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PubMed1988

Incidence and cardiac effects of systemic venous air embolism. Echocardiographic evidence of arterial embolization via noncardiac shunt.

Central nervous system dysfunction in venous air embolism may result from air entering the arterial circulation. Using two-dimensional and pulsed-wave Doppler echocardiography, this study not only documented the frequent presence of air in the right heart chambers of patients undergoing upright neurosurgery or pacemaker insertion, but also documented the presence of air in the left atrium and left ventricle of one patient via noncardiac shunt. Studies in dogs confirmed paradoxical air embolism in the absence of anatomic communications between right and left heart chambers. Systemic venous air also produced a dose-dependent increase in pulmonary artery pressure and diastolic flattening of the ventricular septum with increase in left ventricular filling pressure despite preserved systolic function.

Aged↗
PubMed1982

[Study of principles in pathogenesis and therapy of fat embolism. IV. In vivo studies of drug-induced mobilization of embolized lung fat].

Pluronic F 108 added to serum in a concentration of 1 g/dl proved as the optimal means to increase the fat emulgatory capacity. Similar concentrations were achieved in living rabbits by infusing 4.5 g per kg body weight. In spite of this higher dosage we failed to mobilize 131 J labelled fat, embolized into the lungs of the animals. It is concluded that also in humans there exists no possibility to mobilize fat emboli from the lungs by the application of tensides (non-ionic detergents, lecithin-preparations, bile salts) or of organic solvents (alcohol, ether). All these agents are capable to emulsify fat in vitro, however, only under vigorous shaking.--Because of the side effects of those agents their application on patients, suffering from posttraumatic fat embolism seems not to be justified.

Animals↗
PubMed1994

[Systemic embolism and aortic atheroma. Contribution of transesophageal echography. Apropos of a case of systemic embolism caused by cholesterol crystals].

Systemic embolisms involving cholesterol crystals sometimes occur following vascular catheterization and may be responsible for a variety of clinical signs. The authors report a case in which the etiological diagnosis included a transesophageal echography (TEE) which revealed atheromatous plaques on the thoracic aorta which were probably responsible for the projections. It is possible that episodes of embolism, either fibrinocruoric or due to the release of cholesterol crystals, arising from the thoracic aorta, have hitherto been underestimated by imaging methods such as scans and angiographs. Further studies with TEE may make it possible to estimate the extent of this disorder.

Aged↗
PubMed1997

[Pulmonary embolism and cerebral stroke from paradoxical embolism in a young woman].

We describe a case of pulmonary embolism and ischemic stroke due to paradoxical embolism in a healthy young woman taking oral contraceptives to treat an ovarian cyst. It was not possible to identify the site of the thromboembolus. Ultrasound techniques played an important role in identifying the peripheral arterial obstructions and in diagnosing acute pulmonary hypertension. Transesophageal echocardiography provided detailed information on both the morphology and the evolution of the atrial thrombus straddling the foramen ovale within the aneurysmal interatrial septum. The patient was given anticoagulant treatment, initially with heparin and subsequently with warfarin over a period of six months. Repeated ultrasound controls showed no thrombus, regression of the signs of pulmonary hypertension and, lastly unchanged systemic arterial obstruction.

Adult↗
PubMed1994

[Possible lung embolism following embolization of a hemangioma with fibrin glue].

More than 50% of all congenital haemangiomas are located on the head and neck. Because most orofacial haemangiomas exhibit the tendency to grow rapidly, they are often treated by embolisation and excision. CASE REPORT. The case of a 5-year-old patient is presented, who was admitted to the hospital for embolisation and immediate surgery of a haemangioma of the right side of the face and upper lip. After the injection of 2 ml fibrin glue she suddenly developed hypotension, tachycardia, a low oxygen saturation, and a low end-tidal carbon dioxide partial pressure. There was no failure of the breathing circuit and no airway obstruction could be found. Most likely these symptoms were due to transport of the fibrin glue from the haemangioma into pulmonary vessels. The therapy included the administration of heparin and antihypotensive drugs. After stabilisation, the patient was transferred to the intensive care unit for 1 day without further complications. CONCLUSION. Pulmonary embolism after injection of fibrin glue into an orofacial haemangioma has not previously been reported, but it should be considered that systemic complications can occur after injecting substances for embolisation into vessel-rich tissues.

Child↗
PubMed1995

Spontaneous closure of a patent foramen ovale and disappearance of impending paradoxical embolism after fibrinolytic therapy in the course of massive pulmonary embolism.

