Therapy For Massive Pulmonary Embolism Research Articles

First-Line Treatment for Massive Pulmonary Embolism: Counterpoint-Tried-and-True Catheter-Directed Thrombolysis Is a More-Established Therapy for Massive Pulmonary Embolism.

First-Line Treatment for Massive Pulmonary Embolism: Counterpoint-Tried-and-True Catheter-Directed Thrombolysis Is a More-Established Therapy for Massive Pulmonary Embolism.

Diagnosis and management of intra-operative pulmonary embolism under general anaesthesia in a peripheral tertiary care centre with limited resources.

Sir, It is difficult to detect and diagnose acute pulmonary embolism (APE) in patients under general anaesthesia (GA) as signs and symptoms such as dyspnoea, chest pain, haemoptysis and syncope are not evident.[1] A 64-year-old male, with left sided carcinoma buccal mucosa and American Society of Anesthesiologists physical status II, was listed for left anterior hemi-mandibulectomy with bilateral multinodal neck dissection and left sided pectoral muscle musculocutaneous flap (PMMC) under GA. Preoperative contrast enhanced computed tomography (CECT) thorax was unremarkable. After induction, haemodynamics remained stable during excision of the primary lesion. Approximately, 5 hours into the surgery, while raising the PMMC, the patient developed sudden pronounced hypotension with a mean arterial pressure of 45 mmHg and a decrease in end tidal carbon di-oxide (EtCO2) 38 mmHg to 15 mmHg. This was associated with bradycardia (heart rate 44-48/min) and a gradual fall in oxygen saturation to 86-88%. Peak airway pressures gradually increased from 21 cmH2O to 32 cmH2O with an associated increase in plateau pressures from 19 cmH2O to 29 cmH2O. Central venous pressures were elevated and bilateral breath sounds were marginally reduced with no adventitious sounds. There was no significant acute blood loss, nor any evidence of sepsis. Immediately, the inhalational agent was switched off and the fraction of inspiratory oxygen increased to 100%. Intravenous mephentermine 6 mg (two boluses), hydrocortisone 100 mg and atropine 0.6 mg were administered intravenously. A single intravenous adrenaline bolus of 10 μg was subsequently administered, followed by an infusion at the rate of 0.02 μg/kg/min. Immediate arterial blood gas (ABG) analysis showed hypercarbia as well as hypoxia [Table 1a]. Transthoracic echocardiography (TTE) through subcostal four chamber view showed dilated and strained right heart chambers (McConnell sign) and distended inferior vena cava [Figure 1a and b]. A probable diagnosis of APE was made.Table 1: Arterial blood gas analysisFigure 1: (a) Echo showing dilated IVC and RA (b) Dilated RA and RV. IVC: Inferior vena cava; RA: Right atrium; RV: Right ventricleOur institute is a tertiary cancer care centre in a small town with limited resources. After adequate resuscitation, a joint consensus among operating room team members was made for pharmacological treatment. Unfractionated heparin (UFH) 5000 IU was administered intra-venously. Activated partial thromboplastin time (APTT) was maintained 1.5-2 times of the normal value. We were in the middle of the surgery (with tumour excised and the PMMC flap raised), and the haemodynamics had stabilised. Repeat blood gas analysis came normal [Table 1b]. So, we decided to complete the surgery. Post-surgery, the patient was kept on mechanical ventilation. Vitals in the postoperative period remained stable. A dose of 2500 IU of UFH was repeated as the reported APTT was 38.3 seconds. The patient underwent computed tomographic pulmonary angiography which showed no filling defect [Figure 2] and was shifted onto subcutaneous low molecular weight heparin 60 mg twice a day. On post-operative day (POD) 1, the patient was weaned off the ventilator. He was shifted to the ward on POD 2. He was found haemodynamically stable during follow-up.Figure 2: CT Pulmonary Angiography (Post Surgery)APE leads to significant separation of EtCO2 and PaCO2 values intra-operatively. It causes a sudden decrease in EtCO2 and an increase in PaCO2. This separation in EtCO2 and PaCO2 values is also an important tool to measure thrombolysis under GA.[1] TTE coupled with EtCO2 changes seems to be useful in intra-operative cardio- circulatory failure to exclude other differential diagnoses.[2] The 2019 consensus European Society of Cardiology (ESC) guidelines strongly recommend intravenous UFH as a treatment of choice in haemodynamically unstable APE.[3] Catheter-directed therapy (CDT) had been done for APE.[4] CDT is recommended by the American College of Chest Physicians as second-line therapy for massive pulmonary embolism.[5] Our case is a classic example of APE in head and neck malignancy. The involvement of a multidisciplinary team can also help in preparedness for emergent and unanticipated situations.[6] We emphasise that vigilant monitoring of EtCO2, timely use of TTE and systemic anticoagulation with adequate intraoperative haemodynamic resuscitation can lead to safe completion of surgery with minimal morbidity and mortality. Though UFH is not a recommended modality in the intra-operative period, due to the limitations of our set -up, CDT was beyond our purview. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to concealidentity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Unexpected bleeding site post thrombolytic therapy for massive pulmonary embolism

