Pulmonary Artery Thrombosis Research Articles

Pathophysiology of thromboembolism in patients with COVID-19

Introduction and aim. A small number of critically ill patients with coronavirus disease (COVID-19) develop thromboembolism (arterial or venous), both micro- and macrovascular complications such as deep vein thrombosis, pulmonary embolism, and pulmonary arterial thrombosis. The objective of the study is to describe the pathophysiology of venous thromboembolism in patients with COVID-19. Material and methods. In this article a narrative review regarding pathophysiology of thromboembolism in patients with COVID-19. Analysis of the literature. The development of coagulopathy is a consequence of the intense inflammatory response associated with hypercoagulability, platelet activation, and endothelial dysfunction. The pathophysiology that relates pulmonary thromboembolism (PTE) with COVID-19 is associated with a hypercoagulable state. PTE is suspected in hospitalized patients presenting dyspnea, decreased oxygen requirement, hemodynamic instability, and dissociation between hemodynamic and respiratory changes. In COVID-19-associated coagulopathy, initially, patients present with elevated levels of fibrinogen and D-dimer, with minimal changes in prothrombin time and platelet count. The main risk factor for the development of pulmonary embolism is the increase in D-dimer that is associated with the development of PTE. The administration of iodine-based contrast agent to patients with COVID-19 would affect P-creatinine and renal function, where Ultrasound is viewed as cost-effective and highly portable, can be performed at the bedside. Conclusion. Acute respiratory distress syndrome severity in patients with COVID-19 can explain PTE as a consequence of an exaggerated immune response.

Systemic embolic events associated with persistent foramen ovale: A case report

Introduction. Embolization into the systemic circulation through the persistent foramen ovale is known as paradoxical embolization. Coexistence of paradoxical embolism with pulmonary thromboembolism is rare and it requires detailed examination. The objective of this study was to present an unusual case of stroke that was complicated by the occurrence of pulmonary thromboembolism, with thrombosis of the superior mesenteric artery, and arterial infarction of numerous visceral organs, a few days after its onset. Case Report. A 60-year-old female patient was admitted to the Emergency Center with clinical symptoms of acute ischemic stroke, with sudden left hemiparesis. Computed tomography showed a fresh ischemia in the basin of the right anterior cerebral artery. The initial clinical course was favorable, with gradual regression of neurological symptoms. On the seventh day of hospitalization, the patient presented with a sudden worsening of symptoms. Computed tomography confirmed multiple infarctions of the liver, spleen and both kidneys, partial thrombosis of the superior mesenteric artery, as well as thrombosis of both pulmonary arteries and two fresh ischemic zones, namely right temporal and parieto-occipital, cortico- subcortical. A persistent foramen ovale was found by transesophageal echocardiography, which also confirmed the existence of an atrial septal aneurysm. In the further course, there was an improvement of symtoms. The patient was referred for further rehabilitation therapy. A surgical closure of persistent foramen ovale was indicated. Conclusion. Paradoxical embolism remains a pathology rarely mentioned by clinicians, although it can affect the functional and vital status and prognosis of the patient. Good cardiac evaluation and detection of persistent foramen ovale in every patient with embolic ischemia is of great importance.

Thrombosis of aneurysmal pulmonary arteries in patent ductus arteriosus with Eisenmenger syndrome.

ABSTRACTA 45-year-old lady with patent ductus arteriosus with Eisenmenger's syndrome had presented with hemoptysis. Computed tomography revealed aneurysmally dilated pulmonary arteries with a large calcified organized thrombus.

