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At least 595 records · Page 33Linked to original sources
PubMed2001

The clinical relevance of embolic events detected by transesophageal echocardiography during cemented total hip arthroplasty: a randomized clinical trial.

UNLABELLED: The first aim of this prospective clinical study was to characterize the relationship between embolic events observed during cemented total hip arthroplasty using transesophageal echocardiography (TEE), and changes in cardiopulmonary function. The second aim was to assess the efficiency of a modified cementing technique that was developed to reduce the risk of embolism. The modification consists in a vacuum drainage placed in the proximal femur to reduce the increase of intramedullary pressure during insertion of the prosthesis. One hundred twenty patients were randomized into two groups. Group 1 received a total hip arthroplasty cemented conventionally, whereas Group 2 was cemented with the modified technique. Continuous TEE, hemodynamic monitoring, and blood gas analysis were done during the perioperative period. Severe embolic events were imaged during the insertion of the femoral component and the reduction of the hip joint. Embolism occurred in 93.3% of patients operated on with the conventional cementing technique, compared with 13.3% of patients operated on with the modified technique (P < 0.05). Intraoperative shunt values during insertion of the femoral component increased from 8.2% to 10.3% (P < 0.05) in Group 1 patients, whereas there was no significant change in Group 2 patients. We observed no clinical signs of fat embolism syndrome in any study patient. The results of the study indicate that embolic events observed using TEE can cause increased pulmonary shunt values during hip arthroplasty, especially in patients with systemic disease (ASA physical status III). The modified surgical technique effectively reduced the incidence of embolization during cemented hip arthroplasty. IMPLICATIONS: Use of conventional cementing techniques is associated with echocardiographic evidence of embolism in 93% of patients and with a significant increase in pulmonary shunting. The incidence of embolism and change in shunting are reduced with a modified cementing technique that limits increases in intramedullary pressure.

Aged↗
PubMed2002

Paradoxical air embolism from patent foramen ovale in scoliosis surgery.

STUDY DESIGN: A case was reported in which paradoxical air embolism arose from the patent foramen ovale in scoliosis surgery. OBJECTIVES: To present a case of suspected paradoxical air embolism after scoliosis surgery. SUMMARY OF BACKGROUND DATA: Embolic accident during scoliosis surgery may be caused by air, thrombus, or fat. There is growing attention on patent foramen ovale involved in paradoxical embolism. The devastating consequences are caused by multiple artery occlusions. METHODS: Details of a recent documented neurologic complication (paraplegia, weakness of right arm, and blurry vision) after scoliosis surgery have been analyzed in medical publications. RESULTS: The surgical procedure was not imputed. The causative role of epidural catheter for analgesia was considered, but it is likely that a paradoxical embolism occurred in this case, based on the multifocal (cerebral and spinal) neurologic dysfunction, the evidence of cerebral ischemia (on computed tomography), and the presence of a patent foramen ovale (on postoperative transesophageal echocardiography). Although no intraoperative embolism detection was available, air embolism was highly suspected because there was no absolute argument to exclude cruor or fatty embolism. CONCLUSIONS: It is critical to detect a patent foramen ovale before surgery and cerebral embolization intraoperatively. This might permit ascertainment of the etiologic diagnosis in case of a complication in surgery for scoliosis.

Arthrodesis↗
PubMed1994

Sudden maternal deaths probably due to obstetrical pulmonary embolism in Malaysia for 1991.

Obstetric pulmonary embolism forms the most serious vascular problem during pregnancy. The following report is a retrospective study into maternal deaths in Malaysian mothers probably due to obstetrical pulmonary embolism. Obstetric pulmonary embolism can be divided into amniotic fluid embolism and obstetric blood clot embolism. There were 37 maternal deaths attributable to this cause -9.9 per cent of all maternal deaths to blood clot embolism and 6.7 per cent to amniotic fluid embolism. Most cases were diagnosed clinically because a postmortem examination was not done. Eleven cases of embolism were associated with Caesarean delivery. The typical profile of a Malaysian mother dying from obstetrical pulmonary embolism is that of a Malay mother in the "non-risk" parities of one to four and usually aged between 31-35 years. In the management of these patients, there should be an urgency in diagnosis and improvement in diagnostic procedures. Health staff at all levels should be trained to pick up patients who present with features of deep vein thrombosis.

