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At least 1,243 records · Page 69Linked to original sources
PubMed2001

Endovascular repair of occluded subclavian arteries following penetrating trauma.

PURPOSE: To describe the endovascular repair of 2 subclavian arteries occluded due to penetrating trauma. CASE REPORTS: Two male patients were admitted with zone-I neck stab wounds. Both were hemodynamically stable and had absent pulses in the ipsilateral upper limb with decreased Doppler pressures. There were no signs of critical ischemia or active bleeding. On arteriography, complete occlusion of the second segment of the left subclavian arteries in both patients was demonstrated. Stent-graft repair and embolectomy under local anesthesia were successfully performed. No procedure-related complications occurred, and both patients were discharged after 2 days. At 1-year follow-up, stent-graft patency was demonstrated in both patients. CONCLUSIONS: Endovascular repair is a feasible and safe option in the management of occluded subclavian arteries due to penetrating trauma. This may represent another indication for stent-grafting in the expanding role of this technique.

Adult↗
PubMed2003

An update on bronchial blockers during lung separation techniques in adults.

Techniques for one-lung ventilation (OLV) can be accomplished in two ways: The first involves the use of a double-lumen endotracheal tube (DLT). The second involves blockade of a mainstem bronchus (bronchial blockers). Bronchial blockade technology is on the rise, and in some specific clinical situations (e.g., management of the difficult airway during OLV or selective lobar blockade) it can offer more as an alternative to achieve OLV in adults. Special emphasis on newer information for the use of Fogarty embolectomy catheter as a bronchial blocker, the torque control blocker Univent, and the wire-guided endobronchial blocker (Arndt blocker) is included. Also this review describes placement, positioning, complications, ventilation modalities, and airflow resistances of all three bronchial blockers. Finally, the bronchial blockers can be used in many cases that require OLV, taking into consideration that bronchial blockers require longer time for placement, assisted suction to expedite lung collapse, and the use of fiberoptic bronchoscopy. The current use of bronchial blockers, supported by scientific evidence, dictates that bronchial blockers should be available in any service that performs lung separation techniques.

Adult↗
PubMed2004

Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism.

Pulmonary embolism (PE) is associated with significant perioperative morbidity and mortality. Transesophageal echocardiography (TEE) may permit direct visualization of PE or secondary signs of pulmonary artery (PA) obstruction. However, its utility in diagnosing PE in the intraoperative setting has yet to be defined. Therefore, we performed intraoperative TEE examinations in 46 patients immediately before pulmonary embolectomy. TEE examinations were reviewed for signs of thromboemboli within the right, left, and main PA, and secondary signs of acute PA obstruction (right ventricular dysfunction, moderate-to-severe tricuspid regurgitation, leftward bowing of the interatrial septum). The definitive location of thromboemboli was determined from the surgical record. Echocardiographic evidence for the presence of PE was correctly demonstrated in 46% of all patients (n = 21 of 46). However, the sensitivity for direct visualization of thromboemboli at any specific location was only 26%. TEE was least sensitive for thromboemboli in the left PA (17%). TEE evidence of right ventricular dysfunction was observed in 96%, tricuspid regurgitation in 50%, and leftward interatrial septal bowing in 98% of examinations. Therefore, the use of intraoperative TEE to diagnose acute PE via direct visualization is limited. Indirect TEE evidence of PA obstruction may be helpful in supporting a diagnosis of PE.

Adult↗
PubMed2002

Treatment of acute massive/submassive pulmonary embolism.

Thirty-five consecutive patients with massive and submassive pulmonary embolism (PE) were reviewed. In 75% of these cases, PE could be suspected on the basis of electrocardiogram alone. Echocardiography was quite useful for diagnosing PE and assessing right ventricle after-load at the bedside. Spiral computer tomography was effective for obtaining a definitive diagnosis even in a relatively hemodynamically unstable patient. Thrombolysis therapy was given to 30 cases and was apparently effective in 17 cases (17/30, 56.7%). Percutaneous cardiopulmonary support (PCPS) was needed for 7 severe cases. Seven patients, including 5 of the PCPS recipients, underwent surgical embolectomy. Overall mortality was 28.6% (10/35), and surgical mortality was 28.6% (2/7). The significant predictors for mortality were systolic blood pressure <100 mmHg, dopamine >5 microg x kg(-1) min(-1), pH <7.4, PaCO2 >40 torr, base excesss <-5 mmol/L, urine output <0.8ml x kg(-1) x h(-1), intubation, cardiopulmonary resuscitation, duration from attack to emergency room >5h, shock duration >4h, aspartate aminotransferase >100U/L, alanine aminotransferase >100U/L and lactate dehydrogenase >600U/L. Predictors of surgical intervention were dopamine >5 microg x kg(-1) min(-1), shock duration >4h and PCPS. Early initiation of thombolysis therapy is recommended, except in case where it is absolutely contraindicated. Because it is difficult in the early phase of PE to make a decision to perform surgery, aggressive application of PCPS is recommended for the cardiogenic shock associated with massive PE.