Frequency and Predictors of Pulmonary Arterial Stump Thrombosis following Pneumonectomy or Lobectomy

Objectives: Pulmonary artery stump thrombosis (PAST) following pneumonectomies/lobectomies is rare; its clinical importance is unknown. The objectives of this study were to analyze the prevalence and risk factors of PAST and the clinical significance in patients with pneumonectomy/lobectomy. Methods: All adult cases who underwent pneumonectomy/lobectomy in our hospital for any reason and who underwent control contrast-enhanced thoracic CT during the follow-up period were included in the study. Demographic and clinical features of the patients, data on surgery, and the features of thrombi were recorded. Results: During the 4-year study period, a total of 454 patients underwent pneumonectomy/lobectomy (93 pneumonectomy and 361 lobectomy). Among the patients, 202 patients (50 pneumonectomy and 152 lobectomy) with at least one follow-up thorax CT were included in the analyses. PAST was detected in 9 (4.5%) of 202 patients and mostly seen in patients with pneumonectomy (lobectomy: 2.6% vs. pneumonectomy: 10%, p = 0.043) and in patients whose pulmonary artery was ligated by using stapler (suture ligation 1% vs. stapler: 7.4%, p = 0.034). Pulmonary artery stump was also longer in patients with PAST (8.48 ± 11.22 mm vs. 23.55 ± 11.22 mm, p < 0.001). Univariate logistic regression analysis showed that pneumonectomy and longer pulmonary artery stump length were found to be significantly associated with PAST (p = 0.041 and p = 0.001, respectively). Conclusions: PAST was detected in 4.5% of our subjects undergoing lobectomy/pneumonectomy. PAST was found to be significantly higher in subjects who underwent pneumonectomy, those with longer pulmonary artery stump, and those with pulmonary artery stump ligated by using stapler.

Acute pulmonary embolism and deep vein thrombosis due to protein S deficiency in a young female presenting with chest pain

Protein S deficiency is a major risk factor for venous thromboembolism, posing a diagnostic challenge due to atypical presenting complaints. Acute pulmonary embolism is a common, treatable but potentially fatal condition, currently third most common cause of cardiovascular death. It is important for physicians to consider pulmonary embolism as a differential diagnosis in young adults presenting atypical symptoms with dilated right atrium, right ventricle and elevated pulmonary artery pressure on echocardiography. Computed tomography pulmonary angiography (CTPA) confirms pulmonary artery thrombosis. Prompt management with anticoagulant should be done to improve the outcome of patients.

Multidisciplinary Management of Massive Pulmonary Arterial Thrombosis after Early Complete Repair of Tetralogy of Fallot

Multidisciplinary Management of Massive Pulmonary Arterial Thrombosis after Early Complete Repair of Tetralogy of Fallot

Budd-Chiari Like Syndrome in a Dog: Hematology, Biochemistry, Histopathology and CT Scan Angiography Findings

A nine months old mix breed dog was presented by lethargy, symptoms of abdominal pain, mild respiratory distress and abrupt onset of massive and hemorrhagic ascitesthat responded to medical treatments partially. The dog had a history of car accidentthree months earlier. Mild non-regenerative microcytic anemia,hypoalbuminemia, hypoproteinemia, elevated liver enzymes, mild pulmonary edema and high protein transudate in abdominal cavity weredetected. Abdominal ultrasonography demonstrated hepatomegaly and intra-abdominal fluid collection. Histopathological examination of the liver biopsy showed a diffuse sinusoidal distension with some area of hepatocyte necrosis. The histopathological findings, together with increased level of liver enzymes, and moderate panhypoproteinemia, high protein transudate and abdominal pain were all in favorof the diagnosis of post-sinusoidal hypertension secondary to obstruction of hepatic venous outflow (Budd-Chiari-like syndrome). CT angiography confirmed a massive thrombosis in caudal vena cava and pulmonary artery. Unfortunately, 24 hours after CT scan study the patient was spontaneously expired. However, because the owner did not give his consent for the autopsy, the detailed data is not acquired. In conclusion, obstruction of venous blood flow and Budd-Chiari like syndrome must be considered in dogs with ascites, hepatomegaly, and symptoms abdominal pain.

