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PubMed1989

Massive pulmonary embolism.

An otherwise healthy 48-year-old woman presented in respiratory extremis from massive pulmonary embolism and promptly arrested. She underwent open-chest cardiopulmonary resuscitation followed by portable partial cardiopulmonary bypass and embolectomy but could not be resuscitated. Massive pulmonary embolism is frequently a desperate situation, but aggressive therapy with thrombolysis or embolectomy (in patients with contraindications to thrombolysis) may be lifesaving.

Female↗

PubMed2004

Protruding aortic arch thrombus: treatment with minimally invasive surgical approach.

BACKGROUND: Protruding aortic arch thrombus is associated clinically with life-threatening emboli. Definitive treatment for aortic arch thrombus removal has demanded complicated vascular surgical procedures, with high morbidity and mortality. METHODS AND RESULTS: Transesophageal echocardiography (TEE) enabled diagnosis of a protruding thrombus at the aortic arch in 5 patients, and a simultaneous lesion in the descending aorta in 1 patient. Four patients had visceral emboli, coinciding with peripheral emboli in 2 patients, and the fifth patient had peripheral and cerebral emboli. One patient had had ischemic stroke and femoral emboli a few months previously. Mean patient age was 51 years. None had clinical evidence of coronary or peripheral atherosclerotic occlusive disease. Risk factors included hypertension (n = 2), smoking (n = 4), and preexisting thrombophilia (n = 4). Five patients underwent TEE-guided aortic balloon thrombectomy from the arch with a 34-mm occluding balloon catheter. One patient also underwent balloon thrombectomy from the descending aorta with a 14F Foley catheter. Access into the aorta was obtained through the iliac artery (n = 4) during laparotomy because of visceral ischemia or through the transfemoral approach (n = 2). Previous procedures included superior mesenteric embolectomy (n = 3), segmental bowel resection (n = 1), splenectomy (n = 1), and peripheral arterial embolectomy n = 3). Real-time intraoperative TEE enabled visualization of the protruding thrombus and assisted with maneuvering of the balloon catheter. At completion peripheral thrombectomy thrombus material was retrieved in 4 patients. Postoperatively there were no clinically proved new procedure-related visceral emboli, and all patients received anticoagulant therapy thereafter. Follow-up TEE within 2 weeks and up to 7 years revealed no recurrent aortic arch thrombus. CONCLUSIONS: TEE-guided aortic balloon thrombectomy used in 6 procedures was effectively completed without visceral or peripheral ischemic complications. It enabled removal of the life-threatening source of emboli from the proximal aorta, thereby averting the need of major aortic surgery.

Aortic Arch Syndromes↗

PubMed1990

Aortic dissection presenting as acute leg ischaemia.

Lower limb ischaemia as the only or main clinical manifestation of aortic dissection is a rare event. Two cases are presented where this occurred resulting in attempted embolectomy before the correct diagnosis was made. The diagnosis should be considered when embolectomy fails to retrieve thrombus and when angiography demonstrates spiral lucencies within the lumen of large vessels or non-filling of major vascular branches. The value of pre-operative angiography is emphasized.

Aged↗

PubMed1986

Management of vascular complications of bacterial endocarditis.

Peripheral arterial emboli that result from bacterial endocarditis may be silent or catastrophic. Cardiac surgical intervention may prevent embolism, but the guidelines for timing of intervention are unclear. An accepted approach is to intervene only if two episodes of peripheral embolism occur. Our recent experience suggests a more refined approach is in order. Eight children with active bacterial endocarditis have been treated with embolic complications. One patient with abdominal pain and GI bleeding was treated with heparin for multiple peripheral mesenteric emboli. Four patients had femoral embolectomies, one twice. Three patients developed embolomycotic aneurysms of the aorta in two cases and the common iliac in one; all were ruptured and two survived with staged reconstruction in one and extra-anatomic bypass in the other. Staph aureus and Strep viridans were the organisms involved most often. A review of the details of care in these patients leads to the following conclusions: angiographic survey reveals that most patients have multiple emboli; early embolectomy may prevent formation of infected aneurysms; Staph aureus infected patients are at risk for development of infected aneurysms; patients with large floppy vegetations in the left heart on echocardiography are at high risk for embolism; and 2 to 3 weeks from onset of endocarditis is the peak time for embolic risk.

