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Thrombolysis is advocated as the treatment of choice for hemodynamically important pulmonary embolism. This paper reports the case of a patient with subacute massive pulmonary embolism in which thrombolysis was not considered appropriate because transesophageal echocardiography demonstrated a patent foramen ovale and impending paradoxical embolism.
We evaluated the changes in hepatic arterial and portal perfusion in nonembolized as well as in embolized lobes after portal venous branch embolization (PVE) with dynamic helical computed tomography (CT). Six patients with hepatic malignancies, who underwent PVE prior to a subsequent hepatectomy, were the subjects of this study. We performed CT examinations before PVE and 2 weeks after PVE to make a volumetric analysis. At the same time, we performed single-location dynamic sequences after the injection of a 50-ml bolus of contrast medium, and we then created time-density curves from circular regions of interest drawn over the aorta, parenchyma of the right and left lobe of the liver, and spleen. We calculated the arterial perfusion index (ml/min per ml of tissue) and the portal perfusion index by dividing the maximum rate of enhancement of the liver before and after the splenic peak by the peak aortic enhancement. We then calculated the arterial and portal flows (ml/min) from the perfusion index and values of CT volumetry. In the right lobe, where the portal flow was occluded, the arterial perfusion index and flow increased significantly after PVE. In contrast, the arterial perfusion index and flow both decreased in the left lobe after PVE in a reverse response to the increase in the portal perfusion index and flow. The total arterial flow of the liver thus seemed to slightly increase; however, the change was not significant. By performing PVE an increased arterial perfusion was induced in the embolized lobe, with a concomitant decrease in arterial perfusion in the nonembolized lobe.
Cardiac troponin I levels were increased in 24 of 147 patients (16%) with documented acute pulmonary embolism and in 20 of 594 patients (3%) without pulmonary embolism (p <0.001). In patients with acute pulmonary embolisms, 8 of 24 (33%) with increased cardiac troponin I levels and 9 of 123 (7%) with normal cardiac troponin I levels died during hospitalization (p <0.001).
Two-dimensional transthoracic echocardiography is commonly performed to detect a possible cardiac source of systemic embolism and it has been the mainstay of detection and diagnosis of cardiac masses. The transesophageal approach has enhanced the ability to detect cardiac sources of embolism by allowing a better visualization of posterior cardiac structures such as the left atrium with left atrial appendage, pulmonary veins and thoracic aorta and by providing higher resolution images to improve assessment of the presence and extent of cardiac masses. In this case report, echocardiography, using both transthoracic and transesophageal approach, allowed to detect a neoplastic mass arising from the upper left pulmonary vein in a patient presented with a transient ischemic attack. Further investigations showed a malignancy involving the lung. To our knowledge, this is the first reported case in which a cerebral embolic episode represents the clinical onset of a lung cancer, pointing out the importance of echocardiography in all cases of undetermined cerebral ischemic attack.
The postcontrast CT scans and angiography of 26 lesions in 23 patients with hepatomas who underwent transcatheter arterial embolization therapy were reviewed. Newly developed low density and high density areas and gas were noted on CT scans of the tumors after embolization in 100, 8 and 58% of the lesions, respectively. The CT findings of residual tumors correlated well with those of follow-up angiography. When discrete smooth round low density zones were observed on CT, there was no residual neovascularity on follow-up arteriography. When there were nodular or thick septum-like structures in low density lesions, arteriography revealed residual tumor vascularity in the lesions. CT proved useful not only in evaluating the effects of embolization, but also in providing important information about residual tumors.
We report ultrasound-guided direct percutaneous injection of n-butyl cyanoacrylate for preoperative embolization of carotid body tumor in a 50-year-old patient. Angiographic road map assistance was used for protection of parent arteries during the injection. After embolization, complete devascularization of the tumor was achieved without complications. The tumor was removed surgically with minimal blood loss. This procedure is effective and promising for preoperative embolization of carotid body tumors.
The authors used new fibrous collagen embolic material (5 by 75 microns in size) for flow-directed hepatic artery embolization in four rabbits; the purpose of the study was to examine the acute effects of the material on hepatic microcirculation. Extent of hepatic dearterialization, level of arterial occlusion, collateral formation and status of portal sinusoidal perfusion were evaluated under a dissection microscope after embolization. The collagen material produced proximal and peripheral hepatic arterial occlusion with complete hepatic dearterialization, including the bile duct. Portal sinusoidal perfusion appeared to be intact. No intrahepatic microcollaterals were observed.