C80. Pulmonary Embolism in Congenital Heart Disease with Pulmonary Arterial Hypertension: a Case Series

Abstract Background Pulmonary arterial hypertension (PAH) is a frequent complication of congenital heart disease (CHD), notably in patients with left-to-right shunts. Patients with severe PAH due to CHD, Eisenmenger syndrome (ES), represent a high-risk group of pulmonary artery (PA) thrombosis patients. We present serial adult cases of CHD with PAH complicated by pulmonary embolism (PE). Case Description We found 3 cases of pulmonary embolism on adult congenital heart disease in our center. All of the patients were female, with an age range of 36 to 61 years old. The presenting symptoms were shortness of breath, WHO classification class II-III. All patients were hemodynamically stable. CHD and estimated RV systolic pressure were evaluated with echocardiography. CT-PA was performed in all patients, which findings were supporting PE. All patients were treated with anticoagulation. After three months, right heart catheterization was conducted in two patients, and one patient was refused. Discussion The prevalence of PE among adult patient with CHD and PAH range from 17 to 21%. PE was frequently found in older patients, women, and patients with lower oxygen saturation. To date, no uniformity regarding routine prophylaxis anticoagulation therapy in ES due to the high bleeding risk in this population despite being at risk of PA thrombosis. We conclude that risk stratification for PA thrombosis in adult CHD-PAH patients is essential, and further research is needed to prevent PE in this population.

C80. Pulmonary Embolism in Congenital Heart Disease with Pulmonary Arterial Hypertension: a Case Series

Abstract Background Pulmonary arterial hypertension (PAH) is a frequent complication of congenital heart disease (CHD), notably in patients with left-to-right shunts. Patients with severe PAH due to CHD, Eisenmenger syndrome (ES), represent a high-risk group of pulmonary artery (PA) thrombosis patients. We present serial adult cases of CHD with PAH complicated by pulmonary embolism (PE). Case Description We found 3 cases of pulmonary embolism on adult congenital heart disease in our center. All of the patients were female, with an age range of 36 to 61 years old. The presenting symptoms were shortness of breath, WHO classification class II-III. All patients were hemodynamically stable. CHD and estimated RV systolic pressure were evaluated with echocardiography. CT-PA was performed in all patients, which findings were supporting PE. All patients were treated with anticoagulation. After three months, right heart catheterization was conducted in two patients, and one patient was refused. Discussion The prevalence of PE among adult patient with CHD and PAH range from 17 to 21%. PE was frequently found in older patients, women, and patients with lower oxygen saturation. To date, no uniformity regarding routine prophylaxis anticoagulation therapy in ES due to the high bleeding risk in this population despite being at risk of PA thrombosis. We conclude that risk stratification for PA thrombosis in adult CHD-PAH patients is essential, and further research is needed to prevent PE in this population.

Long-term pathological changes in lungs after COVID-19

World literature is paying increasing attention to the long-term course of COVID-19 and symptoms that appear after the acute coronavirus infection. The symptoms, functional state of the lungs, and the X-ray changes are assessed. Nevertheless, post-COVID lung histology has not been described yet.The aim of this article is to study the long-term pathological changes in the lungs after acute COVID-19. Methods. We analyzed autopsy lung material from 19 deceased who had COVID-19. The average age of the deceased was 68.82 ± 14.6 years. All patients were found to have IgG to SARS-CoV-2. The median time to death following viral interstitial pneumonia was 72 days. Results. The causes of death and thrombotic complications (infarctions of various organs and venous thrombosis) were analyzed. Histological examination revealed thrombosis of small pulmonary arteries and capillaries of interalveolar septa, microinfarctions, hemorrhages, foci of organizing pneumonia, and nonspecific interstitial pneumonia.Conclusion. The first assessment of histological changes in human lungs showed that the most common post-COVID pathologic changes are microcirculation disorders combined with small areas of acute lung damage. The obtained data are essential for understanding the pathogenesis of post-COVID syndrome, necessitate diagnostic of microvasculature disorders using laboratory tests, scintigraphy, and CT imaging, as well as search for the therapeutic strategies.