Our case suggests that a negative transesophageal contrast echocardiographic study during stable hemodynamic conditions does not definitively rule out the possibility of a functional PFO with transient right-to-left shunting in situations of increased right heart pressures. In addition, we confirm that thrombolysis can be considered as an alternative to surgery in high-risk patients with impending paradoxical embolism. The risk-to-benefit ratio of this choice, however, should be individually evaluated.

Echocardiography, Transesophageal↗
PubMed2003

Recent developments in diagnostic imaging techniques and management for acute pulmonary embolism: multicenter registry by the Japanese Society of Pulmonary Embolism Research.

OBJECTIVE: There are many reports on the diagnosis and management of acute pulmonary embolism (APE), but there have been no investigations concerning the actual conditions in which recent developments in diagnostic imaging techniques and therapies have been applied in clinical practice. The present study was designed to investigate the changes in diagnostic imaging techniques and therapies for APE. METHODS AND PATIENTS: Three hundred and nine APE patients diagnosed during January 1994-October 1997 (Group 1) were compared with 257 APE patients diagnosed during November 1997-October 2000 (Group 2) in terms of the diagnostic imaging techniques and therapies for APE. RESULTS: Compared with Group 1, pulmonary angiography and contrast-enhanced computed tomography were more frequently performed for diagnosis in Group 2 [45.3% vs 56.8% (p = 0.0069) and 13.9% vs 57.6% (p < 0.0001), respectively]. Heparin and vena cava filter were used more often in Group 2 [74.4% vs 82.1% (p = 0.033) and 18.4% vs 33.9% (p < 0.0001), respectively]. The frequency of thrombolytic therapy was unchanged between the two groups. Warfarin use in discharged patients increased from 71.9% to 83.8% (p = 0.0022). However, the examination rates for deep vein thrombosis (DVT) were low (60.8% in Group 1 and 65.4% in Group 2, p = 0.29) and unchanged using any imaging techniques. CONCLUSION: The diagnostic imaging techniques for APE increased in variety and the management has improved, while the diagnosis for DVT remains unchanged.

Acute Disease↗
PubMed1995

[Aneurysm of the interatrial septum with atrial septal defect, disclosed by pulmonary embolism complicated by paradoxical embolism].

The authors report the case of a patient admitted to hospital for bilateral phlebitis of the lower limbs, associated with an atrial septal defect. The presence of significant pulmonary hypertension accounted for the paradoxical embolism by inversion of the intracardiac shunt. No recurrence has been observed with a follow-up of six months on anticoagulant treatment.

Embolism↗
PubMed1989

Pulmonary embolism and cancer: predisposition to venous thrombosis and embolism as a paraneoplastic syndrome.

In patients with a malignant primary disease the risk of thromboembolic complication is demonstrably increased. This is undoubtedly attributable to a whole range of factors (multifactorial etiology) which are highlighted in the present synoptic study. In addition to local influences from the tumor, a particular role appears to be played by an increased aggregation of thrombocytes, various tumor cell products, polyglobulism, hypercalcemia, increased release of thrombocinase, microthrombotic embolization, and a decrease in antithrombin III.

Humans↗
PubMed1998

Pulmonary embolism exclusion: a practical approach to low probability using the PIOPED data. Prospective Investigation of Pulmonary Embolism Diagnosis.

A recent trend among physicians is the categorisation of lung scans as normal [excludes pulmonary embolism (PE)], high probability (confirms PE) and non-diagnostic (no judgement on PE risk). The low probability scan is therefore being eliminated as a functional category. This occasional survey contends that such an approach is misguided. Correction of the original PIOPED data with certain assumptions provides a more reproducible, albeit restricted, low probability scan category which excludes PE in 97% of cases in the low pre-test clinical category. Patients with a low probability scan with risk factors for PE (i.e. medium clinical risk) will require further investigation. More important, the very low probability scan category excludes PE in 98% of patients with low and more than 92% of patients with medium pre-test clinical likelihood. The demise of "low probability" is premature.

Bayes Theorem↗
PubMed2003

The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids.