Adult↗
PubMed1994

Echocardiographic diagnosis of paradoxical embolism and the potential for right to left shunting.

Echocardiographic techniques are useful in establishing the presumptive clinical diagnosis of paradoxical embolism. Once a clinical diagnosis of systemic embolism has been established and a potential systemic venous source for embolic material has been diagnosed, echocardiographic (and particularly transesophageal echocardiographic techniques) can readily establish the presence or absence of an intracardiac communication and can help define the potential for right to left shunting across that communication (using saline contrast techniques). Except for the rare circumstance where echocardiography has been used to actually image paradoxical embolization in progress (such as may occur during intraoperative monitoring), the technique can only show the potential for such a mechanism for systemic embolization. Because patency of the foramen ovale is a common anatomic variant (occurring in approximately 25% of subjects) and transesophageal contrast echocardiography will show at least transient right to left shunting in most patients with patent foramen ovale, a mechanistic relationship between such findings and the occurrence of a systemic embolic event cannot be immediately inferred. Clinical assessment of alternative mechanisms for systemic embolization is required to judge the likelihood that the potential for paradoxical embolization is, in fact, the cause for systemic embolism in a given patient.

Cardiomyopathies↗
PubMed1997

[Fat embolism--a too infrequently determined pathoanatomic diagnosis].

In 1993, pulmonary fat embolism occurred in 92 cases (17%) out of 527 clinical autopsies. It was found in 62% of patients who had suffered bone fractures, in 9% with soft tissue surgery and in 53% after resuscitation; non-traumatic fat embolism was present in 6% of the cases. The comparison group of 50 persons with lethal polytrauma revealed pulmonary fat embolism in 52% of the cases. Bone-marrow embolism and microthrombi accompanied fat embolism of the lungs; furthermore some of the persons with pulmonary fat embolism also expressed minor degrees of renal (55%) and cerebral (25%) fat emboli. A retrospective analysis of the clinical data revealed no specific symptoms: a so called fat embolism syndrome had not been discovered clinically in any of the cases with histologically proven fat embolism. The significance of pulmonary fat embolism as a cause of death with regard to histological and clinical findings is discussed.

Cause of Death↗
PubMed2003

Does this patient have pulmonary embolism?

CONTEXT: Experienced clinicians' gestalt is useful in estimating the pretest probability for pulmonary embolism and is complementary to diagnostic testing, such as lung scanning. However, it is unclear whether recently developed clinical prediction rules, using explicit features of clinical examination, are comparable with clinicians' gestalt. If so, clinical prediction rules would be powerful tools because they could be used by less-experienced health care professionals to simplify the diagnosis of pulmonary embolism. Recent studies have shown that the combination of a low pretest probability (using a clinical prediction rule) and a normal result of a D-dimer test reliably excludes pulmonary embolism without the need for further testing. OBJECTIVE: To evaluate and demonstrate the accuracy of pretest probability assessment for pulmonary embolism using clinical gestalt vs clinical prediction rules. DATA SOURCES: The MEDLINE database was searched for relevant articles published between 1966 and March 2003. Bibliographies of pertinent articles also were scanned for suitable articles. STUDY SELECTION: To be included in the analysis, studies were required to have consecutive, unselected patients enrolled; participating physicians in the studies, blinded to the results of diagnostic testing, had to estimate pretest probability of pulmonary embolism; and validated diagnostic methods had to be used to confirm or exclude pulmonary embolism. DATA EXTRACTION: Three reviewers independently scanned titles and abstracts for inclusion of studies. An initial MEDLINE search identified 1709 studies, of which 16 involving 8306 patients were included in the final analysis. DATA SYNTHESIS: A clinical gestalt strategy was used in 7 studies, and in the low, moderate, and high pretest categories, the rates of pulmonary embolism ranged from 8% to 19%, 26% to 47%, and 46% to 91%, respectively. Clinical prediction rules were used in 10 studies, and 3% to 28%, 16% to 46%, and 38% to 98% in the low, moderate, and high pretest probability groups, respectively, had pulmonary embolism. CONCLUSIONS: The clinical gestalt of experienced clinicians and the clinical prediction rules used by physicians of varying experience have shown similar accuracy in discriminating among patients who have a low, moderate, or high pretest probability of pulmonary embolism. We advocate the use of a clinical prediction rule because it has shown to be accurate and can be used by less-experienced clinicians.