Background: Massive pulmonary embolism (PE) is a deadly disease that can be managed by thrombolytic therapy to save patients' lives. A case of postpartum woman Who presented to the emergency department (ED) with cardiac arrest due to massive PE. Case presentation: We report a case of 34-year-old woman who presented to the ED with cardiac arrest due to massive PE 2 weeks post-uncomplicated spontaneous vaginal delivery. She was managed by a comprehensive multidisciplinary team approach, cardio-cerebral resuscitation (CCR), and systemic thrombolysis. The thrombolysis resulted in massive vaginal bleeding, which led to a prolonged cardiac arrest. This was recognized timely and managed adequately. The patient survived and was discharged home with a good neurological and cardiovascular outcome. Conclusion: Vaginal bleeding may occur post thrombolysis in post-partum life-threatening PE, which can be resolved by a multidisciplinary team-based approach coupled with CCR.

Catheter Directed Thrombolytic Therapy for Massive Pulmonary Embolism in Nigeria: Case Report

Catheter Directed Thrombolytic Therapy for Massive Pulmonary Embolism in Nigeria: Case Report

A case of successful systemic thrombolysis in massive thromboembolia of pulmonary artery against the background of pregnancy

We present a clinical case of successful systemic thrombolysis in a pregnant patient with massive pulmonary embolism. A 29-year old patient at 28 weeks of pregnancy was hospitalized 2 hours after sudden suffocation in a presyncopal state and hypotension of 90/50 mm Hg. ECG showed the signs of overload of right heart chambers in the form of a typical S1-Q3-T3 (McGinn–White) syndrome, as well as the Kosuge sign. Echocardiography verified pulmonary 3 Grade hypertension (81 mm Hg), enlargement of the right atrium and ventricle, 3 Grade tricuspid regurgitation and paradoxical movement of the interventricular septum. Multislice computed tomography of the chest with contrast of the pulmonary artery revealed a defect of contrast in the right main pulmonary artery, occlusive clearance, and thrombotic mass, extending to the bifurcation of the left main pulmonary artery ("clot - rider"). Thrombolytic therapy was started with recombinant tissue plasminogen activator (alteplase 10 mg bolus, then 90 mg for 2 hours). The patient was daily examined by a gynecologist. The viability of the fetus, monitoring of possible hemorrhagic complications of the placenta were evaluated. After thrombolysis, the patient began to note clinical improvement in the form of a regression of dyspnea. According to echocardioscopy control, the signs of overload of right heart chambers completely regressed. There were no complications both in the mother and in the fetus during the subsequent days until discharge. On 25.05.16 there was uncomplicated delivery vaginally of live full-term girl. Thus, when there is life-threatening massive pulmonary embolism, the application of General principles of diagnosis and treatment of this disease in patients with pregnancy is warranted. The carrying out of thrombolytic therapy in massive pulmonary embolism enables to reduce the manifestations of pulmonary hypertension, right ventricular failure, and to conduct births on time. Used intravenous thrombolytics have no teratogenic effect in the later stages of pregnancy.Received 18 April 2017. Accepted 5 June 2017.Funding: The study did not have sponsorship.Conflict of interest: The authors declare no conflict of interest.