A CLOG IN THE RV: RIGHT VENTRICULAR THROMBUS IN TRANSIT

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Right ventricular (RV) thrombi are an uncommon condition associated with pulmonary embolism. They may form within the cardiac chamber due to structural heart disease or presence of foriegn objects such as a ventricular assist device, or may represent a thrombus in transit from a peripheral source. We present the case and imaging of a patient who presented with extensive thrombosis involving the right ventricle and pulmonary arteries, in the context of periprocedural interruption of anticoagulant therapy. CASE PRESENTATION: A 35-year-old woman with a history of hypothyroidism, polycystic ovaries, and recently diagnosed metastatic cholangiocarcinoma presented with sudden onset right sided sharp chest pain and shortness of breath, in association with left calf pain. She had been on rivaroxaban for a history of venous thromboembolism, which had been interrupted peri-procedurally for implantation of a port. Physical examination was notable for hypoxia (oxygen saturation 85% on room air), hypotension (96/48 mm Hg), tachypnea, and signs of respiratory distress. Laboratory workup showed elevated N-terminal proBNP (748 pg/mL), with normal troponin. Computed tomography (CT) imaging of the chest with contrast demonstrated a large right ventricular thrombus extended through the pulmonic valve into the main pulmonary artery and its bifurcations, with numerous bilateral lobar, segmental and subsegmental emboli. Systemic anticoagulation with heparin was initiated. She was deemed not to be a candidate for catheter based thrombolysis, owing to the position of the thrombus, and neither for open cardiac surgery, given the late stage of her malignancy. She was started on a morphine infusion for relief of pain, and was transitioned to hospice shortly thereafter. DISCUSSION: In one study RV thrombus was found to be present in about 4% of cases of pulmonary embolism.[1] RV thrombi can be classified into various groups, depending on the shape and mobility of the thrombus.[2] We present this case to demonstrate the imaging findings of extensive RV thrombosis contiguous with thrombosis in the main pulmonary artery. There are no guidelines and little evidence on the best approach to the treatment of RV thrombi. While thrombolysis is indicated in patients with a massive pulmonary embolism, its utility in patients with RV thrombosis without hemodynamic instability remains less clear. Catheter based thrombolysis can be challenging, as in our patient, if the anatomy of the thrombus is such that it precludes adequate placement of the catheter. CONCLUSIONS: The diagnosis and management of RV thrombus is challenging; further studies and guidelines are warranted. REFERENCE #1: Casazza F, Becattini C, Guglielmelli E, et al. Prognostic significance of free-floating right heart thromboemboli in acute pulmonary embolism: results from the Italian Pulmonary Embolism Registry. Thromb Haemost. 2014 Jan;111(1):53-7. REFERENCE #2: Naeem K. Floating thrombus in the right heart associated with pulmonary embolism: The role of echocardiography. Pak J Med Sci. 2015 Jan-Feb; 31(1): 233–235. DISCLOSURES: No relevant relationships by Dan Kazmierski, source=Web Response No relevant relationships by Si Li, source=Web Response No relevant relationships by jacob miller, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response No relevant relationships by Dhaval Patel, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response

Point-of-care echocardiography and thoracic ultrasound in the management of critically ill patients with COVID-19 infection: Experience in three regional UK intensive care units.

Point-of-care ultrasound (POCUS) has an established role in the management of the critically ill. Information and experience of its use in those with COVID-19 disease is still evolving. We undertook a review of cardiac and thoracic ultrasound examinations in patients with COVID-19 on the intensive care unit (ICU). Our aim was to report key findings and their impact on patient management. A retrospective evaluation of critically ill patients with COVID-19 was undertaken in three adult ICUs, who received point-of-care cardiac and/or thoracic ultrasound during the 2019-2020 COVID-19 pandemic. We recorded baseline demographic data, principal findings, change in clinical management and outcome data. A total of 55 transthoracic echocardiographic examinations scans were performed on 35 patients. 35/55 (64%) echocardiograms identified an abnormality, most commonly a dilated or impaired right ventricle (RV) and 39/55 (70%) scans resulted in a change in management. Nine patients (26%) were found to have pulmonary arterial thrombosis on CTPA or post-mortem. More than 50% of these patients showed evidence of right ventricular dilatation or impairment. Of the patients who were known to have pulmonary arterial thrombosis and died, 83% had evidence of right ventricular dilatation or impairment. 32 thoracic ultrasound scans were performed on 23 patients. Lung sliding and pleural thickening were present bilaterally in all studies. Multiple B-lines were present in all studies, and sub-pleural consolidation was present bilaterally in 72%. POCUS is able to provide useful and clinically relevant information in those critically ill with COVID-19 infection, resulting in change in management in a high proportion of patients. Common findings in this group are RV dysfunction, multiple B-lines and sub-pleural consolidation.