Adult↗
PubMed1990

Systemic heparinization does not prevent clot formation in coil embolization.

Therapeutic transcatheter closure with Gianturco-type steel coils has been applied to a variety of vascular communications in children with congenital heart disease. Vessel closure depends upon successful thrombus formation around the coil. Since systemic anticoagulation with heparin is commonly used during catheterization and cardiac surgery, we studied the effect of systemic heparinization on the efficiency of vessel occlusion by coil embolization in lambs. Catheters inserted in femoral arteries were used to arteriographically locate and size 36 systemic arteries in 9 lambs weighing 4.2 to 7.4 kg. Twenty-four vessels were embolized prior to heparinization with 400 u/kg heparin, IV. Effective anticoagulation was demonstrated by post-heparin activated clotting time (ACT) values greater than 300 sec. Seven vessels (29%) were not successfully coil-embolized because of inadequate coil position or distant embolization of the coil; 17 (71%) of these vessels were shown to be successfully occluded by arteriography 6 to 77 min later. After a period of systemic heparinization ranging from 71 to 159 min, 9/17 arteries remained occluded, 7/17 could not be examined arteriographically due to early demise of the animal, and only 1/17 showed recanalization. A second group of 12 vessels were embolized after heparinization. Eight (75%) were successfully occluded, and 4 (25%) were not successfully coil-embolized because of inadequate coil position or coil embolization to distant arteries. We conclude that systemic heparinization had no measurable effect on occlusion rates in coil-embolized systemic arteries in the lamb. These data support the use of systemic heparinization, when indicated, during or following therapeutic coil embolization in children.

Animals↗
PubMed2002

Long-term follow-up of patients with giant cell tumor of the sacrum treated with selective arterial embolization.

BACKGROUND: Giant cell tumors of the bone can behave as aggressive and sometimes lethal tumors. In the sacrum, the tumor can be extremely difficult to manage. Standard treatments, including surgery and radiation, are associated with significant complications and recurrence rates. The goal of this study is to evaluate the long-term outcome of selective arterial embolization as an alternative treatment modality. METHODS: From 1975 to 2001, 18 patients were treated with selective intraarterial embolization. The embolization method was a combination of Gelfoam particles and coils for peripheral and central occlusions, respectively. The number of embolizations was based on clinical symptoms, radiographic response, and the vascularity of the tumor. Nine patients received intraarterial cisplatin as part of their treatment. The median follow-up was 105 months. RESULTS: Of 18 patients, 14 responded favorably to embolization with improvement in pain and neurologic symptoms. Computed tomographic and magnetic resonance imaging scans showed reossification and stabilization of tumor size. Arteriograms showed diminished vascularity. With long-term follow-up, three patients developed late disease recurrences within the sacrum. Kaplan-Meier analysis showed that the risk of local recurrence is 31% at 10 years and 43% at 15 and 20 years. The long-term outcome was not affected by intraarterial cisplatin. There was one death that occurred 1 day after embolization. CONCLUSIONS: Most patients demonstrate an objective early radiographic response to embolization. Long-term follow-up shows that the response is durable in approximately one half of the patients. Given the potential morbidity of other treatments, embolization should be included in the armamentarium of treatment for this difficult disease. Embolization may be used alone or in conjunction with other therapy. Long-term follow-up is recommended for all patients because late disease recurrence or sarcomatous change can occur.

