Site Of Embolization Research Articles

Left atrial appendage orifice morphology in sickness and in health.

The left atrial appendage (LAA) is the primary site of embolism in individuals with atrial fibrillation (AF). We aimed to evaluate the morphological features of the LAA orifice in patients with sinus rhythm, paroxysmal AF, and persistent AF using three-dimensional (3D) transesophageal echocardiography (TOE). We also intended to identify morphometric parameters of the LAA orifice that may be potentially associated with an increased risk of ischemic stroke. We prospectively enrolled 106 patients undergoing TOE. Patients were divided into three groups: group1 (sinus rhythm), group2 (persistent AF), and group3 (paroxysmal AF). All patients underwent acomprehensive evaluation through transthoracic echocardiography (TTE) and TOE. Off-line analyses were performed of the recorded images. The LAA minor orifice area and minimal orifice diameter were greater in patients with persistent AF compared with individuals in sinus rhythm. Patients with persistent AF also had deeper LAAs compared with those in sinus rhythm. None of the LAA orifice morphometric measures were related to ischemic stroke risk. The only independent predictors of ischemic stroke were heart rhythm and the CHA2DS2VASc score. Persistent AF is associated with LAA dilation, increased depth, and larger orifice size. To our knowledge, this is the first study to demonstrate LAA orifice structural remodeling in patients with AF using 3D TOE.

Optimal combination of microcoils, flow control, and n-butyl cyanoacrylate-Lipiodol-iopamidol (2:3:1) for feasible embolization of medium-sized arteries in an in vitro vascular model.

To evaluate the behavior of n-butyl cyanoacrylate-Lipiodol-iopamidol at a ratio of 2:3:1 (NLI231) with and without microcoils and/or flow control in embolization of medium-sized arteries in an in vitro vascular model. A vessel model representing a common hepatic artery was prepared. Six scenarios were set for embolization, each ran three times: 1) NLI231 injected alone with flow control to 0ml/min during and up to 5min after embolization; 2) NLI231 injected into a mesh of microcoil of 5% density with the flow control; 3) NLI231 injected into a microcoil of 10% density with the flow control; 4) NLI231 injected alone without the flow control; 5) NLI231 injected into microcoil of 5% density without the flow control; 6) NLI231 injected into a microcoil of 10% density without the flow control. The microcoils were delivered to the embolization site, and NLI231 was injected. After 1h of observation, distal filters were collected, and grades of migration (I = none, II = partial, III = almost all-all) were assessed for each scenario. Embolization was achieved in scenarios with NLI231 and microcoils regardless of flow control (p < 0.01). NLI231 did not migrate in scenarios with microcoils and flow control (p < 0.05). NLI231 with microcoils without flow control can embolize the vessel, but partial migration occurred, and the distal distance of the NLI231 complex from the embolization site was longer (p < 0.01). Combining sparse coiling with NLI231 may be feasible but is limited to use when flow control is available, or where distal embolization is permissible to some extent.

Predictors and risk factors of bile duct injury after transcatheter arterial chemoembolization for hepatocellular carcinoma

PurposeBile duct injury is a serious complication after transcatheter arterial chemoembolization (TACE). If it is not detected early and treated actively, it will not only affect the subsequent tumor-related treatment of hepatocellular carcinoma (HCC) patients, but also may lead to serious consequences such as infection, liver failure and even death. To analyze the risk factors of bile duct injury after TACE in patients with HCC and explore the predictive indicators of bile duct injury after TACE, which is helpful for doctors to detect and intervene early and avoid the occurrence of serious complications.MethodWe retrospectively analyzed the clinical data of 847 patients with primary hepatocellular carcinoma who underwent TACE for the first time in our interventional department. Patients were divided into two groups according to whether bile duct injury occurred after TACE: (1) bile duct injury group, N = 55; (2) no bile duct injury group, N = 792. The basic data, intraoperative conditions and the outcome of bile duct injury were analyzed. The chi-square test was used for comparison of enumeration data. The Mann-Whitney U test was used for comparison of measurement data. Risk factor analysis was performed using binary logistic regression analysis.ResultsBasic data and intraoperative conditions were compared between the bile duct injury group and the group without bile duct injury: preoperative alkaline phosphatase (ALP) (103.24 ± 32.77U/L vs. 89.17 ± 37.35U/L, P = 0.003); history of hepatobiliary surgery (36.4% vs. 20.8%, P = 0.011); intraoperative lipiodol volume (P = 0.007); combined use of gelatin sponge particles (65.5% vs. 35.0%, P < 0.001); hypovascularity (58.2% vs. 24.5%, P < 0.001); and embolization site (P < 0.001). Comparison of postoperative liver function between bile duct injury group and non-bile duct injury group: postoperative total bilirubin (43.34 ± 25.18umol/L vs. 21.94 ± 9.82umol/L, P < 0.001); postoperative γ-glutamyltransferase(GGT) (188.09 ± 55.62U/L vs. 84.04 ± 36.47U/L, P < 0.001); postoperative ALP(251.51 ± 61.51U/L vs. 99.92 ± 45.98U/L, P < 0.001).ConclusionThe dosage of lipiodol in TACE, supplementation of gelatin sponge particles, embolization site, and hypovascularity of the tumor are risk factors for biliary duct injury after TACE. After TACE, GGT and ALP increased ≥ 2 times compared with preoperative indicators as predictors of bile duct injury. Bile duct injury occurring after TACE can achieve good outcomes with aggressive management.

