Preoperative Pulmonary Embolism Research Articles

Technique and short-term outcomes of surgical treatment in patients with renal cell carcinoma and tumor venous thrombosis: experience of the Urology Clinic, N.N. Blokhin National Medical Research Center of Oncology

Objective: to describe the technique of nephrectomy and thrombectomy used in patients with renal cell carcinoma (RCC) and tumor venous thrombosis of various levels, and to identify risk factors of in-hospital death among operated patients.Materials and methods. This study included 768 patients with RCC and tumor venous thrombosis who have undergone surgical treatment. Median age was 58 years (range: 16-82 years); the male to female ratio was 2.3:1. The symptoms of venous tumor thrombosis were identified in 199 patients (25.9 %). In the majority of patients (n = 509; 66.3 %), the tumor thrombus originated from the right renal vein. The cranial border of the tumor thrombus was located in the perirenal inferior vena cava (IVC) in 219 patients (28.5 %), subhepatic IVC in 201 patients (26.2 %), intrahepatic IVC in 171 patients (22.3 %), and above the diaphragm in 177 patients (23.0 %). We used an individual approach to choose an optimal method of vascular control and to identify indications for circulatory support. Two-thirds of patients (n = 512; 66.7 %) underwent temporary block of the second renal vein; 268 patients (34.9 %) - temporary block of the hepatoduodenal ligament and right heart; 11 patients (3.2 %) were operated on with cardiopulmonary bypass.Results. The median surgery time was 190 ± 63.6 min; median blood loss was 3,000 ± 71.6 mL (≥50 % of circulating blood in 35.1 % of patients). Intraoperative complications were registered in 23 patients (3.0 %); eight patients (1.0 %) died during surgery with 4 of them died due to pulmonary embolism (0.5 %), 3 died due to hemorrhagic shock (0.4 %), and 1 died due to myocardial infarction (0.1 %). One hundred and ninety individuals (25.0 %) developed postoperative complications with Clavien-Dindo grade III-V complications observed in 115 cases (15.1 %). Forty-one patients (5.3 %) died in the early postoperative period. The causes of death included multiple organ dysfunction (n = 21; 2.8 %), pulmonary embolism (n = 7; 0.9 %), sepsis (n = 6; 0.8 %), stroke (n = 4; 0.5 %), myocardial infarction (n = 2; 0.2 %), and RCC progression (n = 1; 0.1 %). We have identified several independent risk factors for in-hospital mortality, including ascites (hazard ratio (HR) 8.3; 95 % confidence interval (CI) 3.2-21.4; p < 0.0001), preoperative pulmonary embolism (HR 3.5; 95 % CI 1.3-9.4; p = 0.013), supradiaphragmatic thrombi (HR 1.5; 95 % CI 1.1-2.0; p = 0.003). The in-hospital mortality rate was 3.5 % (20/575) among patients with no risk factors, 9.8 % (16/163) among those with 1 risk factor, 40.0 % (10/25) among those with 2 risk factors, and 60.0 % (3/5) among those with 3 risk factors (area under the curve (AUC) 0.705; p <0.0001 for all).Conclusion. The incidence of severe complications and postoperative mortality rate in RCC patients with tumor venous thrombosis who have undergone nephrectomy and thrombectomy were 15.1 and 6.4 %, respectively. Risk factors for perioperative mortality included ascites, preoperative pulmonary embolism, and supradiaphragmatic thrombosis.

Robotic-assisted hiatal hernia repair and pulmonary embolism: an institution-based retrospective cohort study.

