injury by an experienced hepatobiliary surgeon. Two patients received thrombolytic and anticoagulation therapy after cholecystectomy, without additional surgery. One patient received a liver transplant 3 mo after the injury. After long-term follow-up, these patients had no clinical conditions. ConclusionsDirect repair or suture is important during the early stage of portal vein injury. Conservative thrombolytic and anticoagulation therapy may serve an important role in the treatment of acute massive thrombus in portal vein injury during the middle stage. Liver transplantation is a salvage therapy that should be used during the late stage.

Combined intracoronary thrombolysis, thrombus aspiration and mesh-covered stent implantation for organized massive thrombus burden in ectatic coronary

Organized intracoronary thrombus is associated with adverse outcomes due to distal embolization and no-reflow phenomenon during PCI, particularly in large or ectatic coronary arteries. Intracoronary thrombolysis is an underused but effective and safe strategy. We describe the case of a 56-year-old man admitted due to a subacute myocardial infarction with massive thrombus burden in a right ectatic coronary artery to present the usefulness of a sequential approach with intracoronary thrombolysis, thrombus aspiration and a novel mesh-covered stent implantation as a reasonable and effective strategy to avoid a no-reflow phenomenon during PCI, achieving an immediate successful angiographic result, and a positive long-term clinical outcome.

Left Atrial Massive Thrombus Formation on the Transseptal Sheath Despite Adequate Anticoagulation with Warfarin and Heparin During Pulmonary Vein Isolation

Left Atrial Massive Thrombus Formation on the Transseptal Sheath Despite Adequate Anticoagulation with Warfarin and Heparin During Pulmonary Vein Isolation

症例 大量の冠動脈血栓像を伴う急性心筋梗塞に対して,冠動脈内血栓吸引療法を施行した1例

症例 大量の冠動脈血栓像を伴う急性心筋梗塞に対して,冠動脈内血栓吸引療法を施行した1例

Abstract 52: Statin Therapy Accelerates Venous Thrombus Resolution: Assessment In Stasis And Chemical Injury Induced Thrombosis

Introduction In deep vein thrombosis (DVT), both the induced inflammation response and fibrinolytic capacity are critical in resolving experimental DVT. Unresolved, obstructing thrombi can lead to the burdensome and costly sequelae of the post-thrombotic syndrome. Recently, statins have shown to reduce the incidence of DVT (JUPITER trial). In this study, we investigated the in vivo effects of statin therapy on resolution of already formed DVT using serial intravital microscopy (IVM) imaging and thrombus mass measurements. Methods DVT was induced in C57Bl/6J male mice (N=190) by topical ferric chloride of the femoral vein (chemical injury) or ligation of the IVC (stasis). One day after DVT induction, mice started treatment of atorvastatin (1.14mg/kg), mevastatin (10 mg/kg) or PBS by once daily oral gavage. Serial IVM was preformed at days 2, 4 and 6 utilizing FITC-dextran (ex/em 490/520nm), CLIO-AF555 (ex/em 555/565nm), and MMPSense680 (ex/em 680/700nm) imaging agents for thrombus architecture, macrophage content and MMP activity measurements. Thrombus masses were collected at days 4, 7, 10 in stasis DVT mice and combination statin/enoxaparin (10mg/kg/d, s.c.) were also compared to statin therapy. Platelet activation and coagulation were analyzed using aggregometry and thromboelastography on whole-blood. Results We found that statin therapy reduced DVT burden and inflammation in both chemical- and stasis-induced established DVT up to 10 days compared to control (p<0.05). Serial IVM imaging of statin animals showed an increase in DVT resolution from day 2 to 4 (Δlength -21± 6.0 vs. control -7.1± 5.6%, p<0.01), and decreased inflammation compared to controls (p<0.001). Inflammation was also found to predict the extent of DVT resolution(r=0.84). Statin therapy also reduced thrombus plasminogen activator inhibitor-1, tissue factor, and Mac-3 levels, as well as reducing platelet activation and clot strength(p<0.05). Conclusion Statin therapy accelerates DVT resolution despite reducing thrombus related inflammation. The net reduction of thrombus burden tracked with statin-mediated favorable effects on fibrinolysis, coagulation, and platelet function. These results support statins as a translatable therapy to improve the resolution of DVT.

