Systemic Arterial Embolism Research Articles

Cardiovascular risk in pulmonary alveolar proteinosis

ABSTRACTWe hypothesized that cardiovascular events and/or indices of cardiac dysfunction may be increased in pulmonary alveolar proteinosis (PAP). Systemic and pulmonary arterial hypertension, arrhythmias, pulmonary embolism, stroke and ischemic heart attack were reported. Patients underwent serum anti-GM-CSF antibodies, disease severity score (DSS), Doppler transthoracic echocardiograph, glucose, thyroid hormones, lipids, troponin and pro-Brain natriuretic peptide (BNP) examination. Thirteen patients (8 female) were studied, median age of 47. Pro-BNP inversely related to DLCO% and TLC%; troponin directly related to DSS, age, P(A-a)O2, left atrium-, left ventricle-end-diastole diameter and BMI. On multiple regression analysis DSS was the only parameter significantly and strongly related with troponin (R2 = 0.776, p = 0.007). No cardiovascular event was reported during follow-up. In PAP cardiovascular risk indices relate to lung disease severity. Therefore, PAP patients could be at increased risk for cardiovascular events. Quantitation of its magnitude and potential links to lungs’ physiologic derangement will be addressed in future studies.

Interventional Therapeutic Strategy for Hemoptysis Originating from Infectious Pulmonary Artery Pseudoaneurysms

This study reports 6 cases of hemoptysis originating from infectious pulmonary artery pseudoaneurysms (PAPs). Selective pulmonary angiography revealed PAPs in 5 cases, and segmental pulmonary artery embolization was performed using coils and gelatin sponge particles. Systemic arterial embolization also was performed in 5 cases because of inadequate initial control or for shunts from systemic to pulmonary arteries. At a median follow-up time of 9 months (range, 25 d to 25 mo), no recurrence occurred, although 2 patients died of respiratory failure. Segmental artery embolization combined with systemic artery embolization may be useful in patients with hemoptysis secondary to PAPs.

Horizons in Novel Oral Anticoagulation Therapy in Concomitant Acute Coronary Syndromes and Atrial Fibrillation

Thrombus formation and coronary artery occlusion, in acute coronary syndromes, occur as a result of an atherosclerotic plaque rupture/erosion and the subsequent activation of platelets and coagulation factors. Also, cardioembolic events, in atrial fibrillation, are related to the thrombus formation and the systemic arterial embolization secondary to the blood stasis in left atrium. Antiplatelet treatments in acute coronary syndromes and long-term oral anticoagulation in atrial fibrillation have improved prognosis by reducing ischemic events but both treatments are associated with an increase in the risk of bleeding. Furthermore, thrombin and activated factor X are the key elements in the coagulation cascade and novel oral anticoagulants act by inhibiting these coagulation factors, generating a double effect: the reduction of ischemic events and the increment in hemorrhagic events. To date, the clinical benefit of novel oral anticoagulants, in patients presenting acute coronary syndromes and atrial fibrillation, has not well studied. For that reason, the objective of this manuscript is to explain basic clinical trials testing novel oral anticoagulants in patients with acute coronary syndromes and ongoing trials evaluating the use of new oral anticoagulants in population with acute coronary syndromes and atrial fibrillation: the PIONEER AF-PCI (Rivaroxaban), the RT-AF (Rivaroxaban) and the REDUAL-PCI (Dabigatran) trials.

Systemic Air Embolism following Percutaneous Lung Biopsy.

Systemic air embolism is a serious complication that may occur during a transthoracic percutaneous lung biopsy. Although rarely encountered, sequelae from systemic air embolism may result in a wide range of cardiac and neurologic presentations that are potentially fatal. Prompt clinical and radiologic recognition of systemic air embolism can prevent significant morbidity and mortality. The authors performed a transthoracic percutaneous lung biopsy that was complicated by seizures and transient neurologic deficits. In this article, a case of percutaneous lung biopsy complicated by a systemic arterial air embolism is presented, and strategies for prevention and management of this complication are discussed.