Hiatal hernia (HH) is an abnormal protrusion of components of the abdominal viscera through the esophageal hiatus. The laparoscopic approach is the gold standard for repair with the robotic technique now gaining wide acceptance. Pulmonary embolism (PE) is a well-known post-operative complication but its incidence following robotically assisted HH repairs is not well known. This study provides a descriptive analysis of three patients who developed PE after robotic repairs of their HHs. The incidence of PE in the studied cohort was 2.7% (3 of 112) with a male preponderance (66.7%). The mean age of the patients was 55.3years with a mean BMI of 32.2kg/m2. The average duration of surgery was 4.2h with sizes of the diaphragmatic defects ranging from 3 to 6cm. Confirmatory PE diagnosis was made with a chest CT angiogram and the mean length of hospital stay was 4days. PE although rare, is a preventable cause of in-patient mortality and morbidity with implications on healthcare costs and hospital resource use. The Caprini model provides a guide to pre-operative patient risk stratification and PE prevention, and the patients in this study were in the moderate to high-risk groups. Risk factors common to all patients were: age > 40years, BMI > 30kg/m2 and duration of surgery > 2h with one of the patients having a previous history of PE. There are no established PE chemoprophylaxis guidelines for robotic HH repairs and in this cohort, heparin was commenced 6-8h post-operatively. Thus, there is a need for a consensus chemoprophylaxis guideline in this subset of surgical patients. PE following robotic HH repair is associated with prolonged hospital stay and increased healthcare costs. Guidelines for effective pre-operative chemoprophylaxis for these repairs are needed to optimize patient outcomes.

Risk Factors and Outcomes for Preoperative Asymptomatic Pulmonary Embolism in Patients Aged 60 Years and Over with Hip Fracture.

ObjectiveTo investigate the risk factors for, and outcomes of, preoperative asymptomatic pulmonary embolism (PE) in patients ≥60 years old following delayed operation for hip fracture.MethodsFrom March 2017 to December 2018, 90 patients aged ≥60 years with hip fracture who suffered a delay in surgery were recruited to this prospective study following admission to our hospital. Computed tomography pulmonary angiography (CTPA) was used to detect preoperative asymptomatic PE and calculated its incidence. Time from injury to admission, baseline characteristics, medical comorbidities, and blood biomarker levels were evaluated as potential risk factors. Logistic regression analysis was used to identify risk factors. Mortality and major bleeding events were recorded and compared between individuals with PE and without. Data were analyzed by t‐test, Mann–Whitney U test, χ 2 test, Fisher's exact test, and logistic regression analysis.ResultsThe incidence of preoperative asymptomatic PE was 18.9% (17/90 patients). In the univariate analysis, the risk factors for preoperative asymptomatic PE were male sex, hypertension, cerebrovascular accident, smoking, plasma D‐dimer level, potassium level, urea level, creatinine level, and cysteine level. Multivariate logistic regression analysis showed that the risk of preoperative asymptomatic PE was higher in patients with hypertension (odds ratio [OR] = 10.048; 95% confidence interval [CI], 1.118–90.333), cerebrovascular accident (OR = 20.135; 95% CI, 1.875–216.164), smoking (OR = 48.741; 95% CI, 4.155–571.788), high plasma D‐dimer levels (OR = 1.200; 95% CI, 1.062–157.300), and high plasma potassium levels (OR = 12.928; 95% CI, 1.062–157.300). All patients were followed up for 21.0 months (range, 2 to 36 months). Mortality within the first year postoperatively was higher in patients with PE (29.41% vs 9.59%, P = 0.046).ConclusionsIn view of the high incidence of preoperative asymptomatic PE and the inferior prognosis in individuals with PE, routine CTPA examination for preoperative asymptomatic PE could be useful for patients aged ≥60 years with hip fracture for whom surgery is delayed.

Incidence and risk factors of preoperative venous thromboembolism and pulmonary embolism in patients with ovarian cancer

IntroductionTo determine the incidence and predisposing factors of preoperative venous thromboembolism (VTE), especially pulmonary embolism (PE) in patients with ovarian cancer. Material and methodsThis retrospective study included 387 patients with primary ovarian cancer, whose preoperative work up included both ultrasonography of lower extremity vein and spiral computed tomography pulmonary angiogram, from September 2013 to November 2016. SPSS 22 was used for statistical analyses. ResultsThe incidence of preoperative VTE and PE was 13.4% (52 patients), 9.3%(36 patients), respectively. Both the univariate and multivariate analyses revealed that D-dimer (DDI) level, age, and massive ascites were associated with preoperative VTE. Moreover, DDI level (odds ratio [OR] 3.133, 95% confidence interval [CI] 1.193–8.225, p = .02), massive ascites (OR 9.972, 95% CI 3.687–26.968, p < .001), and preoperative deep vein thrombosis (OR 5.977, 95% CI 2.073–17.228, p = .001) were independent predictors for preoperative PE. Additionally, the incidence of preoperative VTE and PE increased with increasing DDI levels (p < .001). DDI level < 1.5 μg/ml has 100% negative predictive value and 100% sensitivity for diagnosis of preoperative VTE and PE; however, DDI >5 μg/ml, the incidence of preoperative VTE and PE were 18.4% and 14.2% respectively. Moreover, DDI value was significantly correlated with preoperative PE volume (r = 0.746, p < .001). ConclusionPreoperative VTE and PE are common events in patients with ovarian cancer. DDI level is a useful parameter for diagnosing and evaluating preoperative VTE and PE.