Application of Photoplethysmography Combined with Deep Learning in Postoperative Monitoring of Flaps

Photoelectric volumetric tracing (PPG) exhibits high sensitivity and specificity in flap monitoring. Deep learning (DL) is capable of automatically and robustly extracting features from raw data. In this study, we propose combining PPG with 1D convolutional neural networks (1D-CNN) to preliminarily explore the method's ability to distinguish the degree of embolism and to localize the embolic site in skin flap arteries. Data were collected under normal conditions and various embolic scenarios by creating vascular emboli in a dermatome artery model and a rabbit dermatome model. These datasets were then trained, validated, and tested using 1D-CNN. As the degree of arterial embolization increased, the PPG amplitude upstream of the embolization site progressively increased, while the downstream amplitude progressively decreased, and the gap between the upstream and downstream amplitudes at the embolization site progressively widened. 1D-CNN was evaluated in the skin flap arterial model and rabbit skin flap model, achieving average accuracies of 98.36% and 95.90%, respectively. The combined monitoring approach of DL and PPG can effectively identify the degree of embolism and locate the embolic site within the skin flap artery.

Systematic review and meta-analysis of the efficacy and safety of adjunctive use of tirofiban in patients treated with endovascular therapy for acute ischemic stroke at different embolic sites.

The use of tirofiban as an adjunct to endovascular therapy (EVT) for acute ischemic stroke has been controversial. We aimed to assess the differences in safety and efficacy of EVT adjuvant to tirofiban in patients with anterior circulation stroke (ACS) and posterior circulation stroke (PCS). We systematically searched Pubmed, Embase, Cochrane Library, and Web of Science. Cohort studies and randomized controlled trials that compared treatment with tirofiban combined with EVT and EVT alone were included in our meta-analysis. The safety outcomes were symptomatic intracranial hemorrhage, and 3-month mortality. The efficacy outcomes were good functional outcome, excellent functional outcome, and successful recanalization (mTICI ≥ 2b). We performed subgroup analyses of anterior and posterior circulation strokes. We included 15 studies with 4608 patients. For safety outcomes, tirofiban significantly reduced 3-month mortality in the ACS subgroup (odd ratio [OR] = 0.80, 95% confidence interval [CI] = 0.65-0.98, P = .03) without increasing the rate of symptomatic intracranial hemorrhage (OR = 1.12, 95% CI = 0.88-1.44, P = .35). In the PCS subgroup, tirofiban significantly reduced 3-month mortality (OR = 0.63, 95% CI = 0.50-0.80, P = .0001) and symptomatic intracranial hemorrhage (OR = 0.60, 95% CI = 0.37-0.95, P = .03). For efficacy outcomes, in the ACS subgroup, tirofiban significantly improved good functional outcome (OR = 1.24, 95% CI = 1.06-1.45, P = .008) but did not improve recanalization (OR = 1.17, 95% CI = 0.93-1.47, P = .17) and excellent functional outcome (OR = 1.19, 95% CI = 0.97-1.46, P = .10). In the PCS subgroup, tirofiban significantly improved recanalization rate (OR = 1.94, 95% CI = 1.43-2.65, P < .0001) and did not improve good functional outcome (OR = 1.03, 95% CI = 0.81-1.30, P = .81) and excellent functional outcome (OR = 0.84, 95% CI = 0.58-1.20, P = .34). In acute ischemic stroke patients undergoing EVT, tirofiban improves good functional outcomes in ACS patients and increases recanalization rates in PCS patients on the 1 hand, reduces mortality, and does not increase the risk of symptomatic intracranial hemorrhage on the other. Tirofiban is safe and effective in both anterior circulation stroke and posterior circulation stroke patients undergoing EVT. More large multicentre randomized controlled studies are needed in the future.