Massive Left Atrial Thrombus in a Patient With Rheumatic Mitral Stenosis and Atrial Fibrillation While Anticoagulated With Dabigatran

Dabigatran is an oral direct thrombin inhibitor licensed for use by the Food and Drug Administration.1,2 This novel anticoagulant is effective and approved for prevention of stroke and systemic embolism in nonvalvular atrial fibrillation (AF) and prevention of venous thromboembolism in adults receiving elective total hip or knee replacement surgery.1,2 These images present a cautionary account of failed dabigatran anticoagulation in a patient with valvular AF: an indication for which its use has not been approved. A 50-year-old female with severe rheumatic mitral stenosis underwent open mitral valvotomy under cardiopulmonary bypass 25 years prior. On subsequent annual surveillance, she remained asymptomatic and her mitral stenosis remained moderate on echocardiography with a mean transmitral gradient of 8 mm Hg. Permanent AF was previously diagnosed 12 months earlier, and she was commenced on warfarin and metoprolol. She had stable anticoagulation monitoring, no bleeding complications, and normal renal function, but was needle-phobic with psychological …

Pulmonary artery intimal sarcoma: poor 18F-fluorodeoxyglucose uptake in positron emission computed tomography

Intimal sarcoma of the pulmonary artery is a rare malignant tumor that may be misdiagnosed as chronic pulmonary thromboembolism, even if various imaging techniques are used. We report a case of a 58-year-old man with pulmonary artery intimal sarcoma.18F-fleuorodeoxyglucose (FDG) uptake was poor in the mass of the pulmonary artery, and no other hypermetabolic lesions were noted elsewhere. Our presumptive diagnosis was a massive mural thrombus and a concomitant chronic thromboembolism. Intravenous heparin and recombinant human tissue-type plasminogen activator was subsequently administered. However, the patient needed an emergency operation for sudden aggravation of the vital signs, and the tissue diagnosis was intimal sarcoma with poor clinical outcomes.

A Case of Dilated Cardiomyopathy with Massive Left Ventricular Thrombus after Use of a Sibutramine-Containing Slimming Product

Sibutramine, which acts as an anti-obesity drug by inhibiting reuptake of serotonin and norepinephrine, has now been banned due to cardiovascular adverse effects. However, despite being banned, it is not uncommon for people to purchase products with sibutramine or its analogues used as adulterants in non-prescription slimming products or health foods available on the internet. Sibutramine has been associated with rare but serious adverse reactions such as cardiac arrhythmia including QT interval prolongation, myocardial infarction, and cardiomyopathy, as well as increases in blood pressure and pulse rate. Here, we report a case of a 32-year-old male who presented with dilated cardiomyopathy with massive left ventricular thrombus after taking unauthorized sibutramine-containing slimming pills sold over the internet.

Successful Embolectomy of a Migrated Thrombolytic Free-Floating Massive Thrombus Resulting in a Pulmonary Thromboembolism

The optimal treatment for free-floating massive right heart thrombi remains uncertain. However, they appear to increase the risk of mortality compared to the existence of a solitary pulmonary thromboembolism. Thrombolytic therapy has been shown to be effective in most patients, resulting in complete resolution of the massive thrombus and clinical improvement. We report the echocardiographic disappearance of a free-floating right heart thrombus after thrombolysis, however, the thrombus migrated and resulted in pulmonary thromboembolism. It was successfully removed with surgery.