Endovenous Intervention of May-Thurner Syndrome with Thrombus beyond Iliac Vein Stenosis.

PurposeWith the increase in the incidence of venous thrombosis, interest in May-Thurner syndrome (MTS) accompanying iliac vein compression has increased. Some patients with MTS have inferior vena cava thrombosis or thrombosis beyond iliac vein stenosis (TBIVS). This study aimed to identify the characteristics of MTS with TBIVS including pulmonary embolism (PE) and post-thrombotic syndrome (PTS) compared to those of MTS without TBIVS.Materials and MethodsThirty-five patients with deep vein thrombosis associated with MTS were treated between March 2012 and February 2016. Demographic data, medical history, computed tomography findings (iliac vein size of stenosis and stenotic ratio compared with the other side), and clinical outcomes (preoperative PE and PTS) were retrospectively collected and reviewed by dividing into groups with or without TBIVS.ResultsEight of the 35 patients with MTS had TBIVS. The group with TBIVS had a statistically significantly greater iliac vein size (P<0.001) and ratio (P=0.001). PE was more prevalent in the group with TBIVS (63% vs. 15%, P=0.007). However, no statistically significant intergroup difference in PTS prevalence was found.ConclusionThe presence of mild iliac vein stenosis in MTS can be used to predict TBIVS and the requirement for more attention to PE.

Pattern of Venous Thromboembolism Occurrence in Gynecologic Malignancy: Incidence, Timing, and Distribution a 10-Year Retrospective Single-institutional Study.

The aim of this single-institutional 10-year retrospective study was to investigate the clinical pattern (incidence, type, timing, and location) of venous thromboembolism (VTE) in Chinese patients with gynecologic cancer.Cases were identified by searching institutional Electronic Discharge Database. A comprehensive review of medical documentation was then performed to collect relevant data. The detection of VTE was symptom-triggered.A total of 155 VTE events were identified out of 7562 cases over the past 10-year period in our hospital. The incidence of clinically significant VTE was 2.0% in gynecologic malignancy, with vulvar cancer (3.7%) and ovarian cancer (2.5%) being the high-risk types (P = 0.01, Chi-square test). Perioperative period (35.1%) and preoperation (29.1%) were the 2 incidence peaks. Seventeen cases of pulmonary embolism (PE) occurred prior to surgery. Ovarian cancer patients were more likely to present preoperative PE compared to other site of cancer (76.4%; P = 0.01, Chi-square test). More preoperative VTE cases were complicated by PE than those in the perioperative period (39.5% vs 17.3%, P = 0.02, Chi-square test). Bilateral lower extremity deep vein thrombosis (DVT) accounted for 32.6% and there existed a preponderance of left-sided DVT (47.5% vs 17.0%, ratio 2.79:1). Femoral vein (36.6%) was the most common location for DVT.About 2.0% of the Chinese patients with gynecologic carcinoma developed clinical VTE, mostly during perioperative period and the time of diagnosis. The true incidence might have been under-estimated due to several reasons. The need for increased patient education and awareness of VTE is of importance.

Early Identification of Asymptomatic Pulmonary Embolism Proximal to the Subsegmental Arteries After Gynecologic Surgery.