Adolescent↗

PubMed1976

Pulmonary embolism.

Pulmonary embolism is a common and often fatal postoperative complication. Dyspnea is the most common clinical manifestation in pulmonary embolism, and other signs are frequently inconsistent and often vague. The chest film and electrocardiogram may be helpful in excluding other cardiorespiratory diseases but they are frequently unreliable in establishing an objective diagnosis of pulmonary embolism. Documentation of a decreased arterial saturation provides suggestive evidence of pulmonary embolism. Lung scanning is a safe, sensitive procedure for the initial evaluation of symtoms suggestive of pulmonary embolism, and pulmonary arteriography may be necessary to confirm the diagnosis in certain patients. Anticoagulation is effective in the prevention and treatment of pulmonary embolism and proves successful in the vast majority of patients. Emboli that are not fatal gradually resolve in the pulmonary circulation. Vena caval interruption is occasionally beneficial in selected patients, especially those with septic emboli and cor pulmonale, but should only be performed when the indications are quite clear. Under certain selected circumstances pulmonary embolectomy may be indicated. Patients with massive embolism occluding more than one-half of the pulmonary arterial system and prooducing a markedly elevated pulmonary arterial pressure and severe hypoxemia may die in acute right heart failure. Intractable shock unresponsive to aggressive medical therapy in these patients represents an indication for pulmonary embolectomy. The hazards of these surgical procedures demand that a definite diagnosis of pulmonary embolism be made and a systematic approach to the diagnosis and treatment should be followed in all patients with the disorder.

Adult↗

PubMed1992

Diagnostic use of emergency department echocardiogram in massive pulmonary emboli.

Massive pulmonary embolism represents a small percentage of patients presenting to the emergency department with clinical symptoms suggestive of embolic phenomenon. Definitive therapy with thrombolytics or embolectomy is usually delayed until angiographic verification of the clinical suspicion can be obtained. A case is described in which embolectomy was based on clinical diagnosis and confirmatory echocardiogram obtained in the ED. The rapid diagnostic role of echocardiographic data in a subset of patients presenting with clinical symptoms suggestive of massive pulmonary emboli deserves further evaluation.

Acute Disease↗

PubMed2005

[Hydatid pulmonary embolisms. Seven cases].

Hydatid pulmonary embolism is a rare condition. Diagnosis is difficult and there is no consensus on treatment. Prognosis is generally poor. We conducted a retrospective analysis of patients hospitalized between 1994 and 2002 who had a diagnosis of hydatid pulmonary embolism. Seven cases were identified. All patients had a cyst which spontaneously ruptured into the bloodstream. All patients were symptomatic. Chest x-ray revealed images of metastatic pulmonary echinococciasis in all patients. Thoracic CT and/or angioscan provided the diagnosis in five patients. In one, the diagnosis was established with pulmonary angiography. For one other, the diagnosis was established at the pathology examination of the surgical specimen. Searching for the primary localization of the hydatid disease revealed hepatic cysts in all patients, associated in one with a cyst in the right atrium. The cardiac cyst was not operated and all hepatic cysts were removed. Embolectomy was performed in one patient. Medical treatment with albendazole was given in five patients. The clinical course was marked by death in two patients, due to abundant hemoptysia. The five other patients are followed regularly and were doing well at six months to five years. The diagnosis of hydatid pulmonary embolisms is basically obtained with imaging. Treatment is surgical resection of the embologenic focus then embolectomy. The role of medical treatment is not clearly defined. The short- and mid-term prognosis is generally poor.

Adolescent↗

PubMed1989

Septic peripheral embolization from bacterial and fungal endocarditis.