Acute Disease↗
PubMedDate not supplied

Pulmonary embolism: an overview of treatment and nursing issues.

Pulmonary embolism presents with a vague clinical picture. Pathophysiological effects vary from small pulmonary infarcts to life-threatening cardiogenic shock. Therefore, radiological investigation to confirm the diagnosis is required to institute appropriate treatment. This ranges from heparin therapy to surgical embolectomy. Care of this patient group requires vigilant nursing, because of not only the risk of further embolic episodes, but also the potential serious complications of treatment. Prevention of venous thromboembolism can be pharmacological or mechanical. The proactive role that nurses take in prevention of this potentially fatal disease process is often overlooked by the medical literature.

Adult↗
PubMed1997

Noninvasive diagnosis of suspected severe pulmonary embolism: transesophageal echocardiography vs spiral CT.

OBJECTIVE: Patients with pulmonary embolism (PE) and echocardiographic signs of right ventricular overload have worse prognosis and may require aggressive therapy. Unequivocal confirmation of PE is required before thrombolysis or embolectomy. This study compares the value of transesophageal echocardiography (TEE) and spiral CT (sCT) in direct visualization of pulmonary artery thromboemboli in patients with suspected PE and echocardiographic signs of right ventricular overload. MATERIAL AND METHODS: Forty-nine consecutive patients (29 men and 20 women), aged 52.2+/-18.3 years, with clinical suspicion of acute (23) or chronic (26) PE and otherwise unexplained right ventricular overload at transthoracic echocardiography underwent TEE and sCT. Main and lobar (central) pulmonary arteries were searched for emboli with both TEE and sCT, while segmental and subsegmental (distal) pulmonary arteries were searched only with sCT. RESULTS: Of 40 patients with PE confirmed by high-probability lung scan (27) or angiography (13), central pulmonary arterial emboli were found at TEE and sCT in 32 (80%) and 36 (90%) patients, respectively. Neither method reported false central PE (specificity, 100%). When distal pulmonary arteries were analyzed, sensitivity of sCT increased to 97.5%, but three patients with primary pulmonary hypertension according to standard tests were misclassified as having distal PE (specificity, 90.1%). Most patients had bilateral PE according to sCT (34/36) and standard tests (40/40) but not TEE (15/32), probably due to its topographic limitations. CONCLUSIONS: Because of high prevalence of bilateral central pulmonary thromboemboli in patients with hemodynamically significant PE, both sCT and TEE allow its definitive confirmation in most cases. Thrombi reported by sCT distally to lobar arteries should be interpreted with caution.

Acute Disease↗
PubMed1997

Ultrasound-based quantification of emboli during conventional and endovascular aneurysm repair.

PURPOSE: To differentiate and quantify the type and number of lower limb emboli occurring during endovascular aneurysm repair, as compared to conventional surgery. METHODS: Thirty-eight patients underwent elective infrarenal aneurysm repair using a conventional surgical approach in 18 and an endovascular procedure in 20. Emboli were detected using a Doppler ultrasound system with a 2-MHz transducer interrogating the mid superficial femoral artery. Lower limb emboli were differentiated as particulate or gaseous based on the physical distance traversed by the embolic signal. RESULTS: Significantly more particulate (median 108 versus 59, p = 0.015) and gaseous (134 versus 46, p = 0.008) emboli were detected during endovascular aneurysm repair as compared to conventional surgery. Clinically, no case of massive microembolization occurred in either group, but one patient in the conventional group required a femoral embolectomy, and three patients undergoing endovascular repair developed self-limiting trash feet postoperatively. In patients undergoing endovascular aortomonoiliac aneurysm repair, there was only a poor correlation between the number of particulate emboli and either procedural duration or operator experience. CONCLUSIONS: The apparent lack of a relationship between particulate embolization and operative time or technical experience suggests that manipulation of endoluminal devices within the aneurysm sac may not be the sole determinant of intraprocedural embolization. Other as yet undetermined factors may predict patients at high risk for massive embolization.

Aged↗
PubMed2002

Early intervention in massive pulmonary embolism. A guide to diagnosis and triage for the critical first hour.

The diagnosis of massive pulmonary embolism should be considered expeditiously in all patients with unexplained hypotension, syncope, cardiac arrest, or hypoxemic respiratory failure. The presence of right ventricular overload on physical examination or electrocardiogram is an especially important clue. Depending on local expertise and the patient's stability, V/Q scanning, CT angiography, echocardiography, and right heart catheterization can be useful in establishing a diagnosis of pulmonary embolism. Supportive treatment includes oxygen, vasoactive medicines, and sometimes fluids. Although heparin is important in nearly all patients, 70% to 80% of patients also require an IVC filter, thrombolysis, or embolectomy.