Few studies have assessed whether cases of asymptomatic pulmonary embolism (PE) in the early postoperative phase are subsegmental versus more proximal. In this study, we investigated whether asymptomatic PE occurring just after gynecologic surgery was subsegmental, and we examined the background characteristics of patients who experienced PE within 2 months postoperatively. All hospital records were reviewed, yielding a total of 2052 women who had undergone surgeries performed by the gynecologic oncology team between 2003 and 2013 in the National Kyushu Cancer Center. Asymptomatic and symptomatic postoperative PE cases diagnosed by multidetector computed tomography angiography or lung scan were identified; after excluding 2 cases of preoperative PE, there were 15 (0.73%) cases of postoperative PE among 2050 women. Of the 15 cases, 9 (60%) were diagnosed on postoperative day 1 or 2. Of the 9 women, 4 had no or minor symptoms/signs other than decreased oxygen saturation as measured by pulse oximetry (Spo 2), and PE was segmental or more proximal in 3 cases. Only 1 of the 9 cases showed dyspnea. The remaining 4 cases showed dizziness or perspiration, suggesting PE. Univariate analysis showed age, operation time, hypertension, and preoperative d-dimer elevation to be associated with postoperative PE. Multivariate analysis demonstrated that a high (≥ 1 µg/mL) preoperative d-dimer level was associated with postoperative PE (odds ratio, 6.331; 95% confidence interval, 1.567-25.589). Most asymptomatic PE cases occurring within 2 days postoperatively were segmental or more proximal. Identification of early, asymptomatic postoperative PE may be clinically significant because most of these emboli are proximal to the subsegmental arteries.

Inferior vena cava filter placement during thrombolysis for acute iliofemoral deep venous thrombosis.

The objectives of this study were to evaluate the need for inferior vena cava (IVC) filters and to identify anatomic and patient-specific risk factors associated with embolization in patients undergoing thrombolysis for acute iliofemoral deep venous thrombosis (DVT). Consecutive patients who underwent catheter-directed thrombolysis or pharmacomechanical thrombolysis (PMT) for iliofemoral DVT from May 2007 toMarch 2012 were identified from a prospectively maintained database. Patients were categorized in two groups, depending on the status of IVC filtration during the lysis procedures: patients with an IVC filter protection (group A) and patients without an IVC filter protection (group B). The primary outcome was perioperative clinically significant pulmonary embolism (PE) or intraprocedural IVC filter clot capture. Eighty patients (mean age, 50± 16years; 39 women) with symptoms averaging 12± 10days were treated. A perioperative IVC filter was placed in 32 patients, and nine patients had an indwelling patent filter (group A, n= 41). Twenty patients received no filter, and 19 patients had an indwelling thrombosed filter (group B, n= 39). There were no clinically significant PE in either group. In group A, nine patients (22%) had documented embolic clot within the filter nest. The clot volume was deemed clinically significant in only two patients (5%). Factors related to embolization included female gender (odds ratio [OR], 5.833; 95% confidence interval [CI], 1.038-32.797; P= .032) and preoperative clinical PE (OR, 5.6; 95% CI, 1.043-30.081; P= .054). A trend for increased embolization was seen with a higher average number of DVT risk factors(1.44 vs 1; P= .065) and when PMT was used as a single treatment (OR, 4.32; 95% CI, 0.851-21.929; P= .087). IVC filters during thrombolysis should be used selectively in patients with preoperative clinical PE, in women and potentially in patients with multiple risk factors for DVT, or when stand-alone PMT is planned.