OBJECTIVE: To evaluate fibroid uterine volume reduction, symptom relief, and patient satisfaction with uterine artery embolization (UAE) for symptomatic fibroids. DESIGN: Multicenter, prospective, single-arm clinical treatment trial. SETTING: Eight Ontario university and community hospitals. Five hundred thirty-eight patients undergoing bilateral UAE. INTERVENTION(S): Bilateral UAE performed with polyvinyl alcohol particles sized 355-500 microm. MAIN OUTCOME MEASURE(S): Three-month follow-up evaluations including fibroid uterine volume reductions, patient reported symptom improvement (7-point scale), symptom life-impact (10-point scale) reduction, and treatment satisfaction (6-point scale). RESULT(S): Median uterine and dominant fibroid volume reductions were 35% and 42%, respectively. Significant improvements were reported for menorrhagia (83%), dysmenorrhea (77%), and urinary frequency/urgency (86%). Mean menstrual duration was significantly reduced after UAE (7.6 to 5.4 days). Improvements in menorrhagia were unrelated to pre-UAE uterine size or post-UAE uterine volume reduction. Amenorrhea occurring after the procedure was highly age dependent, ranging from 3% (1%-7%) in women under age 40 to 41% (26%-58%) in women age 50 or older. Median fibroid life-impact scores were significantly reduced after UAE (8.0 to 3.0). The majority (91%) expressed satisfaction with UAE treatment. CONCLUSION(S): UAE reduced fibroid uterine volume and provided significant relief of menorrhagia that was unrelated to initial fibroid uterine size or volume reduction. Patient satisfaction with short-term UAE treatment outcomes was high.

Adult↗
PubMed2001

Pulmonary embolism with ST segment elevation in leads V1 to V4: case report and review of the literature regarding electrocardiographic changes in acute pulmonary embolism.

A 62-year-old man presented to the Emergency Department (ED) after having three short syncopal episodes earlier that day soon after experiencing acute onset of shortness of breath. He had no significant past medical history and was a nonsmoker. Initially in the Emergency Department he was without any complaints, but then became acutely short of breath and hemodynamically unstable and died despite resuscitative efforts. His electrocardiogram showed ST segment elevations in leads V1 to V4, which is consistent with an anteroseptal myocardial infarction. Autopsy revealed that this patient did not have a myocardial infarction, but rather died of a pulmonary embolism (PE). This case demonstrates how a PE can mimic an anteroseptal myocardial infarction on electrocardiogram. This patient's lack of risk factors for PE also makes this case unusual.

Electrocardiography↗
PubMedDate not supplied

Lung scan in the diagnosis and management of patent foramen ovale pulmonary embolism, paradoxical embolism.

This case illustrates the reopening of foramen ovale in a young patient with chronic pulmonary hypertension caused by bronchiectasis and chronic pulmonary fibrosis, which resulted in a prominent right-to-left shunt and severe hypoxia. Her clinically unsuspected right-to-left shunt was discovered during ventilation-perfusion scan, which was performed for the evaluation of pulmonary embolism. She had common variable immune deficiency, a primary immunodeficiency disease in which B-lymphocytes produce few or no antibodies. Most patients with this syndrome have an intrinsic defect in their B-lymphocytes that results in reduced immunoglobulin production. In these patients, recurrent respiratory tract infections are common and may result in chronic lung disease, fibrosis, particularly bronchiectasis (20-30%) and even cor pulmonale as happened in our patient [J. Clin. Immunol. 9 (1989) 22-33.].

Adult↗
PubMed1997

Fibrinogenolysis and thrombin generation after reduced dose bolus or conventional rt-PA for pulmonary embolism. The Coagulation Project Investigators of the Bolus Alteplase Pulmonary Embolism Group.

The aim of this study was to compare the effects on fibrinogenolysis and thrombin generation of two recombinant tissue-type plasminogen activator (rt-PA) regimens in patients with pulmonary embolism entering a randomised, controlled study with a 1:2 allocation ratio to rt-PA, 100 mg over 2 h (Group A) or rt-PA, 0.6 mg/kg, maximum dose 50 mg, over 15 min (Group B). In both groups the heparin infusion was stopped 2-4 h before starting thrombolytic treatment and resumed accordingly to the activated partial thromboplastin time (aPTT) or thrombin clotting time (TcT). Seventeen patients in Group A and 30 patients in Group B were evaluated before starting thrombolytic treatment and 2, 6 and 24 h after its end for the following parameters: aPTT, TcT, fibrinogen, fibrinogen degradation products (FDP), plasmin-alpha 2 antiplasmin (PAP) and thrombin-antithrombin III (TAT) complexes. The two groups had similar coagulation parameters at baseline. Two h after starting rt-PA, the aPTT was more prolonged in Group A than in Group B patients (P = 0.01). Patients in Group B showed less reduction in plasma fibrinogen levels at all study times after rt-PA treatment (P = 0.008). The increase in plasma FDP (P = 0.037) and PAP (P = 0.001) levels was lower at 2 and 6 h samples in Group B compared with Group A. TcT was prolonged (P = 0.003) and TAT increased (P = 0.001) during treatment without differences between the two groups. AUC0-24 of fibrinogen, FDP and PAP levels confirmed the statistically significant differences (P = 0.04) between the two groups over the entire 24 h period of the study. Three patients in Group A (17.6%) and three (10.0%) in Group B suffered major or other important bleeding. Our results indicate that the administration of weight-adjusted reduced-dose rt-PA bolus produces less impairment of blood coagulation than the FDA approved regimen.