Algorithms↗
PubMed2005

Venous thromboembolism: diagnosis and management of pulmonary embolism.

Pulmonary embolism (PE) affects 0.5-1 per 1000 people in the general population each year, and is one of the most common preventable causes of death among hospitalised patients. The clinical diagnosis of PE is unreliable and must be confirmed objectively with ventilation perfusion scanning or computed tomography pulmonary angiography. The diagnosis of PE can be reliably excluded, without the need for diagnostic imaging, if the clinical pretest probability for PE is low and the D-dimer assay result is negative. The initial treatment of PE is low-molecular-weight heparin or unfractionated heparin for at least 5 days, followed by warfarin (target international normalised ratio [INR], 2.0-3.0) for at least 3-6 months. Patients with a high clinical pretest probability of PE should commence treatment immediately while awaiting the results of the diagnostic work-up. Thrombolysis is indicated for patients with objectively confirmed PE who are haemodynamically unstable. Percutaneous transcatheter or surgical embolectomy may be life-saving in patients ineligible for, or unresponsive to, thrombolytic therapy. Unresolved issues in the management of venous thromboembolism include the roles of thrombophilia testing, thrombolysis for the treatment of stable PE patients who present with right ventricular dysfunction, and new anticoagulants; and the duration of anticoagulation for first unprovoked venous thromboembolism.

Angiography↗
PubMedDate not supplied

[Embolism in the right heart chambers: the diagnostic and therapeutic aspects].

Deep venus thrombosis may result in pulmonary embolism. In rare instances, embolization has occurred, not directly to the pulmonary arterial tree, but to the right heart chambers. Although the value of echocardiography in the diagnosis is well recognised, their is no consensus for the appropriate treatment. We report herein six cases of floating right atrial thrombi, diagnosed by echocardiography, in patients with pulmonary embolism, or unexplained shock or syncope. Surgical embolectomy was carried out in 4 patients, and thrombolytic therapy in 2, without in-hospital mortality. The high mortality associated to this entity may be improved by rapid echocardiographic recognition and emergency treatment with thrombolysis or surgery. Our data suggest the possible use of thrombolysis as a first-choice therapy in selected patients.

Adult↗
PubMed2000

[Major pulmonary embolism].

The diagnosis of major pulmonary embolism should be considered in case of acute respiratory distress, particularly when there is high thromboembolic risk. Although clinical symptoms are not specific, some are suggestive: syncope or dizziness with cyanosis and polypnoea, and especially arterial hypotension and cardiogenic shock. Diagnostic workup should be rapid and straight forward. Transthoracic echography is particularly useful to detect right heart thrombi and right ventricular overload. More information could be provided by helical computed tomography or perfusion lung scan or less commonly now by pulmonary angiography, depending on the patient's clinical condition and the available equipment. The mortality rate can reach 20 to 30%, and up to 65% after resuscitated cardiac arrest. Rapid desobstruction is justified through surgical embolectomy or intravenous thrombolysis favouring short duration protocols (alteplase over 2 h), in spite of the bleeding risk.

Angiography↗
PubMed1999

Massive thromboembolism due to transcatheter ASD closure with ASDOS device.

Transcatheter occlusion of atrial septal defects (ASD) is currently being investigated as an attractive alternative to surgical correction. Thromboembolic events are rare in both techniques. However, we report a case of massive systemic embolization and residual left atrial thrombus after secundum ASD transcatheter closure by the ASDOS device (Atrial Septal Defect Occlusion System, Dr. Ing Osypka Corporation, Germany). The patient was successfully treated by femoral embolectomies, surgical removal of the device and closure of the ASD without a patch. No thrombophilia was found on subsequent exploration. Transcatheter ASD closure with the ASDOS device may therefore expose the patient to severe embolic complications. Further evaluation is needed before this technique can be safely recommended.

Adult↗
PubMed2000

Intraoperative acute occlusion of aortic bifurcation during extracorporeal circulation.

A 36-year-old male patient showed a significant decrease of arterial pressure in the lower extremities during coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC). Arterial pressure measured in the femoral artery fell to 10-20 mmHg at the end of ECC, whereas in the upper extremities arterial pressure levels were normal. At the end of the surgery a complete ischemia of both lower extremities was observed. We suspected Leriche's syndrome and performed a successful aortic embolectomy through bilateral femoral arteriotomies immediately. An insufficient anticoagulation could be excluded by prolonged "activated clotting time" (ACT), therefore we presumed that the source of embolus was a small aneurysm of the left ventricle. The shape and superficial structure of the extracted embolus, which was partly covered with endocardium, confirmed our suspicion. No complications occurred throughout the postoperative period. On the 10th postoperative day, the patient left our department for postoperative rehabilitation with a normal perfusion of the lower extremities.