Arterial embolization is second only to cardiac failure as a potentially lethal complication of acute infectious endocarditis. Embolization may be encountered with increasing frequency due to the prolongation of life afforded by antibiotics and cardiac valve replacement surgery. While distal organs are more often affected, peripheral embolization of the lower extremities is by no means rare. Over a two-year period, we have treated six patients with acute infectious endocarditis who developed lower extremity ischemia. Four patients had Gram positive bacterial endocarditis while two immunosuppressed patients developed fungal endocarditis. Treatment of all six patients included lower extremity embolectomy or bypass grafting and long-term intravenous antimicrobial or antifungal therapy. Cardiac valve replacement was required in all six patients. All lower extremities were successfully reperfused, and no patient required amputation. Although the four patients with bacterial endocarditis survived, the two patients with fungal endocarditis eventually died. In conclusion, aggressive use of arteriography, embolectomy, antimicrobial drugs, and cardiac valve replacement appear to offer the best chance for survival and limb salvage for arterial embolism related to endocarditis.

Adult↗

PubMed1988

Mural thrombus of the aorta.

Twenty-six peripheral arterial emboli complicating 14 cases of mural thrombi of the aorta were diagnosed between January 1978 and December 1986. None of these patients had any cardiovascular history; their mean age was 49 years. Presenting signs were acute ischemia of the lower limbs in 12 cases and chronic ischemia in two. Arteriograms and CT scan were diagnostic. The mural thrombi were infrarenal in 13 cases and suprarenal in one. Treatment of the thrombus was surgical in all but one patient. In four cases, treatment of the underlying cause was simultaneous with embolectomy; in nine patients, treatment was secondary because further workup was needed. In one case, the patient died following embolectomy before definitive treatment could be undertaken. Results were considered good in 11 cases (unlimited walking distance, no recurrent emboli), and poor in three cases (two major amputations and one death). The incidence of mural thrombi is not known. In our experience, they accounted for 3.8% of nonaneurysmal aortoiliac lesions operated upon during a nine-year period and were responsible for 5% of peripheral arterial emboli. Mural thrombosis of the aorta constitutes a dangerous condition with a potentially lethal final outcome. Recurrent emboli are inevitable without surgical treatment of the source.

Adult↗

PubMed1996

Pulmonary embolism: a frequent cause of acute fatality after lung resection.

Between 1975 and 1993, lung resections were performed in 1735 patients because of malignancies, with an early postoperative mortality of 7.2% (125 patients). Early postoperatively acute cardiorespiratory failure was experienced by 32 patients (1.85%), of whom 26 died despite immediate resuscitation measures. In 20/26 patients autopsy was performed revealing central pulmonary embolism as the cause of death in 19 of them. In one patient a rupture of the free posterior left ventricular wall following transmural myocardial infarction was found. Two patients who could be resuscitated successfully were operated on with extracorporeal circulation after pulmonary angiography had been performed to confirm the diagnosis; however they died 2 days later of right heart failure. Of the survivors three cases had myocardial infarctions, one patient had arrhythmias of unknown etiology. Immediate embolectomy with the use of extracorporeal circulation was performed in two patients, only on the ground of suspected pulmonary embolism and without further diagnostic measures. Both patients survived. Of the 23 cases, with proven pulmonary embolism 17 were still under postoperative prophylaxis with heparin. Six patients were already fully mobilized. We conclude that massive pulmonary embolism is a frequent early postoperative fatal complication after lung resections, which cannot be safely prevented by postoperative heparinization. The only successful life-saving measure in the case of central pulmonary embolism is immediate pulmonary embolectomy, if necessary without further diagnostic measures.

Aged↗

PubMed2003

Emergency pedal artery bypass grafting.