Paradoxical embolism of the right kidney

Cardiologia CROATICA Case presentation: A 40-year-old man presented with shortness of breath, pleuritic chest pain and tachycardia. Five weeks before, the patient was admitted to the hospital due to the fracture of the fifth metatarsal bone of the left foot. The patient was put in a cast for 4 weeks. Pulmonary embolism (PE) was confirmed by a ventilation/perfusion lung scan. Immediately after admission, the patient started to complain about a sharp pain in his right lumbar region. Echocardiography revealed a dilated right ventricle and pulmonary hypertension of 70 mmHg (Figure 1). A CT-angio scan confirmed a massive PE and showed an infarction of the right kidney (Figure 2). Thrombosis of the left popliteal vein was confirmed by ultrasound. Transesophageal echocardiography revealed a patent foramen ovale (Figure 1). After the initial treatment with low molecular weight heparin, the patient became hypotensive and elevated levels of troponin were registered. The patient was transferred to the Coronary Care Unit and treated with alteplase. After the treatment, a normalisation in the both right ventricle diameter and right ventricular systolic pressure was noted. The patient was hemodynamically stable with full regression of his symptoms. A postprocedural Doppler ultrasound showed recanalisation of the right renal artery. Conclusion: Paradoxical embolism and intracardiac shunt should be immediately considered when PE and systemic arterial embolism co-occur. Treatment mainly consists of thrombectomy or thrombolysis.

A United States Marine Presenting With Hemoptysis After Push-Ups

We present an unusual case of right lower lobe intralobar pulmonary sequestration in a previously healthy and physical active 27-year-old U.S. Marine, who presented with new onset hemoptysis after doing push-ups. Diagnosis was obtained by chest X-ray and contrast computed tomography scan. Preoperatively the patient underwent fluoroscopy-guided embolization of the aberrant systemic artery supplying the sequestration. The segmental resection of the sequestration was then successfully performed through a muscle-sparing thoracotomy.

Rationale and design of the Left Atrial Appendage Occlusion Study (LAAOS) III.

Occlusion of the left atrial appendage (LAA) is a promising approach to stroke prevention in atrial fibrillation (AF). However, evidence of its efficacy and safety to date is lacking. We herein describe the rationale and design of a definitive LAA occlusion trial in cardiac surgical patients with AF. We plan to randomize 4,700 patients with AF in whom on-pump cardiac surgical procedure is planned to undergo LAA occlusion or no LAA occlusion. The primary outcome is the first occurrence of stroke or systemic arterial embolism over a mean follow-up of four years. Other outcomes include total mortality, operative safety outcomes (chest tube output in the first post-operative 24 hours, rate of post-operative re-exploration for bleeding in the first 48 hours post-surgery and 30-day mortality), re-hospitalization for heart failure, major bleed, and myocardial infarction. Left Atrial Appendage Occlusion Study (LAAOS) III is funded in a vanguard phase by the Canadian Institutes for Health Research (CIHR), the Canadian Network and Centre for Trials Internationally, and the McMaster University Surgical Associates. As of September 9, 2013, 162 patients have been recruited into the study. LAAOS III will be the largest trial to explore the efficacy of LAA occlusion for stroke prevention. Its results will lead to a better understanding of stroke in AF and the safety and efficacy of surgical LAA occlusion.

Floating Thrombus in the Aortic Arch with Systemic Arterial Embolization

Floating Thrombus in the Aortic Arch with Systemic Arterial Embolization

The Frequency and Significance of Portopulmonary Venous Anastomosis (PPVA): A Case Report and Literature Review

A Portopulmonary Venous Anastomosis (PPVA) is a direct vascular connection between the portal venous system and the pulmonary veins, close to the left atrium. We describe a patient with advanced cirrhosis and moderately severe Hepatopulmonary Syndrome (HPS) in whom (PPVA) was demonstrated by a high resolution computed tomographic scan. In order to reduce the symptoms of hypoxia in our patient, we sequentially performed Transjugular Intrahepatic Portosystemic Shunt (TIPS) followed by a catheter based obliteration of the PPVA. The case raised three questions which were addressed through an extensive literature review. Among patients with advanced cirrhosis, what is the frequency of PPVA? Our literature review suggests that the frequency of finding a PPVA in patients with portal hypertension depends on the imaging technique used. Transhepatic or transvenous portal venography may demonstrate PPVA in about 20% of patients with cirrhosis and varices. Limited published experience with contrast enhanced (bubble) echocardiography suggests that PPVA may be present in about 30% of such patients. An increasing number of case reports of PPVA have been published in recent years. This observation indicates that routine use of High Resolution Computed Tomography (HRCT) and magnetic resonance imaging is able to identify PPVA in cirrhotic patients. The visualization of PPVA with HRCT depends on the timing of the contrast injection and the expertise of the viewer. Among cirrhotic patients with PPVA, what is the clinical significance of the PPVA? There are multiple causes of clinically significant hypoxia in patients with cirrhosis. A PPVA is a right to left shunt that, theoretically, could be associated with clinically significant systemic arterial hypoxemia or emboli. There is not definitive evidence in the published literature that PPVA alone causes clinically significant hypoxia in cirrhotic patients. PPVA is, however, a documented important risk factor for systemic emboli when needle or catheter techniques are used to treat or prevent bleeding from gastroesophageal varices. What is the evidence that the obliteration of a documented PPVA will improve oxygenation in a cirrhotic patient with hypoxemia? Modern imaging methods may demonstrate a PPVA when patients with cirrhosis are investigated because of hypoxia. Previous authors have argued that the right to left shunting of blood in a PPVA does not have enough flow to significantly lower arterial oxygen concentration. Our report documents that the obliteration of a PPVA can be accomplished. However, our patient's oxygenation did not improve with obliteration of the PPVA. We do not believe that PPVA causes hypoxia. But knowledge of the frequency and clinical significance of PPVA is important for the care of patients with cirrhosis.

