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A 23-year-old female underwent uneventful caesarian section, which was followed by massive pulmonary embolism. Pulmonary embolectomy on cardiopulmonary bypass was performed, and was complicated by massive intraabdominal haemorrhage due to a hepatic subcapsular rupture. To our knowledge, this is the first surgically orientated case of postpartum pulmonary embolectomy to be reported in the literature.
An unusual case with delayed presentation of a false popliteal aneurysm following transfemoral embolectomy is reported. It highlights that arterial embolectomy, despite its well-established merits, may have major complications.
PURPOSE: To present the successful primary stenting of a superior mesenteric artery (SMA) occlusion following failed surgical embolectomy. CASE REPORT: A 65-year-old woman with a history of atrial fibrillation underwent surgical embolectomy of an acute embolic occlusion of the superior mesenteric artery (SMA). The following day, symptom recurrence suggested reocclusion, which was confirmed with emergent arteriography. Two balloon-expandable stents were deployed primarily, which ameliorated the patient's symptoms. Follow-up angiography at 3 months showed continued SMA patency, with no evidence of distal embolization or restenosis. The patient remains asymptomatic at 9 months after the stent procedure. CONCLUSIONS: Although more experience is required, primary stenting may be a valuable alternative in the treatment of acute SMA occlusions, in particular, for reocclusions after failed surgery.
A fulminant pulmonary embolism can be treated surgically if thrombolytic therapy is contraindicated. A 31-year-old woman developed a fulminant pulmonary embolism after right-sided deep venous thrombosis 1 day after undergoing a cesarean section. A pulmonary embolectomy with cardiopulmonary bypass was performed, but the patient was brain-dead. After 2 days of echocardiographic observation, her heart was explanted for a 61-year-old man with ischemic cardiomyopathy. His right heart data were unremarkable, and he remains well 16 months after transplantation. Despite the sudden strain on the right ventricle that occurs with a pulmonary embolism, such a heart may be transplanted successfully after a pulmonary embolectomy.
BACKGROUND: The aim of the study was to review early and long term clinical results of percutaneous thrombo-embolectomy in patients with acute embolic occlusions of the infrainguinal arteries. METHODS: Retrospective analysis of consecutive cases. A total of 88 procedures in 84 patients were performed between 1986 and 1996 in a University Hospital (46 men, 42 women; mean age 67.6 +/- 14.4 years). Patients with a history of chronic symptomatic arterial occlusive disease were not included in the analysis. Indications for treatment were severe claudication (n = 45 procedures) and limb threatening ischaemia (n = 43 procedures). Percutaneous thrombo-embolectomy was performed via an ipsilateral approach by means of an end hole aspiration catheter. Local thrombolysis or balloon angioplasty was used as appropriate during the intervention. Follow-up included clinical data, ankle pressure measurements, pulse volume recordings and duplex sonography or angiography if indicated. RESULTS: Technical success was achieved in 85 (96.6%) of the 88 procedures. Two patients (2.3%) suffered major and two patients (2.3%) minor complications. One patient died within 30 days after the procedure. Mean follow-up was 3.7 +/- 2.9 years. Twelve patients (16%) were lost to follow-up. Primary clinical success rate was 88.4% at one and 81.7% at two years and declined to 76.5% at eight years. Out of the 16 interval failures 10 (63%) were due to recurrent embolism to the same leg. They resulted in nine catheter reinterventions and one bypass graft. Six patients were treated conservatively. Cumulative mortality was 11.7% at one year and increased to 29.5% at eight years. CONCLUSIONS: From our single centre experience we conclude that catheter treatment of acute embolic occlusion of infrainguinal arteries is safe and has favourable long-term RESULTS. We therefore regard the technique as a less invasive alternative to surgery.
BACKGROUND: Aim of this study is to evaluate the use of intraoperative intra-arterial urokinase infusion (IIUI) in overcoming residual thrombi after thromboembolectomy in acute lower limb ischemia. METHODS DESIGN: retrospective study over a 3-year period. SETTING: University affiliated hospital. PATIENTS: 21 patients with acute lower limb ischemia who underwent IIUI after embolectomy (18 transfemoral, 3 transpopliteal) had failed to achieve adequate distal perfusion. Postoperatively, all patients were maintained on full dose heparinization. MAIN OUTCOME MEASUREMENTS: complete or partial clot lysis on post-IIUI angiography; restoration of pedal pulses and a viable leg at discharge. RESULTS: Angiographically, complete and partial lysis was demonstrated in 14 and 3 patients, respectively. Two patients with prolonged ischemia required fasciotomy. One of these eventually had an amputation. Altogether, limb amputations (1 above knee, 2 below knee) were necessary in 3 patients. The angiographic appearance of lysis correlated well with the restoration of pedal pulses and/or limb viability. One patient died of myocardial infarction 3 days after the procedure. Postoperatively, there were 5 (24%) wound hematomas of which 1 required surgical exploration. Over a mean follow-up period of 8 months (range 1-16), limb salvage was sustained in the 17 patients with successful angiographic lysis. CONCLUSIONS: IIUI is an effective therapeutic adjunct to failed embolectomy in acute lower limb ischemia. Use of this procedure is recommended as part of the routine management in such cases.