Adolescent↗
PubMedDate not supplied

Malignant insulinoma: permanent hepatic artery embolization of liver metastases--preliminary results.

PURPOSE: To evaluate permanent hepatic artery embolization of liver metastases of malignant insulinoma as a therapeutic procedure. METHODS: Three female patients had persistent severe hypoglycemia after distal pancreatectomy because of a malignant insulinoma. Computed tomography (CT) and CT-portography (CTAP) were used for tumor assessment and follow-up and demonstrated multiple hypervascular metastases 0.5-3 cm in diameter in both lobes of the liver. Unilobar sequential transcatheter embolization of the hepatic artery was performed with an interval of 1-2 months between the procedures. Permanent occlusion was achieved by using a mixture of n-butyl-2-cyanoacrylate and ethiodized oil as an embolizing agent. RESULTS: In all patients, embolization of the hepatic artery was technically feasible and complete occlusion could be obtained. In two patients, collaterals originating from the right inferior phrenic artery were embolized superselectively 3 months after bilobar embolization. CTAP at that time revealed marked decrease in tumor size of more than 50%. All patients responded to the treatment as confirmed by normalization of measurable hormone levels, glucose levels, and disappearance of symptoms. Two patients are still alive after 24 and 31 months from the time of the first embolization. Current investigations revealed normal laboratory data and no further tumor progression in the liver. The third patient died 15 months after the first embolization; she also had developed ileus due to local recurrence of the primary tumor and lymph node metastases. CONCLUSION: Hepatic arterial embolization appears to be an effective means of palliation for liver metastases of malignant insulinoma. Long-term improvement seems most likely to be the result of extensive ischemia from permanent occlusion.

Embolization, Therapeutic↗
PubMed2002

Percutaneous transluminal embolization with coils-treatment of pulmonary arteriovenous malformations.

The clinical values of coils embolization in the treatment of pulmonary arteriovenous malformations (PAVM) and related complications were investigated. Eleven patients with PAVMs verified by pulmonary arterial angiography were treated by transcatheter coils embolization. Chest X-ray (11 cases), computer tomography (7 cases) and/or magnetic resonance imaging (2 cases) were performed before embolization. Blood-gas analysis was done in 5 cases before and after embolization. The follow-up materials of 8 patients were collected to evaluate the effect of embolization with coils. The clinical manifestations included cerebral embolus, hemoptysis and decreased oxygenation in 9 patients and the remaining 2 had no symptoms. 9/11 cases were found by chest X-ray and 8 were diagnosed definitely. 7/7, 2/2 cases were diagnosed by CT or MR and diagnosis was made in all cases. Embolization was performed in 29 vessels. Partial pressure of oxygen in arterial blood of 5 cases changed significantly before and after embolization. Slight complications occurred in 6 patients, such as low fever, chest pain, pleurisy. The follow-up results showed that 7 cases were cured effectively. No primary and secondary device migration, and no medical paradoxical embolization occurred. It was concluded that coils embolization is a well-established method for treating PAVMs. It is a minimally invasive lung preserving treatment with high efficiency and less complication.

Adolescent↗
PubMed2003

[Technique and methods in uterine leiomyoma embolization].