Population-based cohort study of warfarin-treated patients with atrial fibrillation: incidence of cardiovascular and bleeding outcomes

ObjectivesAtrial fibrillation (AF) is the most common cardiac rhythm disorder with a significant health burden. The aim of this study was to characterise patients with recently diagnosed AF and to...

Endovascular Management of Massive Hemoptysis in Patients With Pulmonary Pseudosequestration

Idiopathic chronic lung consolidation is a rare cause of massive hemoptysis. We describe 2 patients with chronic pulmonary consolidation of unknown etiology who presented with massive hemoptysis resulting in airway compromise. Selective angiography demonstrated multiple hypertrophied systemic arteries supplying the area of consolidation, consistent with pulmonary pseudosequestration. Initial endovascular management with embolization resulted in immediate control of hemoptysis. Short interval repeat angiography and embolization was necessary in both patients to treat recurrent hemoptysis secondary to hemorrhage from multiple feeding arteries. Selective bronchial and nonbronchial systemic arterial embolization is an effective treatment for massive hemoptysis secondary to pulmonary pseudosequestration.

Bronchial and Nonbronchial Systemic Artery Embolization in Management of Hemoptysis: Experience with 348 Patients

Background. We aimed to report our experience with bronchial artery embolization (BAE) in the management of moderate recurrent and/or life-threatening hemoptysis. Methods. We evaluated the demographics, clinical presentation, radiographic studies, short- and long-term efficacy, and complications in patients Who underwent BAE, at a tertiary university hospital, from 2003 to 2012. Results. Three hundred forty-one patients underwent BAE for the management of moderate recurrent or life-threatening hemoptysis. Pulmonary TB and bronchiectasis were the most common etiologies for hemoptysis in our locality. The most common angiographic signs for hemoptysis were hypervascularity and systemic-pulmonary artery shunt. BAE was successful in controlling hemoptysis immediately in 95% of patients and at 1 month in 90% of patients. Recurrence of hemoptysis was observed in 9.6% of patients, and reembolization was indicated in 85% of those cases. Complications of BAE were self-limited acute and subacute complications, while chronic complications were not recorded during this study. Conclusions. TB and bronchiectasis are the commonest etiologies for moderate recurrent or life-threatening hemoptysis in our locality. Hypervascular lesions from the bronchial arteries and nonbronchial systemic arteries represented the major vascular abnormalities. Bronchial and nonbronchial systemic artery embolizations were effective to control both acute and chronic hemoptyses, with no serious complications.

Immediate and Late Outcomes of Bronchial and Systemic Artery Embolization for Palliative Treatment of Patients With Nonsmall-Cell Lung Cancer Having Hemoptysis

Hemoptysis in patients with advanced lung cancer can be a life threatening. To evaluate immediate outcomes and late outcomes of bronchial artery embolization (BAE) for palliative treatment in patients with advanced nonsmall-cell lung cancer (NSCLC) having hemoptysis. The BAE was performed in 28 patients with NSCLC. Hemoptysis was defined as follows: massive bleeding greater than 300 mL within 24 hours (n = 8), moderate bleeding of 100 to 300 mL within 24 hours (n =12), and slight bleeding less than100 mL within 24 hours (n = 8). Success rate was 96%. Immediate clinical success within 24 hours after BAE was achieved in 22 of the 27 patients who underwent embolization. The BAE with gelatin sponge particles can provide good management of hemoptysis as a palliative treatment in patients with advanced NSCLC.