Massive Pulmonary Embolism: Extracorporeal Membrane Oxygenation and Surgical Pulmonary Embolectomy.

Massive pulmonary embolism (PE) refers to large emboli that cause hemodynamic instability, right ventricular failure, and circulatory collapse. According to the 2016 ACCP Antithrombotic Guidelines, therapy for massive PE should include systemic thrombolytic therapy in conjunction with anticoagulation and supportive care. However, in patients with a contraindication to systemic thrombolytics or in those who fail the above interventions, extracorporeal membrane oxygenation (ECMO) and/or surgical embolectomy may be used to improve oxygenation, achieve hemodynamic stability, and successfully treat massive PE. Randomized controlled human trials evaluating ECMO in this context have not been done, and its role has not been well-defined. The European Society of Cardiology 2014 acute PE guidelines briefly mention that ECMO can be used for massive PE as a method for hemodynamic support and as an adjunct to surgical embolectomy. The 2016 CHEST Antithrombotic Therapy for venous thromboembolism Disease guidelines do not mention ECMO in the management of massive PE. However, multiple case reports and small series cited benefit with ECMO for massive PE. Further, ECMO may facilitate stabilization for surgical embolectomy. Unfortunately, ECMO requires full anticoagulation to maintain the functionality of the system; hence, significant bleeding complicates its use in 35% of patients. Contraindications to ECMO include high bleeding risk, recent surgery or hemorrhagic stroke, poor baseline functional status, advanced age, neurologic dysfunction, morbid obesity, unrecoverable condition, renal failure, and prolonged cardiopulmonary resuscitation without adequate perfusion of end organs. In this review, we discuss management of massive PE, with an emphasis on the potential role for ECMO and/or surgical embolectomy.

EFFECTIVENESS OF THROMBOLYTIC THERAPY FOR MASSIVE PULMONARY EMBOLISM

Background: Pulmonary embolism (PE) is a common disorder that is associated with significant morbidity and mortality. The primary cause of death in fatal PE is right-sided heart failure. Several randomized, controlled trials comparing thrombolytic therapy with heparin in patients with an acute PE have demonstrated more rapid clot resolution in those treated with thrombolysis. Objective: Study the effectiveness and complications of thrombolytic therapy for massive pulmonary embolism. Patients and Methods: Sixty patients with objectively confirmed massive pulmonary embolism were divided into two equal groups. First group with no contraindication for thrombolytic therapy was treated by (streptokinase or recombinant tissue plasminogen activator) and second group with absolute contraindication for thrombolytic therapy was treated by unfractionated heparin (UFH). Results: CT pulmonary angiography showed that main pulmonary artery embolism was 25%, bilateral saddle shape pulmonary embolism 41.6%, left pulmonary artery embolism 15% and right pulmonary artery embolism 11.6% , and CT was not done in 4 patients because they were unstable. Mortality was high in patients with main pulmonary embolism 13.3%. Mortality was 20% in thrombolytic therapy treated group compared to 50% in heparin treated group and result was statistically significant . Moderate bleeding occurred into left knee in one patient of thrombolytic therapy treated group and mild Hematemesis occurred in one patient of heparin treated group but no mortality occurred due to bleeding. Conclusion: Thrombolytic treatment reduced overall mortality of patients with acute massive PE, and was not associated with major bleeding.

Effect of rivaroxaban on fibrinolytic therapy in massive pulmonary embolism: two cases.

The risk of dying from a pulmonary embolism (PE) is estimated to be about 30% if inotropic support is required and no cardiopulmonary arrest occurs. Fibrinolysis in massive PE is regarded as a life-saving intervention, unless there is a high risk of bleeding following the use of the fibrinolytic therapy. Rivaroxaban is an oral factor Xa inhibitor, however its anticoagulation effects before or after administration of fibrinolytics in massive PE are still unknown. Two patents were admitted: 61-year-old woman with repeated syncope, and a 73-year-old woman was admitted with dyspnea and poor oral intake. Systemic arterial hypotension with radiologic confirmation led to a diagnosis of massive PE in both patients. Rivaroxaban was administered before in one, and after firbrinolytic therapy in the other. One showed similar efficacy of rivaroxaban with currently used anticoagulants after successful fibrinolysis, and the other one without antecedent administration of the fibrinolytic agent showed unfavorable efficacy of rivaroxaban.