We describe a case of successful pulmonary embolectomy that required lobectomy to treat for endobronchial bleeding. Sixty-nine-year-old female got into shock required CPR during rehabilitation after replacement of femur head. Her enhanced computed tomography (CT) showed massive embolism in pulmonary artery. Emergency embolectomy was performed under cardiopulmonary bypass (CPB). A videoscope was employed to see inside the pulmonary artery. At the end of the CPB, endobronchial bleeding occurred. The right bronchus was occluded by balloon and CPB was weaned. The right lower lobectomy was done on the next day. She had got pyothorax by methicillin-resistant Staphylococcus aureus (MRSA), and has recovered after intravenous administration of antibiotics and continuous wash out of pleural space by saline containing 0.02% povidon-iodine. Postoperative scan showed no defects of blood flow and ventilation except resected lobe.
INTRODUCTION: The Authors report their experience in the management of acute lower limbs ischemia through distal popliteal artery approach. PATIENTS AND METHODS: Five popliteal embolectomy through a medial approach were performed; in one patient a posterior approach was carried out. Patients were included in two groups on the basis of ischemia duration: group A<6 hours (3 patients) and group B>6 hours (3 patients). Colour-duplex scan was performed in all the patients The arteriotomy was closed with interrupted 7/0 monofilament polypropylene sutures. RESULTS: There were no peri-operative deaths. The primary limb salvage rate was 83.3% (5 patients). In one case (16.7%) a major amputation was performed. In one case (16.7%) a drop foot occurred. CONCLUSIONS: The popliteal embolectomy is followed by excellent results and should be consider prior to thrombolysis or bypass graft revascularization. An appropriate use of duplex scan and a medial approach can lead to an high successful rates in terms of limb function and limb salvage also in cases with delayed ischemia.
An urgent pulmonary embolectomy on a patient under intraoperative angioscopy for the treatment of massive pulmonary embolism was performed and successfully saved the patient. The case was a 19-year-old man who had been bedridden over along period of time. He developed pulmonary embolism immediately after the initiation of walking rehabilitation. Although anticoagulation therapy was immediately carried out, hemodynamics deteriorated, and as a result, it became necessary to treat this patient with the urgent surgical procedure. Under extracorporeal circulation with the clamping of the aorta, the pulmonary artery was opened. Following embolectomy for the left pulmonary artery, the right pulmonary artery, where the presence of clots had not been confirmed with the naked eye, was inspected using an flexible fiberoptic choledochoscope 4.9 mm in diameter. Consequently, amount of clots were removed using forceps or an aspirating tube. The patient recovered from hypoxemia after surgery. The use of intraoperative angioscopy in the pulmonary artery proved to be very useful to examine the presence of emboli up to tertiary branches of pulmonary artery.
The authors report a case of massive pulmonary embolism compromising the haemodynamic status of a 52 year old man with a formal contraindication to thrombolytic therapy. Unilateral pulmonary embolectomy was performed without cardiac pulmonary bypass, preceded by partial interruption of the inferior vena cava. Postoperative controls confirmed the success of the surgical procedure. Although the indications of surgical embolectomy are limited, especially without cardiopulmonary bypass, it may be considered for the treatment of certain cases of massive pulmonary embolism.
OBJECTS: A retrospective study on patients operated on for intestinal ischemia. PATIENTS AND METHODS: We have carried out a retrospective study on 21 patients suffering from intestinal embolism, in whom an embolectomy was performed at the origin of the superior mesenteric artery. The diagnosis was based on angiography in 12 patients before operation. In the other nine patients the diagnosis was confirmed during operation. RESULTS: After embolectomy the viability of the gut was achieved in 43% of patients (100% if the duration of the symptomathology was less than 12 hours, 56% if it was between 12 and 24 hours, and 18% if it was more than 24). The mortality correlated with the duration of the symptoms. Overall mortality was 57%. CONCLUSIONS: The only way to improve the survival rate is to obtain an early diagnosis, which could be achieved by performing a mesenteric angiography on all patients with sudden and vague abdominal pain and with a history of cardiovascular disease.