Serum cholesterol, triglycerides, phospholipids, and lipoprotein levels were studied by electrophoresis in 43 trauma patients with multiple fractures of the lower extremities and pelvis. Ten healthy volunteers were used for control studies. The fat embolism syndrome was diagnosed in eight of the 43 patients. The lipid values of all the trauma patients were lower than the control values. A decrease in cholesterol and phospholipids was observed in the fat embolism patients during 4 days; these changes were not observed in the other trauma patients. The triglycerides of all the trauma patients increased slowly over a period of 4 days. Changes in the lipoprotein fractions after the trauma were minor. An early increase in the alpha1 lipbrotein fraction was noted in the fat embolism patients simultaneously with a decrease in the pre-beta lipoprotein fraction; the values of the other trauma patients were at the control levels. Normalization was observed in 6 hours. The lipid concentrations of plasma and serum did not change with filtration with 1.2, 5, and 8mum Millipore filters. No differences were noted between the femoral and cubital vein samples.
Pulmonary embolism in reamed femoral nailing has been reported and discussed over recent years. Does an unreamed nailing technique with a solid nail prevent this rare but serious complication of intramedullary fixation? In an animal model in rabbits, we studied the pathophysiologic impact on pulmonary function and the impact on hemostasis of reamed and unreamed nailing of intact femora and tibiae, and of femoral fracture in relation to intramedullary pressure. No statistical difference of PaO2, PaCO2, and PCO2et was found in the femur whether a reamed or unreamed procedure was performed. Two of six animals with unreamed femoral nailing, one of six animal with reamed femoral nailing, and one of five animals with a femoral fracture fulfilled four of four or three of four criteria for embolization (increase of the difference of PaCO2 and PCO2et, decrease of PaO2, increase of blast cells in central-venous blood and bone marrow/fat in histologic section of the lungs and bone). Tibial nailing did not alter pulmonary function in either group. Intramedullary pressure was increased in all animals with perioperative impairment of pulmonary function (375 to 676 mbar). Analysis of the hemostatic results showed a significant difference of platelet activation in reamed versus unreamed nailing of the femur 1 hour after nailing (p < 0.01) and a significant decrease of fibrinogen and antithrombin III (p < 0.001/p < 0.01) in reamed femoral nailing. We conclude that unreamed nailing of the femur with a solid rod may also cause bone marrow embolization with alteration of pulmonary function as long as an important increase of the intramedullary pressure is generated during the nailing procedure.(ABSTRACT TRUNCATED AT 250 WORDS)
PURPOSE: To document the technical results and spectrum of practice of uterine artery embolization (UAE) for fibroids in the health care setting in Canada. The effects of interventional radiologist's (IR's) experience with UAE on procedure and fluoroscopy time were also investigated. MATERIALS AND METHODS: The study involved a multicenter prospective single-arm clinical treatment trial and included the practices of 11 IRs at eight university-affiliated teaching and community hospitals. Vascular access with percutaneous femoral artery approach was followed by transcatheter delivery of polyvinyl alcohol (PVA) particles into uterine arteries with fluoroscopic guidance. Technical success, complications, procedural time, fluoroscopy time, and effects of operator experience were outcomes analyzed. RESULTS: Between November 1998 and November 2000, 570 embolization procedures were performed in 555 patients. UAE was bilaterally successful in 97% (95% CI: 95%-98%). Variant anatomy was the most common reason for failure to embolize bilaterally. The procedural complication rate was 5.3% (95% CI: 3.6%-7.4%). Of the 30 events, three involved major complications (one seizure and two allergic reactions) that resulted in additional care or extended hospital stay. Procedure time and fluoroscopy time averaged 61 minutes (95% CI; 58-63 minutes) and 18.9 minutes (95% CI; 18-19.8) and varied significantly among IRs (P <.001; P <.001). The average 27% reduction in procedure time (20 minutes; P <.001) and 24% reduction in fluoroscopy time (5.1 minutes; P <.001) with increasing UAE experience were significant. CONCLUSIONS: A high level of technical success with few complications was obtained with a variety of operators in diverse practice settings. Increased experience in UAE significantly reduced procedure and fluoroscopy time.
Uterine artery embolization for leiomyomata may fail due to additional blood supply from the ovarian arteries. The potential role of supplemental ovarian artery embolization is unknown. The authors present here the results for their first six patients who were treated with ovarian artery embolization.
The purpose of this study was to determine if contrast material-enhanced magnetic resonance (MR) imaging could be used to stratify patients who have undergone failed primary uterine artery embolization (UAE) for repeated embolization. One hundred one consecutive patients who underwent UAE at a single center were followed prospectively and assessed for the presence of persistent contrast enhancement of leiomyomas on follow-up MR imaging. Among 11 of the 111 patients with primary clinical failure (10%), MR imaging showed persistent enhancement in eight. Of the eight cases of failure with continued tumor enhancement on MR imaging, six were treated with repeated embolization. All six patients showed complete symptomatic relief at 12-month follow-up. In women who have been treated with failed primary UAE, continued enhancement of leiomyomas on MR imaging can be used to identify candidates for successful repeated UAE.