Percutaneous Transcatheter Retrieval of Central Venous Port Fragments in Pediatric Patients; A Single-center Experience From the Pediatric Cardiology Department.

Split/fracture and embolization of central venous/shunt catheters are rare but serious complications in children. Percutaneous retrieval of intravascular foreign bodies is an important minimal invasive treatment. This study is aimed to represent our largest pediatric sample experience till now of 17 years from a single institution. Another aim is to compare the results regarding the removal or leaving in place of embolized or ruptured intravascular or cardiac venous catheter parts in children. A total of 26 cases were included in this study. Any pediatric patient with normal coagulation parameters and a fractured catheter fragment was included in this study. Other intravascular foreign bodies related to interventional devices and/or pacemaker/implantable cardiac defibrillator leads were excluded from this study. Twenty-six patients, of whom 25 had oncologic diseases and 1 had a ventriculoatrial shunt, were included. The median age was 83.5 months (between 20 mo and 18 y) at treatment.Superior vena cava (9 cases), followed by the right atrium (5 cases), were the most two common sites of embolization for cardiovascular foreign bodies. The success rate of percutaneous retrieval was 92.3% in all patients. There were neither complications nor deaths. The retrieval technique revealed a predisposition for extraction through the femoral vein (96.1%) and using snare techniques (100%). Additional catheters like pigtail, National Institutes of Health, or ablation catheters were used for stabilization in selective cases in which the permanent central venous fragments stuck to the vessels. A tractional maneuver and capturing the ruptured material in the middle were other trick points for successful retrieval. Patients were asymptomatic in 76.9% of cases (20/26). Percutaneous retrieval of cardiovascular foreign bodies is a reasonable, safe, and effective way in children when the catheter fragments are free and mobile. It should be considered the preferred treatment option instead of surgery. In patients where catheter fragments are stuck and are adherent to vessels, it could be left, and followed up by anticoagulation. Novel techniques accompanied by an experienced team could be helpful in difficult cases.

Feasibility of the Glue-in-Plug Technique Using a Novel Liquid Embolic Material in a Swine Model

PurposeTo evaluate the feasibility of the glue-in-plug (GIP) technique using n-butyl-2-cyanoacrylate‒Lipiodol (NL)–iopamidol (NLI) for short-segment embolization in swine. Materials and MethodsThe renal arteries, left external iliac artery, subclavian arteries, and common carotid arteries were each embolized in 4 swine using the GIP technique under general anesthesia. First, a type I Amplatzer vascular plug (AVP) (1–2 times the target vessel diameter) was deployed in the target artery. Next, the AVP was filled with NL mixture prepared at a ratio of 1:2 (NL12) (n = 11) or with NLI mixture prepared at a ratio of 2:3:1 (NLI231) (n = 11). Angiography was performed before, immediately after, and 1 hour after embolization to assess embolization and migration of the embolic materials. The embolized arteries were also evaluated histopathologically. ResultsThe migration distance of the embolic material beyond the plug tip was significantly shorter in the NLI231 group than in the NL12 group immediately after embolization (6.5 mm ± 4.5 vs 1.0 mm ± 1.8, P = .0024) and 1 hour after embolization (8.4 mm ± 5.6 vs 1.0 mm ± 1.8, P = .0013). Angiography revealed no sign of recanalization of the target vessels in any artery in either group. Mild inflammatory cell infiltration was observed around the arterial wall at the embolization site in all arteries in both groups. ConclusionsThe GIP technique using NLI231 may be a feasible procedure for short-segment embolization based on these short-term results.

Short-term outcomes of uterine artery embolization for urgent or emergent abnormal uterine bleeding.