Successful thrombolytic therapy for massive pulmonary embolism following abdominoplasty

Successful thrombolytic therapy for massive pulmonary embolism following abdominoplasty

Spontaneous hemothorax following thrombolytic and anticoagulant therapy for massive pulmonary embolism

Massive spontaneous hemothorax following combined thrombolytic and anticoagulant therapy for pulmonary embolism(PE) is a rare event that is little documented in the literature. Here, we describe a rare case of spontaneous hemothorax in a 23-year-old woman with underlying systemic lupus erythematosus following combined administration of tissue plasminogen activator and low-molecular-weight heparin for massive PE. This report of our successful treatment of this case by video-assisted thoracoscopic thoracotomy demonstrates that although the occurrence is rare, massive hemothorax following anticoagulant and/or thrombolytic therapy for PE should be suspected if patients experience chest pain, dyspnea, or signs of anemia, and follow-up physical examination and hemogram should be performed to facilitate diagnosis of this life-threatening complication.

Extracorporeal Membrane Oxygenation As a Bridge Therapy for Massive Pulmonary Embolism After Esophagectomy

Fig 1. The bedside transesophageal echocardiogram at the time of admission to the intensive care unit. The transesophageal echocardiogram showed that the right atrium and the right ventricle were dilated significantly with decreased contractility of the right ventricle.

Inhaled Nitric Oxide as Salvage Therapy in Massive Pulmonary Embolism: A Case Series

Inhaled nitric oxide (INO) has been shown to preferentially lower resistance in the pulmonary vasculature. The relative selectiveness of INO in accomplishing this effect makes it an attractive drug to administer as salvage therapy in patients with acute right ventricular failure secondary to pulmonary embolism. We describe 4 cases in which INO was used as a temporizing agent to decrease right ventricular after-load following massive near-fatal pulmonary embolism. All 4 patients survived to hospital discharge.

Individualization of Thrombolytic Therapy in Massive Pulmonary Embolism

INTRODUCTION: Indications for thrombolytic therapy in massive pulmonary embolism (PE) are controversial given its short-term hemodynamic benefit without demonstrable improvement in mortality. The ACCP recommends thrombolysis in the setting of hemodynamic instability but emphasizes individualization of therapy. We present a case of massive PE successfully treated with thrombolytics for disabling hypoxemia, >2 weeks after symptom onset.

Forearm Compartment Syndrome following Thrombolytic Therapy for Massive Pulmonary Embolism: A Case Report and Review of Literature

Use of thrombolytic therapy in pulmonary embolism is restricted in cases of massive embolism. It achieves faster lysis of the thrombus than the conventional heparin therapy thus reducing the morbidity and mortality associated with PE. The compartment syndrome is a well-documented, potentially lethal complication of thrombolytic therapy and known to occur in the limbs involved for vascular lines or venepunctures. The compartment syndrome in a conscious and well-oriented patient is mainly diagnosed on clinical ground with its classical signs and symptoms like disproportionate pain, tense swollen limb and pain on passive stretch. However these findings may not be appropriately assessed in an unconscious patient and therefore the clinicians should have high index of suspicion in a patient with an acutely swollen tense limb. In such scenarios a prompt orthopaedic opinion should be considered. In this report, we present a case of acute compartment syndrome of the right forearm in a 78 years old male patient following repeated attempts to secure an arterial line for initiating the thrombolytic therapy for the management of massive pulmonary embolism. The patient underwent urgent surgical decompression of the forearm compartments and thus managed to save his limb.