Fifty-five adults who had sustained a tibial fracture, or a femoral fracture, or both, were subjected to a double-blind randomised study to determine the efficacy of methylprednisolone in treating the fat embolism syndrome. This drug maintained arterial oxygen levels, stabilised or reduced the serum level of free fatty acids, and decreased the risk of the fat embolism syndrome in a statistically significant proportion of patients. Gurd's criteria for the diagnosis of the fat embolism syndrome were found inadequate. Other more sensitive criteria for early diagnosis and effective management were determined. There were no deaths or serious morbidity in our series.
Major pulmonary embolism (PE) results whenever the combination of embolism size and underlying cardiopulmonary status interact to produce hemodynamic instability. Physical findings and standard data crudely estimate the severity of the embolic event in patients without prior cardiopulmonary disease (CPD) but are unreliable indicators in patients with prior CPD. In either case, the presence of shock defines a threefold to sevenfold increase in mortality, with a majority of deaths occurring within 1 h of presentation. A rapid integration of historical information and physical findings with readily available laboratory data and a structured physiologic approach to diagnosis and resuscitation are necessary for optimal therapeutics in this "golden hour." Echocardiography is ideal because it is transportable, and is capable of differentiating shock states and recognizing the characteristic features of PE. Spiral CT scanning is evolving to replace angiography as a confirmatory study in this population. Thrombolytic therapy is acknowledged as the treatment of choice, with embolectomy reserved for those in whom thrombolysis is contraindicated.
The correlation between volume embolization ratio (VER), the percentage of aneurysm volume occupied by coils, and aneurysm stability after endovascular treatment with platinum coils was studied in 86 patients who underwent embolization of 88 cerebral saccular aneurysms with standard platinum coils between March 1997 and January 2003. Radiographic follow up was possible of 62 aneurysms with greater than 70% obliteration on immediate post-procedure angiograms for more than 6 months. Immediate post-procedure evaluation found that 12 of 14 small (<4 mm), 12 of 38 medium (4-<10 mm), and two of 10 large (> or =10 mm) aneurysms had high (> or =25%) VER. In addition, the VER was high in 22 of 40 aneurysms with small (<4 mm) and four of 22 with wide necks (> or =4 mm). Evaluation of 57 aneurysms at 6 months after coil embolization found recanalization in two of 25 aneurysms with high VER and 21 of 32 with low (<25%) VER, indicating that aneurysms with high VER are significantly more stable than those with low VER (p < 0.01). VER strongly affects aneurysm stability, so high VER is desirable and a useful predictor of aneurysm stability.
OBJECTIVE: This study was conducted to determine whether an immediate change occurs in the blood flow distribution in hepatic segments after segmental portal vein embolization. CONCLUSION: We found an immediate change in the distribution of blood flow in the liver after embolization; with portal vein embolization, we found an immediate increase in the hepatic artery blood flow in the affected segments.
To study cerebral microembolism and focal impairment of the brain in patients with isolated and combined cardiac affection, we examined 84 patients who had survived cardioembolic stroke (CES). The examination included computed tomography of the head, echocardiography and transcranialdopplerographic monitoring of microembolic signals (MES). Group 1 consisted of 53 (63.1%) patients with one source of cardiocerebral embolism, group 2-31 (36.9%) patients with two potential causes of cardial embolic complications. In group 2 average number of documented MES (3[1;5]) and average number of cerebral ischemic foci (2[1;2]) were greater than those of group 1-2[1;4] and 1[1;1], respectively. As to the size of the lesion, it was found that small, middle-size and large foci were also visualized in group 2 more frequently. Thus, combination of two sources of cerebral embolism observed in 1/3 of CES enhances cardiogenic embologenic potential and probability of microembolism transformation into cerebral focal lesion as a result of potentiation of different ways of thrombogenesis.
It has been postulated in recent years that idiopathic necrosis of the head of the femur may possibly be caused by arteriolar obstruction by fat emboli emanating from a fatty liver, which would act as a reservoir, due to various causes such as alcoholism and prolonged steroid therapy. A similar situation has been found in human pathology in post traumatic fat embolism. The writers have reviewed forty five cases of post traumatic fat embolism which had passed the pulmonary filter. All the cases were reviewed after a minimum of two years, since this is considered the minimum time within which necrosis can manifest itself radiologically. In none of these cases was there any evidence of necrosis of the head of the femur. These findings, supported by other critical considerations. do not lend support to the theory of fat embolism as a case of idiopathic bone necrosis.