To evaluate the outcomes of uterine artery embolization (UAE) for patients with urgent or emergent abnormal uterine bleeding (AUB). Retrospective review of all patients from 1/2009-12/2020 who were treated urgently or emergentlywith UAE for AUB. Urgent and emergent cases were defined as those requiring inpatient admissions. Demographic data were collected for each patient including hospitalizations related to bleeding and length of stay (LOS) for each hospitalization. Hemostatic interventions other than UAE were collected. Hematologic data were collected before and after UAE including hemoglobin, hematocrit, and transfusion products. Data specific to the UAE procedure included complication rates, 30-day readmission, 30-day mortality, embolic agent, site of embolization, radiation dose, and procedure time. 52 patients (median age: 39) underwent 54 urgent or emergent UAE procedures. The most common indications for UAE were malignancy (28.8%), post-partum hemorrhage (21.2%), fibroids (15.4%), vascular anomalies (15.4%), and post-operative bleeding (9.6%). There were no procedure-related complications. Following UAE, 44 patients (84.6%) achieved clinical success and required no additional intervention. Packed red blood cell transfusion decreased from a mean of 5.7 to 1.7 units (p < 0.0001). Fresh frozen plasma transfusion decreased from a mean of 1.8 to 0.48 units (p = 0.012). 50% of patients received a transfusion prior to UAE, while only 15.4% were transfused post-procedure (p = 0.0001). Emergent or urgent UAE is a safe and effective procedure to control AUB hemorrhage secondary to a variety of etiologies.

A Case Report of Myocardial Infarction due to a Dislodged Thrombus in the Ascending Aorta

Background: Ascending aortic thrombosis is extremely rare and its pathogenesis is unclear. Clinical manifestations are often related to the site of embolism caused by thrombus dislodgement. Currently, surgery is considered the first choice to prevent embolism and recurrence, while medical therapy is an option for patients who refuse surgery or for whom surgery is contraindicated.

Atrial septal defect occluder device embolization: Experience of a tertiary care cardiac center.

Percutaneous device closure of atrial septal defect (ASD) has become an increasingly popular procedure as it offers several advantages. However, it is associated with infrequent, but life-threatening complications such as device embolization. To analyze the risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. A retrospective study was performed at a tertiary referral center for cardiac services. Pre-procedure, intra-procedure, and post-procedure data of patients whose ASD device embolized was collected retrospectively and analyzed for risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Results: Thirty devices were embolized, out of which 13 were retrieved percutaneously in the Catheter laboratory, whereas 17 patients underwent surgery. Fourteen patients had an unfavorable septal morphology for device closure. Ten devices were embolized in the catheter laboratory, five in the intensive care unit, and two in the ward. The devices were embolized to almost all chambers of the heart and great vessels. One patient had an inferior vena cava rim tear while attempting percutaneous retrieval. One patient required a short period of total circulatory arrest (TCA) for retrieval of the device from ascending aorta, while another required a lateral position for retrieval from descending aorta. One patient required re-exploration for bleeding, while another had an air embolism and succumbed. Once embolization occurs, the risks associated increase manifold. Most of the surgical extractions are uneventful; however, there could be certain complications that may need repair of valvular apparatus, the institution of TCA, or the need for the lateral position. Air embolization though very rare can occur which could be fatal.

Experimental study of the effects of absorbable gelatin sponge and non‑absorbable polyvinyl alcohol particle material used in transcatheter arterial embolization on liver tissues.

Hepatic trauma is a leading cause of death in major abdominal trauma, and transcatheter arterial embolization has been widely used to treat it. However, there is limited research on whether absorbable gelatin sponge (AGS) and non-absorbable polyvinyl alcohol particles (PVA) have different effects on liver tissue, making it an important area of exploration. The present study investigated this issue using animal experiments by performing transhepatic arterial embolization with AGS and PVA. The effects on normal liver tissue in rabbits were examined by detecting liver function and inflammatory indexes, conducting histopathological examination, and using western blotting to detect apoptotic proteins. There were significant differences between the AGS and PVA groups after embolization. The AGS group exhibited a trend of improvement at ~1 week after embolization, and all indicators were statistically different until day 21 compared with the PVA group. The AGS group exhibited improved repair of hepatocytes and the biliary system based on H&E staining, while the PVA group exhibited more severe necrosis of the hepatocytes and biliary system around the embolization site. The western blotting results indicated that the Bcl-2/Bax ratio decreased on day 1 and day 3, and then rebounded in the AGS group on days 7 and 21, demonstrating gradual repair of hepatocytes compared with the PVA group.

Post-Embolization Hemoglobin Changes: When to Consider Re-intervention.