Massive pulmonary embolism in spite of temporary vena caval filter

Anticoagulation still remains the primary therapy for venous thromboembolism (VTE) in order to prevent the most life-threatening form of VTE, pulmonary embolism (PE). Nevertheless in some patients anticoagulation is impossible. Then vena caval filters serve as a valuable second line therapy against the most feared complication of VTE, fatal PE. We want to present a patient with preceding PE and DVT in whom for the perioperative period a temporary vena caval filter was placed and who showed the complication of a nearly fatal PE. A seventy-two year-old white male was admitted for thrombolytic therapy for massive pulmonary embolism, which was performed successfully. Some hours later the patient developed gastrointestinal bleeding. An adenocarcinoma of the colon was diagnosed and an end-to-end hemicolectomy performed. A temporal caval filter (Gunther filter) was placed in the infrarenal vena cava for the perioperative period. Seven days later the patient syncopated with acute massive onset of dyspnea. A helix computertomography scan of the lung showed again massive central pulmonary embolism with right heart enlargement. An immediate pulmonary embolectomy had to be performed. Subsequent venal cavography revealed a thrombosed vena caval filter and a thrombus proximal to the filter. This case report should emphasize the fact that although a vena cava filter might be of high benefit in patients with contraindication for anticoagulation to prevent recurrent PE, in some cases it can be insufficient and lead to enormous complications.

Massive pulmonary embolism – surgical embolectomy provides superior results for early mortality and morbidity compared to thrombolytic therapy

Background: Therapy of massive pulmonary embolism (PE) is still a matter of debate. Aim of this study was to assess outcome and quality of life (QoL) of patients with massive pulmonary embolism treated either by surgical embolectomy (SE) or thrombolytic agent (TA).

Thrombolytic therapy for venous thromboembolism: Current clinical practice

Venous thromboembolism (VTE) is a life-threatening condition for which thrombolytic therapy may be beneficial. The appropriate setting for the use of thrombolytic therapy remains controversial. More than 10 years ago we described the case-based practice patterns for the use of thrombolytics in VTE, and now, in the context of recent studies and guidelines, we sought to reevaluate the use of thrombolytics and to determine whether beliefs have changed. Active pulmonologists in 11 southeastern states were selected to complete a web-based questionnaire that included background questions and hypothetical case scenarios involving VTE and potential treatment with thrombolytics. Eighty-one physicians completed the survey and 84% reported using thrombolytic therapy for VTE within the last 2 years. In the absence of absolute contraindications, 99% of respondents would strongly consider using systemic thrombolytic therapy for massive pulmonary embolism (PE) with hypotension, 83% would strongly consider thrombolysis for a large PE with severe hypoxemia, and 62% would strongly consider thrombolysis for PE with echocardiographic evidence of right ventricular dysfunction. In a patient with massive PE and hypotension with certain contraindications, 91% of respondents would still strongly consider thrombolysis. Most practicing pulmonologists would strongly consider administering thrombolytic therapy for massive PE with hypotension or hypoxemia, and a majority favor thrombolysis for PE in the setting of echocardiographic evidence of right heart dysfunction. Despite the evolving data and guidelines for the management of VTE, our findings are similar to prior survey results, emphasizing the need for further physician education and future randomized trials to clarify the therapy for this potentially deadly condition.

Abstract No. 10: Catheter-Directed Therapy for Massive Pulmonary Embolism: Systematic Review & Meta-Analysis of the Modern Technique

The use of systemic thrombolysis carries a 5% risk of major hemorrhage including a 0.5-1% risk of hemorrhagic stroke. We used evidence-based methods to evaluate the safety and efficacy of modern catheter-directed therapy (CDT), as a potential alternative treatment to systemic thrombolysis, in patients with massive PE.

Thrombolytic Therapy for Massive Pulmonary Embolism in a Patient With a Known Intracranial Tumor

The objective was to describe and review the use of thrombolytic therapy in a patient with an intracranial tumor and massive pulmonary embolism. This is the first reported case of a patient with a known glioblastoma multiforme and massive pulmonary embolism who was successfully treated with alteplase. Pulmonary embolism was demonstrated by a ventilation-perfusion scan and transthoracic echocardiogram with repeat studies demonstrating resolution of the thromboembolism and reperfusion of pulmonary vasculature. A review of the literature revealed that the incidence of intracranial hemorrhage with thrombolysis is <3% and compares favorably with the much higher mortality rate of 25% to >/=50% in patients with hemodynamically unstable pulmonary emboli. The benefit of thrombolysis may outweigh the risks of intracranial hemorrhage in these patients, and careful consideration for its use in these patients is warranted.

The use of sildenafil in the therapy of massive pulmonary embolism

The use of sildenafil in the therapy of massive pulmonary embolism