OBJECTIVE: Uterine leiomyomas are the most common benign tumors of the female urogenital tract. Beside the classic surgical treatment options the minimal-invasive embolization therapy of the leiomyomas increasingly gains importance world-wide. Technique, complications, and results of uterine leiomyoma embolization will be presented. METHODS: After careful evaluation of indications for embolization the procedure is mostly performed under conscious sedation. A single-sided femoral access route together with cross-over technique generally allows for a flow-directed embolization via both uterine arteries. After embolizing the vessels supplying the tumor, the uterine arteries should be still patent. RESULTS: The success rate of embolization of uterine leiomyomas ranges between 85 and 100%, whereas a reduction in size of the tumors in 42 to 83% and a relief of symptoms in up to 96% can be achieved. The total complication rate is about 10% with mainly "minor complications". Worldwide only three deaths following embolization of uterine leiomyomas were reported. CONCLUSION: The high technical and clinical success rate together with a low complication rate make the embolization of uterine leiomyomas a minimally-invasive alternative to the classic treatment. As long term results are not available indication to embolization of uterine leiomyomas must be carefully established in consensus with gynecologists.

Adult↗
PubMedDate not supplied

Microcatheter embolization of intractable idiopathic epistaxis.

PURPOSE: To assess the efficacy and safety of microcatheter embolization in the treatment of intractable idiopathic epistaxis. METHODS: Thirty-seven patients underwent microcatheter embolization in 1991-1998. We evaluated retrospectively the technical and clinical outcome, the number of complications, the duration of embolization in each case, and the number of blood transfusions needed. All embolizations were done with biplane digital subtraction angiography (DSA) equipment. The procedure was carried out under local anesthesia using transfemoral catheterization, except in one case where the translumbar route was used. Tracker 18 or 10 microcatheters were advanced as far as possible to the distal branches of the sphenopalatine artery. Polyvinyl alcohol (PVA) particles were used for embolization in most cases, while platinum coils or a combination of these two materials were occasionally used. The primary outcome was always assessed immediately by angiography. Follow-up data were obtained from patient records, by interviewing patients on the telephone or by postal questionnaires when necessary. The mean follow-up time was 21 months. RESULTS: The embolization was technically successful in all 37 cases. A curative outcome was achieved in 33 cases (89%). The mean duration of the procedure was 110 min. Four patients (8%) had mild transient complications, but no severe or persistent complications were encountered. Twenty-three patients needed a blood transfusion. Slight rebleeding occurred in three patients during the follow-up; all responded to conservative treatment. One patient suffered two episodes of rebleeding within 2 months after primary embolization. Re-embolizations successfully stopped the bleeding. CONCLUSION: Embolization is the primary invasive modality for treating intractable idiopathic epistaxis. It proved both safe and effective over a relatively long follow-up.

Angiography, Digital Subtraction↗
PubMed2006

Atrial fibrillation - patients at high risk for cerebral embolism.

OBJECTIVE: Patients with atrial fibrillation (AF) have a risk of cerebral embolism. Echocardiographic parameters elevate this risk significantly. However, there is little knowledge about the long-term fate and the rate of clinically silent cerebral embolism under continued oral anticoagulation. The aims of our study were to assess prognosis of patients with AF and determine a high risk group with an increased risk of cerebral embolism under oral anticoagulation. METHODS: Consecutive patients with persistent or permanent AF and left atrial (LA) thrombi, dense spontaneous echo contrast (SEC) and/or reduced LA appendage peak emptying velocities (LAAv) were included in the study (N = 128). Patients with AF and without echocardiographic risk factors (N = 114) served as controls. All patients were examined with transesophageal echocardiography, cranial magnetic resonance imaging and clinically during a period of three years. RESULTS: During the three-year follow-up period 6 (5%) of the high risk patients had cerebral embolism with neurological deficits. 4 (3%) patients died due to embolic events and 17 (13%) patients had silent embolism as documented on MRI. In the control group 8 (7%) patients had embolic events (n = 1 clinically apparent and n = 7 silent embolism) documented on MRI, one was clinically apparent. Study patients with an event had more commonly previous thromboembolism (p < 0.0001). CONCLUSIONS: Patients with peristent or permanent AF and LA thrombi, dense SEC or reduced LAAv have an explicitly increased risk of cerebral embolism (21%) despite oral anticoagulation. Previous thromboembolic event is another important predictor for an event.