1906 PREOPERATIVE PULMONARY EMBOLISM DOES NOT PREDICT POOR POSTSURGICAL OUTCOMES IN RCC PATIENTS WITH VENOUS THROMBUS

You have accessJournal of UrologyKidney Cancer: Advanced (II)1 Apr 20131906 PREOPERATIVE PULMONARY EMBOLISM DOES NOT PREDICT POOR POSTSURGICAL OUTCOMES IN RCC PATIENTS WITH VENOUS THROMBUS E. Jason Abel, Christopher G. Wood, Nathan Eickstaedt, Justin E. Fang, Patrick Kenney, Aditya Bagrodia, Daniel Ramirez, Bishoy A. Gayed, Tracy M. Downs, Ramy F Youssef, Christopher Odom, Arthur Sagalowsky, and Vitaly Margulis E. Jason AbelE. Jason Abel Madison, WI More articles by this author , Christopher G. WoodChristopher G. Wood Houston, TX More articles by this author , Nathan EickstaedtNathan Eickstaedt Madison, WI More articles by this author , Justin E. FangJustin E. Fang Houston, TX More articles by this author , Patrick KenneyPatrick Kenney Houston, TX More articles by this author , Aditya BagrodiaAditya Bagrodia Dallas, TX More articles by this author , Daniel RamirezDaniel Ramirez Dallas, TX More articles by this author , Bishoy A. GayedBishoy A. Gayed Dallas, TX More articles by this author , Tracy M. DownsTracy M. Downs Madison, WI More articles by this author , Ramy F YoussefRamy F Youssef Dallas, TX More articles by this author , Christopher OdomChristopher Odom Dallas, TX More articles by this author , Arthur SagalowskyArthur Sagalowsky Dallas, TX More articles by this author , and Vitaly MargulisVitaly Margulis Dallas, TX More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2325AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Renal cell carcinoma (RCC) patients who present with pulmonary embolism (PE) and venous thrombus may not be offered surgery because of concerns with anti-coagulation and presumed poor post-surgical outcomes. The objective of this study was to evaluate post- surgical recurrence and cancer specific survival in RCC patients with venous thrombus who had PE diagnosed at initial presentation. METHODS After IRB approval, we reviewed the records from 2000-2011 at 3 tertiary hospitals (UW, UTMDACC, UTSW) for all consecutive RCC patients who had nephrectomy with thrombectomy. Clinical and pathologic predictive factors for recurrence and survival were collected for each patient. Univariate and multivariate analysis was used to evaluate whether PE at presentation was associated with RCC recurrence or survival after nephrectomy with thrombectomy. RESULTS Preoperative PE was diagnosed in 35/782 (4.4%) RCC patients undergoing nephrectomy with thrombectomy with a median follow-up time of 22 months. Patients with PE at initial diagnosis were more likely to have higher level thrombus (p<0.01) but no differences were found between groups for age, gender, race, tumor diameter, Fuhrman grade, sarcomatoid de-differentiation, peri-nephric fat invasion or histologic subtype. In N0M0 patients, there was no difference (p=0.36) in the rate of RCC recurrence for 395/782(50%) or 7/17(41%) patients without PE or with PE respectively. On multivariate analysis, peri-nephric fat invasion, Fuhrman grade, and thrombus height, but not preoperative PE status, were predictive of recurrence risk. Similarly, there was no difference in the rates of lung metastases for 67/123 (53%) N0M0 patients without PE or 3/7 (43%) patients with PE (p=0.71). Preoperative PE diagnosis was not predictive of death from RCC (p=0.58). On multivariate analysis, presence of metastatic disease, peri-nephric fat invasion, sarcomatoid de-differentiation, Fuhrman grade 4, and tumor diameter were independently predictive of risk of death from RCC. CONCLUSIONS PE at initial diagnosis is not associated with worse post-surgical recurrence or survival in RCC patients with tumor thrombus. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e781 Peer Review Report Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information E. Jason Abel Madison, WI More articles by this author Christopher G. Wood Houston, TX More articles by this author Nathan Eickstaedt Madison, WI More articles by this author Justin E. Fang Houston, TX More articles by this author Patrick Kenney Houston, TX More articles by this author Aditya Bagrodia Dallas, TX More articles by this author Daniel Ramirez Dallas, TX More articles by this author Bishoy A. Gayed Dallas, TX More articles by this author Tracy M. Downs Madison, WI More articles by this author Ramy F Youssef Dallas, TX More articles by this author Christopher Odom Dallas, TX More articles by this author Arthur Sagalowsky Dallas, TX More articles by this author Vitaly Margulis Dallas, TX More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes of RCC patients with venous thrombus presenting with pulmonary embolism: A multicenter analysis of 782 consecutive patients.