Risk Of Pulmonary Artery Thrombosis In Type 2 DM Patients Hospitalized With Covid-19

For the first time on the Fergana Valley model, prognostic markers of the risk of thrombotic complications in COVID-19 patients with type 2 diabetes were studied. It was found that the level of glycemia, the concentration of proinflammatory cytokines IL-6, ferritin and CRP, and the marker of thrombus formation - d dimer, have a prognostic significance, with the maximum prognostic significance of the concentration of CRP. The prognostic significance of ultrasound in the aspect of thrombosis of the branches of the PA in patients with COVID-19 against the background of type 2 diabetes was established. Predictor markers are mean PA pressure, LV myocardial mass index, signs of increased intraventricular pressure in the RV, and evidence of peripheral venous thrombosis.

Overview of the Covid-19 Coagulopathy Complications, Pathogenesis and Treatment Recommendations

Kristina Bubulytė1, Pijus Ruokis1 1Lithuanian University of Health Sciences, Medicine academy, faculty of Medicine Abstract. Covid-19 disease is a respiratory disease caused by the SARS-CoV-2 virus. In severe cases the disease presents itself with coagulation disorders, the most common complications of which are pulmonary artery thromboembolism (PATE), venous and arterial thrombosis, and disseminated intravascular coagulation […]

Pulmonary Artery Intimal Sarcoma Diagnosed as Pulmonary Embolism

Background: Pulmonary artery intimal sarcoma (PAIS) is a rare malignancy of vasculature that carries a very poor prognosis that is often misdiagnosed as a pulmonary embolism due to overlapping clinical and radiological features. It is a very aggressive malignancy with surgery the mainstay of initial management. Chemotherapy is normally given postoperatively, although it is not clear if chemo and radiotherapy bring any improvement, some data report an increase in survival in patients who received multimodality therapy vs single therapy.&#x0D; Case: A 48 year-old female was initially diagnosed with a pulmonary embolism based on clinical presentation and imaging. She was treated vigorously but continued to show no improvement after two weeks. She underwent an open thrombectomy and a large concurrent pulmonary artery intimal sarcoma (PAIS) was found. The mass was adherent to the intima and extended into the left and right pulmonary arteries. The tumor was not fully resected and tissue results showed poorly differentiated sarcoma. A treatment plan was then initiated to include systemic chemotherapy. She developed metastatic disease despite receiving multimodal therapy and died with within 2 years from the initial diagnosis.&#x0D; Conclusion: Persistent symptoms in patients diagnosed and treated adequately for pulmonary artery thrombosis should indicate a possible comorbid condition including sarcoma. This is particularly the case in the older age group with imaging that suggests central embolism despite treatment.

In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease.

Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.

Simultaneous arterial and venous thromboembolic events associated with COVID-19. A case report

Infections with COVID-19 can induce thrombophilia and increase the risk of thrombotic events. We describe a case of a 64- years-old male who presents with intermediate-risk pulmonary embolism and brachial artery thrombosis secondary to an undiagnosed patent foramen ovale and COVID-19 infection. The patient was successfully treated with thrombolysis and heparin infusions and was discharged home with long-term anticoagulation. Managing patients with multiple pathologies occurring concurrently requires effective inter-speciality working in order to take a holistic approach to managing the patient opposed to managing the conditions in isolation. This case report highlights how clinical guidelines can support decision making of the individual pathologies but working as a team will enable the best care.