Adult↗
PubMed2000

[Surgical treatment for infective endocarditis with multiple embolic complications].

A 59-year-old man was transferred to our hospital because of severe right leg pain, dyspnea and anuria. Due to severe cyanosis of the legs below the knees and severe hyperkalemia, he had undergone embolectomy of the right femoral artery and hemodialysis. Medical treatment for infective endocarditis was started after the first operation, because transesophageal echo cardiography revealed severe aortic regurgitation and massive vegetation of the aortic valve. Amputation of the right leg below the knee and of the left leg below the Lisfranc joint was performed after 19 days and aortic valve replacement with patch closure of a perivalvular abscess was performed one month after the first operation. The post-operative course was uneventful. He was weaned from hemodialysis and the follow-up echocardiographic study revealed no vegetation.

Abscess↗
PubMed1999

[Management of serious pulmonary embolism].

In-hospital mortality is high when pulmonary embolism is complicated by hemodynamic instability and/or pulmonary hypertension. Death occurs frequently within the first hours after admission. This implies specific diagnostic and therapeutic management. Spiral CT seems to be an excellent diagnostic procedure in this setting. However, pulmonary angiography and perfusion lung scan can also be employed. Cardiac echography can help in the diagnosis and therapeutic decision making. Supportive therapy mainly includes correction of hypovolemia if present, a limited volume loading in other cases, and the use of dobutamine. Norepinephrine is the drug of choice when hypotension is present. Thrombolytic agents are indicated in case of hemodynamic instability. Modalities of administration and contra indications are currently well established. Surgical embolectomy should be performed in cases of uncontrolled shock, when thrombolysis is contra-indicated or uneffective.

Angiography↗
PubMed2000

[A case of acute pulmonary embolism fourteen days after hysterectomy].

We describe a 54-year-old female with acute pulmonary embolism. She showed a syncope attack and hypotension fourteen days after hysterectomy for uterine cancer. Preoperative echocardiogram revealed that thrombus in the right atrium was coming and going through the tricuspid valve. Emergent pulmonary embolectomy through the sternotomy under cardiopulmonary bypass was performed 4.5 hours after the diagnosis without homologous blood transfusion. Postoperative perfusion scintigram 20 days after the operation showed normal filling of the both lungs except for the localized defect at the distal portion of the right middle lobe. The patient was discharged on the 22nd postoperative day and she has been followed up with anticoagulation therapy. It is essential that we have the opportunity to salvage an otherwise helpless situation by a high index of suspicion and a prompt surgical intervention.

Acute Disease↗
PubMedDate not supplied

[Thromboembolectomy with a Fogarty catheter. Our clinical experience].

BACKGROUND: The Fogarty thromboembolectomy (TE) has been considered for a long time the best treatment for acute peripheral arterial occlusion. However, recently new therapeutic options like thrombolytic agents (local or systemic) have been introduced. METHODS: A total of 66 patients who underwent Fogarty TE for acute thromboembolic limb ischemia has been retrospectively studied. Patients with documented atherosclerotic pathology who were treated with other revascularization procedures were excluded. Patients were divided into four groups: 1) upper limb embolism, 2) lower limb embolism, 3) thrombosis on atherosclerotic plaque or on a graft, 4) post-traumatic thrombosis. Twelve patients underwent Fogarty TE for upper limb thromboembolic ischemia and 54 for lower limb; 57.5% of patients had atrial fibrillation. RESULTS: Procedures were successful in 59 patients (89.4%). Further surgical procedures (bypass, arterioplasty, further embolectomy) were performed in 35.1% (19/54) of patients of groups 2 and 3 with acute lower limb ischemia. Results were very good in group 1 and 4. Seven of the 54 patients treated for lower limb ischemia underwent limb amputation (12.9%), while hospital mortality was similar for lower and upper limb (31.4 and 33.3% respectively). CONCLUSIONS: The Fogarty TE is still a good option to revascularize acute ischemic peripheral arteries with good results in a high number of patients and should be particularly used where it is possible to perform additional techniques in case of failure.

Acute Disease↗
PubMed2000

The current role of thrombolytic therapy for pulmonary embolism.

Thrombolytic therapy for pulmonary embolism can rapidly reverse right ventricular failure and reduce mortality and morbidity among appropriately selected patients. Individuals being considered for this treatment should be screened for potential major bleeding problems, which, if present, should lead to alternative management with catheter or surgical embolectomy. There is no ideal thrombolytic agent; nor have indications for thrombolysis been precisely defined. Available data indicate that patients with moderate or severe right ventricular dysfunction gain the most from this pharmacologic strategy.

Cardiac Output, Low↗