OBJECTIVES: To determine the value of emergency pedal artery bypass. MATERIAL AND METHODS: Data were drawn from a prospective vascular database. Inclusion criteria were: acute onset of critical forefoot ischemia, emergency surgery, no pre-operative angiographic imaging of the pedal vasculature and attempted revascularisation of a pedal vessel. Follow-up was obtained from outpatient records. The grafts were considered patent if a pedal pulse was palpable. RESULTS: Eight out of 208 pedal vascular procedures performed between January 1996 and June 2002 were entered into the study. This cohort consisted of 3 women and 5 men (age 23-85 years, median 71). Operations were performed because of thrombo-embolic occlusion of the tibial vasculature (5 patients), severe tibial embolism following a percutaneous angioplasty of the superficial femoral artery, trash foot following aortic reconstruction and acute occlusion of tibial run-off vessels following a crural reconstruction. Two patients suffered an early graft occlusion, one of them resulting in major amputation. At a median follow up of 17 months (10-52 months) the remaining 6 grafts were patent. CONCLUSIONS: If catheter directed methods (local lysis, aspiration embolectomy) or surgical procedures (embolectomy, tibial bypass) fail to treat critical foot ischemia, pedal probatorial dissection and pedal bypass is worthwhile.

Adult↗

PubMed2003

Left ventricular outflow tract myxoma.

This article reports a left ventricular outflow tract (LVOT) myxoma, presenting with peripheral embolus, in a 90-year-old patient during the follow-up due to ischemic heart disease. Among LVOT myxomas, which are usually very rare and most likely to present with manifestations due to obstruction, this is the first case presenting with peripheral embolus. In this study, diagnosis was based on the histopathological evaluation of the embolectomy material. The report emphasizes the importance of evaluation of the embolectomy material in appropriate patients who present with peripheral emboli, and where an intracardiac mass is suspected.

Aged↗

PubMed1998

Anaesthetic and surgical airway management during tracheo-oesophageal fistula repair.

A retrospective review of 61 cases of airway management for newborn tracheo-oesophageal fistula (TOF)/oesophageal atresia repair is presented. Standard management included induction of general anaesthesia and muscle relaxation before tracheal intubation, rigid bronchoscopy, careful placement of the tracheal tube below the TOF if possible, and occlusion of the fistula with a Fogarty embolectomy catheter in certain high risk cases. Gastrostomy was not routinely performed. Ventilation proceeded without difficulty in 48 cases. Ventilation difficulties were encountered in 13 cases. Eight of the 13 cases had large TOF, and four had other causes of difficult ventilation not related to the fistula. No patient with a small TOF had ventilation problems because of the TOF. Three patients had a large TOF successfully occluded with an embolectomy catheter through the bronchoscope. There were no complications ascribed to this technique. An algorithm is suggested for anaesthetic-surgical airway management in these cases.

Algorithms↗

PubMed2002

The use of inferior vena cava filter as a treatment modality for massive pulmonary embolism. A case series and review of pathophysiology.

The use of inferior vena cava (IVC) filter for massive pulmonary emboli (PE) with cardiopulmonary instability has not been clinically studied. We present a case series of six such patients who received an IVC filter with anticoagulation rather than thrombolysis because of high risk of bleeding. Acute pulmonary embolectomy was considered, but was not possible for a variety of individual clinical situations. These six hospitalized patients prospectively followed during their admission. They were triaged to three medical intensive care units (ICUs) and one surgical ICU in three university teaching hospitals. One patient was transferred from another institution. All six patients had severe hypoxia and tenuous cardiopulmonary status. All required high inspiratory oxygen and hemodynamic support; two required mechanical ventilation and vasopressors. An IVC filter was placed emergently and anticoagulation was started immediately All six patients had resolution of pulmonary thromboemboli (PTE) on anticoagulation while the IVC filter prevented further PE. All six patients were discharged home in their pre-critical illness state. None ofthe patients suffered complications from this therapy and had excellent resolution ofcardiopulmonary collapse. The IVC filter placement prevented further major embolic events while the PTE resolved with anticoagulation. An IVC filter should be considered as an adjunct to anticoagulation therapy for those patients with massive PE and cardiopulmonary instability who are not candidates for thrombolysis, and acute pulmonary embolectomy is not readily available or is of very high risk.

Adult↗

PubMed1991

Early and late results after surgery for massive pulmonary embolism.