Decline in hemoglobin (Hgb) levels is common post-embolization, but there is no consensus on the classification of patients based on risk for re-bleeding or re-intervention. The current study evaluated post-embolization Hgb level trends with the goal of understanding the factors predictive of re-bleeding and re-intervention. All patients who underwent embolization for gastrointestinal (GI), genitourinary, peripheral, or thoracic arterial hemorrhage from 01/2017 to 01/2022 were reviewed. Data included demographics, periprocedural pRBC transfusion (TF) or pressor requirements, and outcome. Lab data consisted of Hgb values pre-embolization, immediately post-embolization, and daily values on days 1-10 after embolization. Hgb trends were compared between patients across TF and re-bleeding outcomes. Regression model was used to examine factors predictive of re-bleeding and magnitude of Hgb reduction post-embolization. A total of 199 patients were embolized for active arterial hemorrhage. Perioperative Hgb level trends were similar for all sites and between TF + and TF- patients, showing a decline reaching a nadir within 6days post-embolization followed by an upward trend. Maximum Hgb drift was predicted by GI embolization (p = 0.018), TF before embolization (p = 0.001), and use of vasopressor (p = 0.000). Patients with Hgb drop > 15% within the first two days post-embolization had a higher chance of having a re-bleeding episode (p = 0.04). Perioperative Hgb trends showed a consistent downward drift followed by an upward shift, irrespective of TF requirement status or site of embolization. Using a cut-off value of 15% Hgb reduction within the first two days post-embolization may be helpful to assess re-bleeding risk.

Spectral CT Imaging of Prosthetic Valve Embolization after Transcatheter Aortic Valve Implantation

Transcatheter heart valve (THV) embolization is a rare complication of transcatheter aortic valve implantation (TAVI) generally caused by malpositioning, sizing inaccuracies and pacing failures. The consequences are related to the site of embolization, ranging from a silent clinical picture when the device is stably anchored in the descending aorta to potentially fatal outcomes (e.g., obstruction of flow to vital organs, aortic dissection, thrombosis, etc.). Here, we present the case of a 65-year-old severely obese woman affected by severe aortic valve stenosis who underwent TAVI complicated by embolization of the device. The patient underwent spectral CT angiography that allowed for improved image quality by means of virtual monoenergetic reconstructions, permitting optimal pre-procedural planning. She was successfully re-treated with implantation of a second prosthetic valve a few weeks later.

Causes and treatment strategies of unilateral leaflet escape of bileaflet mechanical prosthetic heart valves after surgery: a case series

BackgroundDuring the eleven years from 2010 to 2021, preliminary statistics have shown that Fuwai Hospital completed 23,571 mechanical valve replacements for various types of valves, and 1139 mechanical valve replacements were performed in Guangyuan First People's Hospital. Only two patients developed valve leaflet escape, so valve leaflet escape is a rare postoperative complication.Case presentationIn 2010 and 2021, two patients were selected after they had unilateral leaflet escape after having mechanical valve replacements in Fuwai Hospital of Chinese Academy of Medical Sciences and Guangyuan First People's Hospital. Both patients underwent reoperations with the classic operation and the new bileaflet mechanical prosthetic heart valve was sutured. The treatment of detached single lobe and distal vessel was comprehensively determined, and the condition was treated according to the patient's symptoms, CT results, ultrasound results and other test results, as well as whether this detached lobe caused any abnormal hemodynamics of the distal vessel. The patient with mechanical aortic valve escape completed the 10-year follow-up, and patient with mechanical mitral valve escape completed the 3-month follow-up. there was no thrombosis or hematoma at the embolic site; the patient had no lower limb symptoms.ConclusionsThe reason for the leaflet escape may be related to the valve design and the leaflet material. If the detached leaflets are damaged and if the distal blood vessels are affected, simultaneous surgical treatment is required. Those patients whose vessels were not damaged by the valve lobe should be carefully monitored.

Transvenous embolization of cerebrospinal fluid-venous fistulas: Independent validation and feasibility of upper-extremity approach and using dual-microcatheter and balloon pressure cooker technique

BackgroundTransvenous embolization is emerging as a promising treatment for cerebrospinal fluid-venous fistulas (CVF) associated with spontaneous intracranial hypotension (SIH).ObjectiveTo perform an independent validation of the efficacy and safety of the...