433 Background: Renal cell carcinoma (RCC) patients who present with pulmonary embolism (PE) and venous thrombus may not be offered surgery because of concerns with anti-coagulation and presumed poor post-surgical outcomes. The objective of this study was to evaluate post-surgical recurrence and disease specific survival (DSS) in RCC patients with venous thrombus who had PE diagnosed at initial presentation. Methods: After IRB approval, we reviewed the records from 2000-2011 at 3 tertiary hospitals (UW, UTMDACC, UTSW) for all consecutive RCC patients who had nephrectomy with thrombectomy. Clinical and pathologic predictive factors for recurrence and survival were collected for each patient. Univariate and multivariate analysis was used to evaluate whether PE at presentation was associated with RCC recurrence or DSS after nephrectomy with thrombectomy. Results: Preoperative PE was diagnosed in 35/782 (0.5%) RCC patients undergoing nephrectomy with thrombectomy with a median follow-up time of 22 months. Patients with PE at initial diagnosis were more likely to have higher level thrombus (p&lt;0.01) but no differences were found between groups for age, gender, race, tumor diameter, Fuhrman grade, sarcomatoid de-differentiation, peri-nephric fat invasion or histologic subtype. In N0M0 patients, there was no difference (p=0.36) in the rate of RCC recurrence for 395/782(50%) or 7/17(41%) patients without PE or with PE respectively. On multivariate analysis, peri-nephric fat invasion, Fuhrman grade, and thrombus height, but not preoperative PE status, were predictive of recurrence risk. Similarly, there was no difference in the rates of lung metastases for 67/123 (53%) N0M0 patients without PE or 3/7 (43%) patients with PE (p=0.71). Preoperative PE diagnosis was not predictive of death from RCC (p=0.58). On multivariate analysis, peri-nephric fat invasion, sarcomatoid de-differentiation, Fuhrman grade, and thrombus height, were independently predictive of risk of death from RCC. Conclusions: PE at initial diagnosis is not associated with worse post-surgical recurrence or survival in RCC patients with tumor thrombus.

Preoperative Pulmonary Embolism Does Not Predict Poor Postoperative Outcomes in Patients with Renal Cell Carcinoma and Venous Thrombus

Patients with renal cell carcinoma who present with pulmonary embolism and venous thrombus may not be offered surgery because of presumed poor postoperative outcomes. In this multicenter study we evaluated perioperative mortality, recurrence and cancer specific survival in patients with renal cell carcinoma and venous thrombus diagnosed with preoperative pulmonary embolism. We reviewed consecutive patient records from our 3 tertiary hospitals to identify patients with renal cell carcinoma and venous thrombus treated with surgery from 2000 to 2011. Univariate and multivariate Cox proportional hazards analysis was used to evaluate whether preoperative pulmonary embolism or other clinical variables were associated with postoperative disease recurrence or cancer specific survival. Pulmonary embolism was identified preoperatively in 35 of 782 patients (4.4%) with renal cell carcinoma. Those with pulmonary embolism preoperatively were more likely to have higher level thrombus and higher T stage (p <0.01). No differences were found in other clinical or pathological features between the groups. There was no difference in 90-day mortality in patients diagnosed with pulmonary embolism preoperatively. Of 395 patients without metastasis preoperatively 147 (37.2%) showed metastatic renal cell carcinoma at a median followup of 22 months. There was no difference in the recurrence rate of renal cell carcinoma in patients with pulmonary embolism (p = 0.36). Recurrence in the lung was not more common in patients with vs without pulmonary embolism preoperatively (p = 0.71). Also, preoperative pulmonary embolism was not predictive of worse cancer specific survival (p = 0.58). Preoperative pulmonary embolism is not associated with worse early mortality, recurrence or cancer specific survival in patients with renal cell carcinoma and tumor thrombus.