Thrombocytopenia in Patients With Atrial Fibrillation on Oral Anticoagulation Undergoing Percutaneous Coronary Intervention

Thrombocytopenia is often regarded as a risk factor for bleeding complications in patients undergoing percutaneous coronary intervention (PCI). The risk of mild to moderate baseline and acquired thrombocytopenia on bleeding and thrombotic or thromboembolic complications in patients with atrial fibrillation on oral anticoagulation therapy undergoing PCI, however, remains largely unknown. Management of Patients With Atrial Fibrillation undergoing Coronary Artery Stenting is a multicenter European prospective registry enrolling patients with atrial fibrillation undergoing PCI. We assessed the rate of bleeding complications as defined by Bleeding Academic Research Consortium and a composite of major adverse cardiac and cerebrovascular events (MACCE) including all-cause mortality, myocardial infarction, transient ischemic attack or stroke, stent thrombosis, systemic arterial embolism, or revascularization; and a composite of any harmful event (Bleeding Academic Research Consortium and MACCE) at 12-month follow-up in 861 consecutive patients undergoing PCI. Patients were divided into those with mild to moderate baseline thrombocytopenia (platelet count <150 × 10⁹/L; n = 99) and control group (platelet count >150 × 10⁹/L; n = 762). At hospital discharge, thrombocytopenia had no effect on prescribed antithrombotic treatment, and triple therapy (vitamin K antagonist + aspirin + clopidogrel) was the most common combination in both patient groups (69% vs 73%, p = 0.40). No differences in all-cause mortality (12% vs 11%, p = 0.79), MACCE (23% vs 22%, p = 0.87), or bleeding complications (23% vs 19%, p = 0.26) were detected. Acquired in-hospital thrombocytopenia occurred in 9.7% of patients, and it was associated with similar risk of adverse outcomes compared with control group. In conclusion, mild to moderate baseline thrombocytopenia does not seem to have a clinically significant effect on bleeding or thrombotic or thromboembolic complications after PCI in these frail patients receiving multiple antithrombotic drugs.

A minimal invasive surgical alternative to aberrant systemic arterial supply: Coil embolization

We present the case of a 20-year-old man with hemoptysis for 3 years. Chest radiography revealed increased pulmonary vascular opacities in the left lower lung field. Computed tomography showed an anomalous systemic artery arising from descending aorta supplying the basal segments of the left lower lobe. Bronchial tree was normal. Pulmonary artery angiogram revealed a hypoplastic inferior lobar branch of the left pulmonary artery. There was no direct communication between anomalous artery and pulmonary veins. We diagnosed our case as aortopulmonary collateral with normal lung parenchyma. Coil embolization of the anomalous systemic artery was performed. The patient survived well without evidence of hemoptysis for 18 months after coil embolization.

Embolization of Multiple Systemic Artery to Pulmonary Artery Fistula with Recurrent Hemoptysis

Herein, we report a case of multiple systemic arteries to pulmonary artery fistulas without any underlying causes, presenting recurrent hemoptysis. Transcatheter embolization was successfully performed several times on multiple systemic feeding arteries. Multiple systemic arteries to pulmonary fistulas can be a source of uncontrolled bleeding, and embolization may be a reasonable therapeutic option to control the bleeding.

Anesthetic experiences of severe mitral regurgitation and atrial septal defect newly appeared during the operation after myxoma removal surgery

Cardiac myxomas are the most common primary cardiac tumors, accounting for approximately 50% of all such tumors [1-3]. Around 75% of cardiac myxomas are detected in the left atrium (LA), and 15-20% in the right atrium (RA). Most myxomas arise from the interatrial septum at the fossa ovalis, but in some cases, myxomas have been reported to be attached to valve leaflets or in other locations in the atrium or ventricle [2,3]. The clinical signs and symptoms vary based on location, size, and mobility of myxoma. Most patients are symptomatic, and the triad of symptoms consists of embolism, intracardiac obstruction, and constitutional manifestations. Considering that cerebral and systemic embolism and even sudden death can be caused by cardiac myxomas, surgery is urgently need [1,3]. A 61-year old woman without any medical history, she com plained palpitations that started 20-days prior to her visit. On examination, her heart rate was regular, and her breath sounds were clear with no audible cardiac murmur. The patient denied having any symptoms that suggested a peripheral, cerebral, systemic, or coronary arterial embolism. A transthoracic echocardiogram (TTE) showed a pedunculated circular mass attached to the interatrial septum within the LA measuring 27.87 mm × 20.14 mm. It also showed a normal sinus rhythm with normal ventricular wall thickness and contraction. The LA was enlarged, and the mitral valve (MV) leaflets were mildly thickened and calcified with no regurgitation. From the TTE, clinical impres sion was cardiac myxoma. On arrival in the operating room, electrocardiogram, pulse oxymeter, and non-invasive blood pressure were monitored, and a left radial arterial line was placed before anesthetic induction. Anesthetic induction was begun with 15 mg of ectomidate, 30 μg/kg of fentanyl, and 0.2 mg/kg of vecuronium, and anesthesia was maintained with 10 μg/kg/hr of fentanyl, 50 μg/kg/hr of midazolam, and 0.2 mg/kg/hr of vecuronium. During the operation, a transesophageal echocardiogram (TEE) was performed to confirm the presence of cardiac mass and to detect changes in ventricular wall motion and cardiac valves. The echocardiographic appearance of the mass was typical for atrial myxoma. In mid-esophageal short axis view, a 1.80 cm × 3.63 cm sized circular mass from the interatrial septum was observed (Fig. 1A). In mid-esophageal four chamber and long axis views, a left atrial mass was observed with no MV regurgita tion. In the TEE, no other cardiac problems were detected. Arterial cannulation was done in upper ascending aorta, and bicaval venous cannulation was done in superior vena cava and lower RA. Cardiopulmonary bypass (CPB) then followed, with an aortic cross clamp and an infusion of cold cardioplegia via aortic root cannula. Right atrial wall and interatrial septum were incised, and left atrial mass including left atrial dome was removed. The defects associated with left atrial dome, and the in cision in the interatrial septum and right atrial wall were closed with sutures using prolene. After release of aortic cross clamp and direct current cardioversion, the heart beat recovered. A repeat TEE showed the removal of left atrial mass and an intact interatrial septum with no shunting; however, severe MR was