First case of successful usage of a low-profile flow-diverting stent for treatment of intracranial infectious aneurysm in patient with a mechanical heart valve. Clinical case and literature review

Infectious aneurysms (IA) are cerebral aneurysms that are formed due to the infectious inflammation of the arterial wall. They are a rather rare pathology and in most cases prove to be a complication of infectious (bacterial) endocarditis of the left heart chambers. Timely diagnosis of IA in the pre-hemorrhagic period is problematic due to the variability of the clinical picture of IA, frequent blurred or low-symptomatic clinical course, the possibility of IA formation in the remote period after septic embolism, even despite the background of antibiotic therapy. The presented clinical case illustrates the first successful use of a low-profile flow-diverting stent for the treatment of a young patient with a mechanical heart valve and an infectious aneurysm of the left middle cerebral artery, developed at the site of septic embolism in the acute period of septic bacterial endocarditis accompanied by ischemic stroke. This observation demonstrates the effectiveness of the chosen method of treatment, peculiarities of adequate preoperative preparation, possible postoperative complications and detailed correction of anticoagulant and antiplatelet therapy.

Abstract 13988: A Devastating Case of Clostridial Infective Endocarditis

Introduction: Cardiac necrotizing soft tissue infections (NSTI) have been scarcely reported in the literature. We present a rare case of a disseminated NSTI with myocardial involvement secondary to embolic phenomena from emphysematous infective endocarditis (IE). Case presentation: 73-year-old female on dialysis with atrial fibrillation and diabetes mellitus was transferred for multifocal strokes evidenced on magnetic resonance imaging. Presented with leukocytosis, lactic acidosis, acute liver failure, and right upper extremity (RUE) NSTI. She was started on antibiotics and vasopressors and taken emergently to the operating room for RUE amputation. Following surgery, an electrocardiogram revealed anterior STEMI. Bedside transthoracic echocardiogram noted a severely reduced ejection fraction and a mitral valve vegetation. Computed tomography of head and chest revealed pneumomyocardium, portal venous gas, and pneumocephalus. Blood cultures revealed growth of Clostridium perfringens. With severe multi-organ failure and a poor prognosis, comfort care was elected, and the patient expired. Figures: A: RUQ subcutaneous gas. B: Chest wall gas. C: pneumocephalus. D: pneumomyocardium. E: MV vegetation. Discussion: Septic embolization is a devastating sequela of IE. Vegetations &gt; 1cm have increased embolic potential and all-cause mortality. The most common site of embolization is the central nervous system; however, coronary embolization can also occur. Clostridial endocarditis is rare, despite being documented as the first cause of anaerobic IE. Mortality rate of clostridial NSTI and shock exceeds 50%. Source control and rapid identification of infection are paramount for treatment success. A multidisciplinary approach should be employed when treating Clostridial infections, specifically endocarditis. Our case highlights the need for prompt recognition of IE and the interplay of multimodal imaging in the diagnosis of disseminated infection.

Analysis of characteristics of the location of lower extremity deep vein thrombosis and the site of pulmonary embolism in hospitalized patients