Between 1978 and 1990 emergency pulmonary embolectomy with the aid of extracorporeal circulation (ECC) was performed for massive pulmonary embolism (PE) in 44 patients (19-73 yrs; 49 +/- 15 yrs). Cardiopulmonary circulation was stable in 16/44 patients but unstable in 28/44; of the latter, 15 had undergone previous cardiopulmonary resuscitation due to cardiac arrest. Diagnosis of PE was obtained clinically in 15/44 patients, by angiography in 13/44, by echocardiography in 10/44, and by perfusion scintigraphy of the lung in 6/44 patients. There were 9/44 (20%) postoperative deaths. Early mortality was significantly higher in previously resuscitated patients (p less than 0.05). There were 2/36 (6%) late deaths. Actuarial survival was 75% after 4 yrs and 71% after 8 yrs. 77% or 35 survivors were in NYHA-class I and 23% in NYHA-class II after a mean follow-up of 4.6 yrs. Pulmonary embolectomy is indicated in patients with central PE and shock; it is advisable in patients with embolism of the main pulmonary artery or its major branches or in patients with contraindication to thrombolysis. Intraoperative insertion of a vena cava filter is recommended for prevention of recurrent embolism. Preoperative resuscitation and duration of ECC are predictors for early death.

Actuarial Analysis↗

PubMed1981

Delayed pulmonary thrombectomy via a peripheral approach in the treatment of pulmonary embolism and sequelae.

Delayed unilateral pulmonary embolectomy via the peripheral approach has been performed in 12 patients suffering from chronic pulmonary vascular obstruction after a single or repeated embolisms. Arterial hypoxemia and pulmonary hypertension were present in all cases. Embolectomy was performed several months or years after the initial event. There were 2 early and one late death. The surviving patients are doing well clinically and show definite hemodynamic and angiographic improvement.

Adult↗

PubMed1996

Pulmonary embolism. II. Diagnosis and treatment.

Pulmonary embolism is an often underestimated, underdiagnosed, and undertreated disease. As symptoms and signs of pulmonary embolism are nonspecific, the diagnosis still remains a challenge to the attending physician. Diagnostic and therapeutic procedures depend on the clinical presentation of the patient. First we must suspect pulmonary embolism and consider its likelihood in the presence of a number of clinical signs and symptoms. Once pulmonary embolism is suspected, heparin should be administered. Additional basic support is mandatory if required. If the patient's hemodynamic situation is stable, available preferable noninvasive diagnostic options should be considered to confirm or rule out the diagnosis of venous thromboembolism before further administration of anticoagulant or thrombolytic agents. If the patient's status has deteriorated, bedside diagnostic techniques should be applied to reinforce the suspicion or establish the diagnosis. To restore pulmonary perfusion more rapidly than conventional anticoagulation is suspected to do, several dosing regimens of thrombolytic agents are proposed, with recent interest in short-term thrombolysis and bolus lysis with urokinase or recombinant tissue plasminogen activator. If thrombolysis fails or is contraindicated, catheter embolectomy or surgical embolectomy is indicated. The main therapy is prevention. In this article, clinical assessment, imaging techniques, and therapeutic options described in the published literature are discussed and clinical experiences of an emergency department with a noninvasive diagnostic approach are described.

Causality↗

PubMed1980

[The radiological diagnosis of acute intestinal ischaemia (author's transl)].

Angiography was carried out in 27 patients with acute intestinal ischaemia. In 23 patients a primary, and in four a secondary vascular cause was found. Plain films are of little value in the early diagnosis of mesenteric infarcts, since radiologically demonstrable changes first develop after 10 to 12 hours following the incident. A definitive early diagnosis of an acute mesenteric infarct can only be made by angiography. Surgical intervention for proximal mesenteric artery occlusion is only likely to be successful if carried out within 10 hours. 80% of six patients with major occlusions and five with angiospastic mesenteric insufficiency died. One out of three embolectomies was successful. Amongst seven patients with occlusions of jejunal and ileal branches, just over half died; three out of four embolectomies were successful. Five patients with ileal occlusions survived.

Acute Disease↗