Atrial Fibrillation↗
PubMed2004

Preoperative transarterial embolization of vertebral metastases.

The aim of this study was to evaluate the impact of preoperative devascularization of spinal metastases in relation to the preembolization tumor vascularization degree and in relation to the intraoperative blood loss. Twenty-four patients underwent preoperative transarterial embolization of hypervascular spinal metastases. Each tumor was assigned a vascularization grade (I-III) according to tumor blush after contrast agent injection in the main feeding artery. Embolization was performed with polyvinyl alcohol particles in all patients. Surgical reports were reviewed in terms of estimated blood loss. A mild hypervascularization was found in three patients (group I), medium in six patients (group II) and extensive in 15 patients (group III). In 22 out of 24 patients embolization could be performed with a complete devascularization. In two patients, only partial embolization could be performed, due to the main feeding artery arising from the artery of Adamkiewicz. In patients with complete devascularization the mean intraoperative blood loss was 1,900 ml, whereas in the two patients who were not embolized it was 5,500 ml. Intraoperative blood loss was not correlated to the vascularization grade. Angiography and embolization could be performed in all patients without causing permanent neurologic deficit, skin or muscle necrosis. The surgeons concluded that radical tumor resection after embolization was facilitated. Intraoperative blood loss is not correlated with the pre-interventional vascularization degree, if complete devascularization can be achieved with embolization. Preoperative embolization of vertebral hypervascular tumors is safe, effective and facilitates tumor resection.

Adult↗
PubMed2002

Vasoactive peptides in a pulmonary embolism model.

PURPOSE: To investigate changes in atrial natriuretic peptide (ANP) and angiotensin II (AT-II) levels in a canine model of pulmonary embolism (PE), created by embolizing the left posterior pulmonary artery with gelatin powder. METHODS: Pulmonary arterial pressure (PAP) was measured before, immediately after, and 1 day after pulmonary artery embolization. Plasma ANP and AT-II levels were measured by radioimmunoassay (RIA) before and 1, 3, 7, 14, 21, and 28 days after embolization. ANP and AT-II levels were also measured by RIA in both embolized and nonembolized lung tissue 28 days after embolization. RESULTS: No changes in plasma ANP or AT-II were seen within 28 days after embolization. Although the ANP level in the nonembolized lung tissue was significantly increased, the level in the embolized lung tissue was significantly decreased compared with that of sham-operated control lung tissue. The AT-II level in the nonembolized lung tissue was significantly decreased compared with that of the control lung tissue, but the level in the embolized lung tissue did not change. CONCLUSION: Both ANP and AT-II in the nonembolized lung tissue reacted to compensate for vasoconstriction caused by the PE in this model.

Angiotensin II↗
PubMed1992

The importance of pericardial constraint in experimental pulmonary embolism and volume loading.

To clarify the magnitude of the contribution of pericardial constraint to the hemodynamic deterioration that is observed during acute pulmonary embolism, hemodynamics and chamber dimensions (sonomicrometry) were measured during pulmonary embolization and subsequent volume loading in six anesthetized and instrumented open-chest, open-pericardium dogs. Embolization markedly increased peak right ventricular systolic pressure (38 +/- 5 mm Hg before embolism to 64 +/- 12 mm Hg after repeated embolization, p less than 0.05). However, right ventricular stroke volume decreased by only an insignificant amount (17 +/- 7 ml to 15 +/- 6 ml, p = not significant). Indices of left ventricular end-diastolic volume (left ventricular area = anteroposterior x septum-to-left ventricle free wall diameters) and stroke work (stroke work = area of the left ventricular pressure-area loop) were also similar before and after repeated embolization. Volume loading after repeated embolization resulted in increased right ventricular stroke volume (15 +/- 6 ml to 20 +/- 4 ml, p = 0.06), left ventricular area (3320 +/- 600 mm2 to 3470 +/- 580 mm2, p less than 0.05) and stroke work (261 +/- 158 mm Hg to 425 +/- 170 mm Hg x mm2, p less than 0.05). These results are in marked contrast to those in a previously reported study in a closed-chest and closed-pericardium model in which there was a decrease in left ventricular preload and systolic function after similar embolization-induced right ventricular pressure loading. Moreover, there was a further decrease in these parameters as a result of volume loading after embolism in the closed pericardium experiments. In conclusion, pericardial constraint contributes to hemodynamic deterioration during both acute right ventricular pressure loading and subsequent volume loading. The hemodynamic response to both interventions in the intact animal is determined not only by the degree of right ventricular dysfunction but also by the degree of direct ventricular interaction.