To investigate the characteristics and relationship between the location of lower extremity deep vein thrombosis (DVT) and the site of pulmonary embolism in hospitalized patients. The data of patients with lower extremity DVT diagnosed by ultrasound examination and pulmonary embolism diagnosed by CT pulmonary angiography from December 2017 to December 2021 were analyzed retrospectively. According to the location of lower extremity DVT, the patients were divided into mixed DVT, proximal DVT, and distal DVT which was further divided into anterior/posterior tibial vein or peroneal vein thrombosis and calf muscular venous thrombosis. Mixed DVT was referred to the presence of both proximal and distal DVT. According to the involved site of pulmonary artery, pulmonary embolism was divided into three types: main pulmonary artery, left or right pulmonary artery trunk embolism, lobar pulmonary artery embolism and segmental pulmonary artery embolism. The location of lower extremity DVT, the site of pulmonary embolism, the clinical manifestation (shortness of breath, chest tightness, chest pain, hemoptysis, cough, lower limb swelling, lower limb pain, syncope, fever) and risk factors (fracture/trauma, tumor, diabetes, hypertension, atrial fibrillation, infection, surgery, autoimmune diseases, paralysis, pregnancy) of venous thromboembolism (VTE), and the level of D-dimer were analyzed. A total of 209 patients were enrolled finally, including 127 patients with left lower extremity DVT (60.8%) and 82 with right lower extremity DVT (39.2%). Mixed DVT accounted for 39.2%, proximal DVT accounted for 17.3%, and distal DVT accounted for 43.5% (anterior/posterior tibial vein and peroneal vein thrombosis accounted for 14.8%, calf muscular venous thrombosis accounted for 28.7%). The incidences of main pulmonary artery embolism, left or right pulmonary artery trunk embolism in the mixed DVT and proximal DVT were significantly higher than those in the anterior/posterior tibial vein or peroneal vein thrombosis and calf muscular venous thrombosis [41.5% (34/82), 38.8% (14/36) vs. 16.2% (5/31), 10.0% (6/60)], with statistically significant differences (all P < 0.05). The incidences of pulmonary segmental artery embolism in the anterior/posterior tibial vein or peroneal vein thrombosis were higher than those in the mixed DVT and proximal DVT [41.9% (13/31) vs. 26.8% (22/82), 30.6% (11/36)], but the difference was not statistically significant (both P > 0.05). The incidences of pulmonary segmental artery embolism in the calf muscular venous thrombosis were significantly higher than those in the mixed DVT and the proximal DVT [66.7% (40/60) vs. 26.8% (22/82), 30.6% (11/36)], and the difference was statistically significant (both P < 0.05). The levels of D-dimer in patients with calf muscular venous thrombosis combined with main pulmonary artery embolism, left or right pulmonary artery trunk embolism were significantly higher than those in patients with calf muscular venous thrombosis combined pulmonary segmental artery embolism (mg/L: 6.08±3.12 vs. 3.66±2.66, P < 0.05). There were no significant differences in D-dimer levels in other patients with DVT combined with pulmonary embolism in different sites. In terms of the clinical manifestations of VTE, the incidences of lower limb swelling in the mixed DVT and proximal DVT were significantly higher than those in the anterior/posterior tibial vein or peroneal vein thrombosis and calf muscular venous thrombosis [54.9% (45/82), vs. 29.0% (9/31), 15.0% (9/60), both P < 0.05], the incidences of lower limb swelling in the proximal DVT were significantly higher than those in the calf muscular venous thrombosis [41.7% (15/63) vs. 15.0% (9/60), P < 0.05], there were no significant difference in the other clinical manifestations among the DVT groups. There was no significant difference in the incidence of VTE risk factors among the groups. The DVT of inpatients mostly occurred in the left lower limb, and the incidence of distal DVT was higher than that of proximal DVT. Mixed DVT and proximal DVT combined with pulmonary embolism mostly occurred in the main pulmonary artery, left or right pulmonary artery trunk, while distal DVT combined with pulmonary embolism mostly occurred in the pulmonary segmental artery. The levels of D-dimer in patients with lower extremity DVT combined with main pulmonary artery or left and right pulmonary artery trunk embolism were higher than those in patients with pulmonary lobe and segmental artery embolism. The incidence of lower extremity swelling in patients with mixed DVT and proximal DVT was higher than that in patients with distal DVT.

Aortic thrombosis as a dramatic vascular complication in COVID-19 disease.

ObjectiveTo report clinical outcomes of COVID-19 related acute aortic thrombosis (AAT).MethodsConsecutive COVID-19 patients presenting with AAT between April 2020 and August 2021 were included retrospectively. Clinical and radiological data were prospectively collected.ResultsTen patients (men, 90%; mean age, 64 ± 2 years) were included. At the time of AAT diagnosis, four patients were in intensive care unit. Median time between diagnosis of COVID-19 and AAT was 5 days [IQR 0–8.5]. Clinical presentation was acute lower limb ischaemia (n = 9) and mesenteric ischaemia (n = 2). Thrombus localization was the abdominal aorta (n = 5), the thoracic aorta (n = 2) or both (n = 3), with the following embolic sites: lower limbs (n = 9), renal arteries (n = 3), superior mesenteric artery (n = 2), splenic artery (n = 1), cerebral arteries (n = 1). Revascularization was performed in 9 patients, using open (n = 6), endovascular (n = 2) or hybrid techniques (n = 1). Three patients required reinterventions. The 30-day mortality was 30%. Three major amputations were performed in two patients, resulting in a free-amputation survival rate of 50% after a median follow-up of 3,5 months [IQR 2–4.1].ConclusionAAT is a rare and devastating complication of COVID-19 disease, responsible for high mortality and amputation rates.