Sequential duplex ultrasound screening for proximal deep venous thrombosis in asymptomatic patients with acetabular and pelvic fractures treated operatively

Recent evidence-based practice guidelines recommend against routine ultrasound screening for proximal deep vein thrombosis (DVT) in asymptomatic pelvic fracture patients. However, the majority of trauma surgeons favor this practice. Furthermore, the timing of screening has been inconsistently described. The purpose of this study was to examine the utility of sequential scans in asymptomatic acetabular and pelvic fracture patients treated operatively. In 2003, a screening protocol for DVT was begun for asymptomatic patients with these fractures treated operatively. Duplex ultrasound screening was used to evaluate the lower extremities for proximal DVT. Scans were to be obtained preoperatively and then postoperatively on the day before planned discharge from the hospital. A DVT prophylaxis protocol was also instituted. Between 2003 and 2007, 343 patients were identified for study. Patients were followed for thromboembolic complications for a minimum of 3 months. Two hundred twenty-nine patients received both preoperative and postoperative scans. Of these, 35 patients (15%) had an asymptomatic DVT: 16 (7%) preoperatively and 19 (8%) postoperatively. Two patients (1%) with negative scans had a postoperative symptomatic pulmonary embolism (PE) diagnosed the day after surgery, but fatal PE did not occur. In the remaining 114 patients, 27 received a prophylactic inferior vena cava filter, 6 had a preoperative symptomatic DVT or PE before scanning, 25 received only the postoperative scan (3 being positive), and 56 were not scanned postoperatively. Of the 56 not scanned postoperatively, 2 (4%) were readmitted with a symptomatic proximal DVT but none for PE, and a fatal PE did not occur. Despite the possible diagnostic utility of sequential duplex ultrasound screening, it does not decrease the risk of PE in acetabular and pelvic fracture patients. IV.

Diagnostic and Surgical Treatment of the Thrombophlebitis in the Saphenofemoral Junction

This retrospective study reports on the diagnostic and surgical treatment of 10 patients with ascending thrombophlebitis in the proximal great saphenous vein with free-floating thrombi reaching into the common femoral vein. 10 patients were operated in our clinic for thrombophlebitis with free-floating thrombi in the saphenofemoral junction. Diagnosis of free-floating thrombi was made by B-mode and color-coded duplex ultrasound examination. Surgical thrombectomy was performed immediately. No operative complications were observed, while 5 of 10 patients sustained preoperative pulmonary embolism. After successful thrombectomy and perioperative systemic heparinization, patients who had no PE and no thrombophilic disorders were discharged without any further anticoagulant therapy. The results of our retrospective study show that patients with an ascending thrombophlebitis should undergo ultrasound examination to detect free-floating thrombi reaching into the deep venous system. In case of free-floating thrombi, immediate surgical thrombectomy, which is safe and provides rapid recovery from symptoms, is indicated.

Intraoperative Thrombus Embolization During Nephrectomy and Tumor Thrombectomy: Critical Analysis of the University of California-Los Angeles Experience

Vascular invasion commonly occurs in renal cell carcinoma and intraoperative thrombus embolization is a known complication of tumor thrombectomy. We reviewed our experience with this complication to determine frequency, mortality, common factors and management strategies. We retrospectively reviewed a prospective database of cases of open nephrectomy/tumor thrombectomy performed from 1989 to 2008. All cases were reviewed to identify clinicopathological variables, the thrombus extent and intraoperative complications. All cases with events were reviewed to identify preoperative pulmonary embolism, preoperative imaging, thrombus extent, presentation, management and outcome. A total of 282 cases of venous tumor thrombus were identified. Tumor thrombus level was 0 in 133 cases (47.2%), I to II in 85 (30.1%), III in 27 (9.6%) and IV in 29 (10.3%). Thrombus embolization was identified in 5 patients (1.8%). The incidence in level 0 vs I to IV was 0 of 133 cases (0%) vs 5 of 149 (3.4%), which was statistically significant (p = 0.04). Three patients (60%) died of the event. A review of recent series demonstrated a 1.49% incidence with 75% mortality. Intraoperative thrombus embolization is rare but when it occurs, mortality is extremely high. Strict attention to surgical principles is necessary to decrease risk. Extension into the vena cava, preoperative pulmonary embolism and a bland thrombus component may indicate increased risk. Adjunct procedures, such as preoperative filters and endoluminal occlusive balloons, may be justified in patients at high risk. Even with prompt recognition and embolectomy survival is rare.

Massive preoperative pulmonary embolism and suprasellar brain tumor

Massive preoperative pulmonary embolism and suprasellar brain tumor