A 61-year-old woman was transferred to our hospital because of palpitation, tachypnea and repeated syncopal attack. On admission, sinus tachycardia and hypoxia were noted without deterioration of consciousness. The diagnosis of pulmonary embolism was made by pulmonary angiography and right heart catheterization showing multiple pulmonary emboli and pulmonary hypertension. An emergent pulmonary embolectomy was performed under total cardiopulmonary bypass. Residual emboli of bilateral pulmonary arteries were detected with a fiberoptic choledochoscope and removed carefully with forceps. Pulmonary angioscopic evaluation appears to be safe and useful for direct visual detection of emboli and completion of embolectomy.
This study compared seven makes of balloon embolectomy catheter currently available, testing the most commonly used 4 Fr catheters. The volume of fluid and inflation pressure required to burst balloons of each type were measured. All balloons showed a similar shape of inflation curve, but compliance varied considerably, and the pressure required to burst different balloon types varied from 1060 to 1920 cmH2O. Two balloon types consistently fragmented when they burst in free space. On a specially designed mechanical rig balloon catheters were pulled through a 6 mm tube containing a fixed stenosis, with continuous measurement of traction force and intraballoon pressure. Traction force varied from 34 to 129 g (median 40 g) during passage along the tube, and from 254 to 463 g (median 350 g) during passage through the stenosis. The shear force imparted by the balloon to the tube wall was also calculated. This study provides comparative data which may help to guide surgeons in their choice of balloon embolectomy catheter.
Acute massive pulmonary embolism continues to be a major problem even though thrombolysis and surgical management have become well established methods of treatment. Our experiences demonstrate that the need for pulmonary embolectomy is rare, today embolectomy must be considered, when thrombolytics are contraindicated or ineffective, as emergency operation in moribund patients with sudden massive pulmonary embolism, in carefully selected cases with chronic post-embolic obstruction of pulmonary arteries.
Transvenous pulmonary catheter embolectomy is being used as a method of treatment for patients suffering from massive pulmonary embolism. The anaesthetic management of these patients can be complex. Presented is a case of transvenous pulmonary embolectomy in a patient who also had an intravascular volume deficit secondary to haemorrhage and possible reperfusion oedema. A discussion of appropriate monitoring during procedure follows.
Laparoscopic instrumentation of the common bile duct (CBD) via the transcystic route or through direct choledochotomy seems to be safe, but in rare cases, complications such as pancreatitis, bile duct damage, and hemorrhage from cystic artery may occur. We report an unusual complication with this approach. A 62-year-old man with gallbladder stones presented with obstructive jaundice, mild pancreatitis, and a dilated CBD. He underwent laparoscopic cholecystectomy with an intraoperative cholangiogram through the cystic duct. A small stone seen in the CBD was removed using a 6-Fr vascular Fogarty catheter. Two days later, he became jaundiced again with a rising bilirubin. An endoscopic retrograde cholangiogram showed a 1.5-cm round filling defect floating in a dilated CBD. A sphincterotomy was performed, and a balloon catheter was inflated proximally and pulled down. To our surprise, the filling defect was a crystal clear object, which we finally realized was a fully inflated Fogarty catheter balloon. The balloon spontaneously deflated while being caught with a basket. Surgeons should be aware of this possible complication, and every effort should be made to verify that the balloon still is in place after removal of the embolectomy catheter. Whether vascular embolectomy catheter balloons are appropriate for stone removal or more rigid balloons should be used needs further evaluation.
This case report describes a patient with massive pulmonary embolism and acute circulatory failure in whom transesophageal echocardiography permitted the diagnosis of thrombi in the main pulmonary truncus and in the right branch and guided intraoperatively the surgical embolectomy performed under simple venous inflow occlusion because of a contraindication to heparin administration. Transesophageal echocardiography seems to be a very helpful technique to diagnose promptly massive pulmonary embolism and a very useful tool at the time of operation to guide the embolectomy.
We report the case of a 14-year-old boy treated successfully by pulmonary embolectomy for massive pulmonary embolism, 18 days after bilateral hip surgery. He has a family history of pulmonary embolism and an inherited antithrombin deficiency. His diagnosis was confirmed by spiral computed tomography scan. We believe that pulmonary embolectomy has a role in selected cases in children.