Animals↗
PubMed1995

Risk of arterial embolization in 224 patients awaiting cardiac transplantation.

Of patients awaiting cardiac transplantation, 10% to 20% die before a donor heart becomes available. Embolization of left ventricular thrombus is a source of morbidity and mortality in this population. To define the incidence and possible risk factors for systemic arterial embolization, we examined the frequency of arterial embolic events and their relation to clinical, hemodynamic, and echocardiographic variables in 224 consecutive outpatients awaiting cardiac transplantation (left ventricular ejection fraction 0.20 +/- 0.07 and left ventricular end-diastolic dimension 76 +/- 11 mm). Over a follow-up period of 301 +/- 371 days, during which 82 (37%) patients received warfarin, arterial embolization occurred in 6 (3%) patients, 1 of whom was receiving and 5 of whom were not receiving warfarin (difference not specifically significant). The risk of embolization was not statistically different in patients with atrial fibrillation, previous embolization, or left ventricular thrombus on transthoracic echocardiogram, regardless of warfarin therapy. Cumulative risk of sudden death was similar for patients with or without echocardiographically documented left ventricular thrombus. Nonfatal bleeding complications associated with warfarin therapy occurred in 2 (2%) patients. Thus in patients who are awaiting cardiac transplantation and who receive anticoagulation therapy for left ventricular thrombus, atrial fibrillation, or previous arterial embolization, the incidence of clinically detectable arterial embolization is low despite severe ventricular dilatation. Embolization is not likely a major cause of sudden death or morbidity in this population.

Cardiomyopathy, Dilated↗
PubMed1982

Factors associated with correct antemortem diagnosis of major pulmonary embolism.

Difficulties persist in the accurate clinical diagnosis of major pulmonary embolism despite the availability of lung scans and pulmonary angiography. To evaluate factors associated with the correct antemortem diagnosis of pulmonary embolism, we reviewed all 1,455 autopsy reports at the Peter Bent Brigham Hospital from 1973 to 1977. Of 54 patients identified with anatomically major pulmonary embolism at autopsy, 16 (30 percent) had correct antemortem diagnosis. Accuracy was far greater in postoperative patients (64 percent) (p = 0.02) and in patients with autopsy-proved venous thrombosis (55 percent) (p = 0.005). Lung scanning (82 percent) (p = 0.0002) and pulmonary angiography (80 percent) (p = 0.05) during the 10 days prior to death were also associated with an increased tendency to correct clinical diagnosis of pulmonary embolism. In contrast, among 21 patients with autopsy-proved major pulmonary embolism who also had pneumonia, no pulmonary embolism was diagnosed before death (p = 0.0001). Furthermore, among patients 70 years of age or older, only 10 percent with pulmonary embolism at postmortem examination had a correct diagnosis prior to death (p = 0.02). In patients with pneumonia or in elderly patients, an increased awareness of the possibility of pulmonary embolism and more frequent use of lung scanning and pulmonary angiography may increase the accurate clinical diagnosis of pulmonary embolism.

Aged↗