Pulmonary artery thrombosis as the first presentation of Beh\xe7et\u2019s syndrome: a\xa0case report and review of the\xa0literature

BackgroundBehçet’s syndrome is a type of systemic chronic vasculitis of unknown etiology, frequently characterized by recurrent oral and genital ulcers and uveitis. It is less commonly characterized by arthritis and skin, vascular, and gastrointestinal involvements. Behçet’s syndrome affects various sizes of vessels by perivascular infiltration and vasculitis. Unlike other classic types of vasculitis, Behçet’s syndrome patients can present with both arterial and venous involvement. Although vascular Behçet’s syndrome is found in only around 15% of Behçet’s syndrome patients, it is the major cause of morbidity and mortality among them. Furthermore, although deep venous thrombosis has high incidence in Behçet’s syndrome patients, pulmonary artery thrombosis is an uncommon complication. Combining the findings of this and previous case reports of pulmonary artery thrombosis in Behçet’s syndrome patients, we sought to determine the best treatment options for pulmonary artery thrombosis in Behçet’s syndrome patients.Case presentationWe present the case of a 22-year-old Arabian male who was admitted to an emergency department with acute chest pain, dyspnea, and hemoptysis for 2 weeks. He gave a long history of recurrent oral and genital ulcers for the last 4 months but without seeking medical advice. Spiral computed tomography showed arterial filling defects with a pulmonary nodule for which the presence of a pulmonary artery aneurysm ruled out. The lung perfusion scan showed multiple pulmonary perfusion defects. After excluding common infectious diseases such as tuberculosis and brucellosis, a diagnosis of Behçet’s syndrome with pulmonary artery thrombosis was made. Steroids with enoxaparin were initiated. The patient was discharged later on prednisolone (tapering dose) with adalimumab and apixaban. He was on regular follow-up for the next 9 months.ConclusionsVascular involvement in Behçet’s syndrome is a major contributor to morbidity and mortality of Behçet’s syndrome patients. Consequently, early detection of vascular involvement has a major impact on the prognosis of patients with Behçet’s syndrome.

Resolution of pulmonary artery thrombosis in patients with moderate COVID-19 disease

ABSTRACT Novel Coronavirus disease (COVID-19) has been widely described as the cause for a proinflammatory and hypercoagulable state. The inflammatory process involving the alveolar vascular endothelium in the respiratory system, is a determining factor for the onset of primary Pulmonary Artery Thrombosis (PAT) even in patients with heparin prophylactic treatment. Little is known about the efficacy of the anticoagulant therapy during the course of PAT caused by COVID-19. In this paper we describe the results obtained in patients with moderate COVID-19 disease, previously threated with prophylactic enoxaparin, who then received full Anticoagulant treatment after diagnosis of PAT. After three months Computed Tomography Pulmonary Angiography demonstrated a complete resolution of the vascular obstructive lesions in all patients, while all the coagulation tests were normal.

Long COVID-19 Syndrome Precaution And Management

COVID-19 virus defined as illness caused by a novel corona virus which first discovered in Wuhan City, China. And On January 30, 2020, the WHO awarded the global health emergency. This is a review of COVID-19's highly affects on almost all the organs and how we precaution and management as the COVID-19 causes many systemic abnormalities like inflammation, endotheliitis, vasoconstriction, hypercoagulability, edema and Lymphocytopenia, with elevated D-dimer, and disseminated intravascular coagulation. Deep vein thrombosis and venous, thrombosis with pulmonary embolization, systemic and pulmonary arterial thrombosis, embolism are reported, ischemic stroke changes, and myocardial infarction are reported also. It can lead to acute coronary syndrome, with heart failure and myocarditis, arrhythmias. Kidney affection was usually secondary to systemic allover disturbances. Stroke may occurred. Delirium and seizures symptoms are common. Impaired the tastes are reported with Psychological disturbances are commonly, Lactate dehydrogenase may be elevated. Many skin manifestations including patchy erythematous rash are noticeable, One of the biggest barriers standing in the way of ending the pandemic the misinformation about the COVID-19 vaccines. At this critical time the Demand for vaccines very effective as it rigorously tested and found to be safe, also Vaccines have no effect on recipients’ genetic material and not effect on fertilization also Antibodies from are estimated to last two to four months, so those who have had a previous infection still get this vaccinated.