Adult↗
PubMed2006

Pulmonary embolism: accuracy and safety of a negative CT pulmonary angiogram and value of a negative D-dimer assay to exclude CT pulmonary angiogram-detectable pulmonary embolism.

This is a retrospective study to determine the accuracy and safety of a negative CT pulmonary angiogram (CTPA) based on clinical outcome and to determine the usefulness of a negative D-dimer assay before CTPA. A total of 483 patients with a negative CTPA study were followed up for 3 months, with the aim of detecting episodes of venous thromboembolism and mortality. Three hundred and forty-nine patients had an immunochromatographic D-dimer assay called 'Simplify', carried out before a CTPA examination. Seventy-eight patients had a negative D-dimer assay and a negative CTPA. Three patients had a negative D-dimer assay and a positive CTPA. All three patients had a moderate pretest clinical probability. Of the 483 patients who had a negative CTPA and a 3-month follow up, 444 (92%) were alive and 39 (8%) had died. Of the 444 patients who were alive, none had any further suspected episode of thromboembolism or had received anticoagulation therapy within the follow-up period. Of those who died, none of the deaths was thought to be as a result of pulmonary embolism (PE). Single-detector helical CT can be used safely as the primary diagnostic test to evaluate PE. Negative Simplify D-dimer assay and low pretest clinical probability exclude CTPA-detectable PE, and a CTPA is unnecessary in this cohort of patients.

Adult↗
PubMed2006

Investigating pulmonary embolism in the emergency department with lower limb plethysmography: the Manchester Investigation of Pulmonary Embolism Diagnosis (MIOPED) study.

OBJECTIVES: To measure the diagnostic accuracy of computerised strain gauge plethysmography in the diagnosis of pulmonary embolism (PE). METHODS: Two researchers prospectively recruited 425 patients with pleuritic chest pain presenting to the emergency department (ED). Lower limb computerised strain gauge plethysmography was performed in the ED. All patients underwent an independent reference standard diagnostic algorithm to establish the presence or absence of PE. A low modified Wells' clinical probability combined with a normal D-dimer excluded PE. All others required diagnostic imaging with PIOPED interpreted ventilation perfusion scanning and/or computerised tomography (CT) pulmonary angiography. Patients with a nondiagnostic CT had digital subtraction pulmonary angiography. All patients were followed up clinically for 3 months. RESULTS: The sensitivity of computerised strain gauge plethysmography was 33.3% (95% confidence interval (CI) 16.3 to 56.2%) and specificity 64.1% (95% CI 59.0 to 68.8%). The negative likelihood ratio was 1.04 (95% CI 0.68 to 1.33) and positive likelihood ratio 0.93 (95% CI 0.45 to 1.60). CONCLUSIONS: Lower limb computerised strain gauge plethysmography does not aid in the diagnosis of PE.

Adult↗
PubMed2000

Suspected pulmonary embolism: prevalence and anatomic distribution in 487 consecutive patients. Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism (ANTELOPE) Group.

PURPOSE: To evaluate the prevalence and anatomic distribution of pulmonary embolism (PE) in a group of consecutive patients clinically suspected of having PE. MATERIALS AND METHODS: Four hundred eighty-seven consecutive patients clinically suspected of having PE were examined in six Dutch hospitals from May 1997 through March 1998. Patients underwent ventilation-perfusion (V-P) scintigraphy, spiral computed tomographic (CT) angiography, and/or digital subtraction pulmonary angiography according to a strict diagnostic protocol. Independent readers reviewed all of the diagnostic image studies in centralized readings. The largest pulmonary arterial branch in which PE was detected was recorded. RESULTS: The prevalence of PE was 27% (130 of 487 patients). There was a significant difference in PE size between the high-probability and nondiagnostic V-P scans: The high-probability scans tended to depict larger emboli, but they also showed small subsegmental emboli. Twenty-nine (22%) of 130 patients had subsegmental PE; 23 of these 29 patients had a high-probability V-P scan. CONCLUSION: The largest pulmonary arterial branch with PE was central or lobar in 66 (51%), segmental in 35 (27%), and isolated subsegmental in 29 (22%) patients.

Adult↗