Right Hemisphere Cerebral Infarction Due to Air Embolism from Percutaneous Lung Biopsy: A Case Report

Percutaneous transthoracic needle biopsy is a common procedure in interventional radiology. Systemic arterial air embolism causing cerebral infarction is a rare but much feared complication of percutaneous lung biopsy. We present a comprehensive review of iatrogenic air embolism post-lung biopsy, a complication that is often sub optimally managed. Patho-physiology, clinical features, and risk factors and management are reviewed.

Clinical analysis of paradoxical cerebral embolism from pulmonary embolism

Objective To explore the diagnosis and treatment of cerebral embolism from pulmonary embolism (PE).Methods The clinical data of 5 cases with PE accompanied by cerebral embolism covering a period from October of 2007 to July of 2011 were retrospectively analyzed.Results In this study,the average age of 5 cases (all female) was 46.5 years old.PE was diagnosed through enhanced CT and ECT in lung among all 5 cases.Moderate to severe pulmonary hypertension was confirmed by echocardiogram.Two cases was patent foramen ovale and one was congenital atrial septal defect.Each patient was diagnosed to be new-onset cerebral infarction by MRI.Three cases underwent cerebral arterial thrombolysis.All of them survived and long-term anticoagulant treatment with Warfarin.INR was adjusted between 2.0 and 2.5 by change of Warfarin dose.Among them,one patient had cerebral embolism again just 3 days after the latest cerebral embolism; the other 4 patients did not suffer from cerebral embolism during the follow-up.Conclusions Paradoxical cerebral embolism is common.For clinical patients with PE,especially pulmonary hypertension accompanied by systemic circulation arterial embolism or unexplained systemic cerebral arterial embolism,paradoxical cerebral embolism should be considered. Key words: Pulmonary embolism; Paradoxical cerebral embolism; Diagnosis

Bronchial and nonbronchial systemic artery embolization in managing haemoptysis: 31 years of experience

The authors report on 31 years of experience with bronchial (BAE) and/or nonbronchial (NBAE) systemic artery embolisation for managing haemoptysis. A total of 534 patients who underwent bronchial artery angiography for haemoptysis between 1979 and 2010 were retrospectively evaluated. Of these patients, 477 (89%) had active bleeding and underwent BAE and/or NBAE (295 males and 182 females, aged between 12 and 71 years). Embolisation techniques, materials, major and minor complications and relapses were recorded. Complete resolution of haemoptysis was achieved within 24 h in 458/477 (96%) cases and within 48 h in 2% of cases. The aetiology of haemoptysis was as follows: cystic fibrosis (23%), bronchiectasis (13%), tuberculosis sequelae (8%), chronic obstructive pulmonary disease (COPD) (6%) and no apparent cause (21%). Major complications were recorded in 3/477 (0.6%): stroke (n=1), transient ischaemic attack (TIA) (n=1) and transient quadriplegia (n=1). Minor complications were recorded in 143/477 (30%): chest pain 86/143 (60%) and dysphagia 29/143 (20%). During a mean follow-up period of 14 (8-36) months, haemoptysis recurrence was observed in 42/110 cases (38%) of cystic fibrosis and in 77/367 cases of other diseases (21%). BAE and NBAE are effective and safe for acute treatment of haemoptysis, with low recurrence and complication rates. Interventional radiologist experience is crucial to the successful haemoptysis control and preventing complications.