A Complication Hanging by a Thread

Question: A 75-year-old man presented with a 1-month history of mild abdominal pain and cramping, associated with weight loss (3 kg). He denied any nausea, vomiting, chills, diarrhea, or hematochezia. The patient reported no trauma. He had a history of ampullary adenocarcinoma treated with pancreaticoduodenectomy 2 years earlier. The postoperative course was marked by hemorrhagic shock owing to a splenic artery pseudoaneurysm that was successfully treated by trans-arterial embolization. On physical examination, the patient was afebrile and had normal vital signs. He had a slight tender abdomen on palpation. Blood tests revealed a C-reactive protein level of 20.2 mg/L (reference value, <3.5 mg/L) and a white blood cell count of 3670/mm3 with 87% neutrophils. Other laboratory tests were unremarkable. A contrast-enhanced computed tomography (CT) scan showed a status post embolization of the splenic artery with hyperattenuating embolic material (Figure A) and long thin hyperattenuating foreign bodies in the small bowel lumen (Figure B–D; the entire CT scan is provided as supplemental material) that were better assessed on a coronal maximum intensity projection view (Figure E). The small bowel wall was normal. There was no sign of bowel perforation, no fluid collection, and no sign of active or recent bleeding. The colon was normal. The pancreaticojejunal anastomosis was unremarkable. There was no evidence of tumor recurrence. What is the diagnosis? Look on page 55 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The pancreaticoduodenectomy was complicated with a pseudoaneurysm arising from the splenic artery (Figure F) that was successfully treated with transarterial embolization with steel wire coils. A postembolization CT scan showed complete occlusion of the lesion and the splenic artery (coronal view; Figure G). There was no bleeding recurrence, and the patient was discharged. The patient was regularly followed-up with a CT scan that showed no evidence of tumor recurrence and no modification of the embolization site. A multidisciplinary team recommended conservative management with no invasive procedure to remove the migrated coils. The patient spontaneously and painlessly evacuated the coils in stools 5 weeks after the diagnosis (Figure H). A contrast-enhanced CT scan performed 3 weeks later showed the evacuation of migrated coils, and the persistence of coils in the splenic artery (Figure I). The patient is currently asymptomatic and free from tumor recurrence. Complications of splenic artery embolization include splenic infarction (1%–2%), splenic abscesses, left pleural effusion (10%), or basal atelectasis (30%), and rarely portal thrombosis. Migration of coils is exceptional and has been described after embolization of splenic pseudoaneurysms owing to vascular coil erosion into the gastrointestinal tract.1Shah N.A. Akingboye A. Haldipur N. et al.Embolization coils migrating and being passed per rectum after embolization of a splenic artery pseudoaneurysm, "the migrating coil": a case report.Cardiovasc Intervent Radiol. 2007; 30: 1259-1262Crossref PubMed Scopus (36) Google Scholar, 2Tekola B.D. Arner D.M. Behm B.W. Coil migration after transarterial coil embolization of a splenic artery pseudoaneurysm.Case Rep Gastroenterol. 2013; 7: 487-491Crossref PubMed Scopus (21) Google Scholar, 3Takahashi T. Shimada K. Kobayashi N. et al.Migration of steel-wire coils into the stomach after transcatheter arterial embolization for a bleeding splenic artery pseudoaneurysm: report of a case.Surg Today. 2001; 31: 458-462Crossref PubMed Scopus (46) Google Scholar As previously reported, migration was a delayed complication (3 months to 10 years in the literature). Of note, several cases reported evidence of infection at the erosion site, which was not present here. Management depends on the extent of material migration and symptoms and ranges from conservative treatment to more invasive procedures (endoscopic or surgical retrieval). No evidence suggests that specific coils are more prone to secondary migration. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIwMDVhZjJiODcwMzAzNjk2ZmI2YWIzMjUzYjdlYWQxOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjgwMjM3NDk5fQ.LS386lU7wuNg_A2l4X5T61IP2FppVGq2DNjFd7aTwKDD2CnGpQETIi90YGkob6isNUAcHjGC4yhMDhQNo1DG5HKu1dFwUcd02ku-3-ijbtwufokHYbR9GkgBLJJrKiVWexXPcCmjZ80L7FxHY7cNGxrNvpL2raueVLp6qDpzbURZecPBVy2dgcAXpt6jsm1aasdWat3eZkIIzv_GjPqtCeiF2xd_C5fCUMsrsLpgVJRc4TUlfE7LeeevSOcSauQrdo1mVy7_4gMzUgxnWKEuzCzZQJNc2cgIvMo0DQPGSs8o2SDa7TKbqSjnpikBuxPR43PNpPDaTpv5tnSCsdVXbQ Download .mp4 (6.04 MB) Help with .mp4 files Video