Letter to the Editor Unexpected cause of syncope in a young woman

Letter to the Editor Unexpected cause of syncope in a young woman

An autopsy case of acute pulmonary trunk thromboembolism due to massive right atrium thrombus

An autopsy case of acute pulmonary trunk thromboembolism due to massive right atrium thrombus

Study Design of PROCEDURE Study a Randomized Comparison of the Dose-Dependent Effects of Pitavastatin in Patients with Abdominal Aortic Aneurysm with Massive Aortic Atheroma: Prevention of Cholesterol Embolization during Endovascular and Open Aneurysm Repair with Pitavastatin(PROCEDURE) Study

Outcomes of abdominal aortic aneurysm (AAA) repair have improved in the 2 decades since the emergence of endovascular aneurysm repair (EVAR). However, EVAR is considered a contraindication for shaggy aorta because of the high risk of shower embolization. Recently, statins have been implicated in preventing embolization in patients with shaggy aorta via its pleiotropic effects, including atheroma reduction and coronary artery stabilization. We selected pitavastatin, a statin with potent effects, discovered and developed by a Japanese company because it has shown excellent pleiotropic effects on atheromatous arteries in the Japanese population. A randomized comparison study of dose-dependent effects of pitavastatin in patients with AAA with massive atheromatous aortic thrombus (PROCEDURE study) has begun. PROCEDURE has an enrollment goal of up to 80 patients with AAA with massive aortic atheroma (excluding intrasac atheroma), randomly allocated into 2 groups receiving pitavastatin at a dose of 1 or 4 mg/day. The endpoints of the PROCEDURE study include change in atheroma volume, major adverse events related to shower embolization after aneurysm repair, and lipid-lowering effects. When complete, results of the PROCEDURE study should provide objective evidence to use statins preoperatively for AAA with massive aortic atheroma.

Coronary embolism in a patient with massive left atrial thrombus and mechanical valve thrombus: hybrid treatment with surgery and percutaneous intervention

A 67-year-old female was admitted to the emergency department with chest pain for the last 24 hours. She had a history of rheumatic mitral stenosis and had received a mechanical mitral valve (24-mm bi-leaflet St. Jude valve) three years ago. She had been inadequately anti-coagulated for the last two months. At the time of presentation, her international normalized ratio (INR) was 1.02. The electrocardiogram (ECG) revealed atrial fibrillation with a heart rate of 130 beats per minute, right bundle brunch block, and precordial ST segment elevation (Fig. A). Transthoracic echocardiography (TTE) revealed hypokinesis of the apex, apical and mid septal walls, with an ejection fraction of 40%, in normal range of mitral valve area of 2.3 cm2; the peak and mean transmitral gradients were 15 mmHg and 7 mmHg, respectively. Transesophageal echocardiography (TEE) showed up to 1.4 cm fibrillar thrombi on the mitral prosthetic valve and a huge thrombus completely filling the left atrial walls except for the mitral prosthetic valve line and extending to the right and left pulmonary vein ostia on the posterior wall and into the appendix (Fig. B, Video file 1*). Based on the symptom of chest pain and ECG findings, she was diagnosed as subacute anterior myocardial infarction and underwent coronary angiography, which revealed total occlusion of the proximal segment of the left anterior descending artery. The patient was anticoagulated with unfractionated heparin. Lesion wiring and predilatation were done using 2.0x12 and 2.5x20 mm balloons. A 2.75x32 mm bare metal stent was implanted (Fig. C). Heparin was infused for 10 days with adjustment of activated partial thromboplastin time (aPTT) level to 50-70 seconds. Because the follow-up TEE showed no regression of the thrombus on the mechanical valve or of the left atrial thrombus, surgical thrombectomy was planned. Median sternotomy was performed and huge left atrial thrombus fragments (7.5x3 cm, 6x4 cm, 6.5x5 cm, 1.7x0.7 cm, and 1.5x0.7 cm) were excised without mechanical valve replacement (Fig. D). The patient was discharged with optimal anticoagulation. She was asymptomatic and had normal mechanical valve functions on TTE examination at the twomonth follow-up. 784