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PubMed1994

High-dose bolus injection of urokinase. Use during cardiopulmonary resuscitation for massive pulmonary embolism.

Bolus administration of high-dose thrombolytic agents has been reported for the treatment of acute pulmonary embolism. We describe the case of a 60-year-old woman who suffered a massive pulmonary embolism with cardiopulmonary arrest 21 h after an exploratory laparotomy. After 20 min of unsuccessful cardiopulmonary resuscitation (CPR), a bolus of 2,000,000 U of urokinase was injected via a peripheral vein. Ten minutes later, the circulatory system stabilized, and the patient survived without subsequent bleeding. In our opinion, bolus lysis made a definitive contribution to the success of the resuscitation. Several other case reports and small series showed successful treatment of pulmonary embolism during similar circumstances using high-dose bolus injection of thrombolytic agents. Mechanical thrombus fragmentation using a pulmonary artery catheter or pulmonary embolectomy has not been shown to be more successful during resuscitation. We conclude that bolus administration of thrombolytic agents during CPR for massive pulmonary thromboembolism may be an acceptable and successful technique, which also is available even in the community hospital setting.

Cardiopulmonary Resuscitation↗
PubMed2002

Major pulmonary embolism: review of a pathophysiologic approach to the golden hour of hemodynamically significant pulmonary embolism.

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.

Blood Gas Analysis↗
PubMed1977

Left ventricular function in massive pulmonary embolism.

Serial echocardiographic and angiographic measurements of left ventricular function were obtained in a patient with massive pulmonary embolism before and after pulmonary embolectomy. These data suggest that left ventricular dysfunction secondary to right ventricular failure is the results of markedly decreased left ventricular filling in this settings.

Echocardiography↗
PubMed1977

Saddle embolism of the innominate artery.

A case of saddle embolism to the innominate artery in a patient with congestive myocardiopathy is presented. Embolectomy was successfully performed under local anesthesia using a combined carotid and axillary approach.

Adult↗
PubMed1983

The clinical profile of unresolved pulmonary embolism.

Nearly all patients with pulmonary embolism (PE) have complete clinical and hemodynamic and at least near complete roentgenographic and angiographic resolution within four to six weeks of the acute event. To classify the syndrome of unresolved pulmonary embolism we reviewed our experience and that of the English literature to extract 30 well-described cases. The mean age at presentation was 45 years, and most patients were less than 60 years old. Almost all complained of dyspnea, and the majority had at least one clinical event suggestive of PE. Most had clinical evidence of pulmonary hypertension. Roentgenographic, arterial blood gas and electrocardiographic findings were nonspecific, though the perfusion lung scan was always abnormal. Most patients exhibited mild-to-moderate pulmonary hypertension. The severity of pulmonary artery obstruction was quite variable and did not correlate with the magnitude of arterial hypoxemia or pulmonary hypertension. Most patients did not improve with long-term anticoagulation therapy and underwent pulmonary embolectomy with acceptable mortality. Postoperative improvement correlated with improved arterial blood gas levels, abatement of pulmonary hypertension, and more satisfactory pulmonary perfusion.

Adolescent↗
PubMed1988

Sarcoma of the pulmonary artery.

A patient is described in whom clinical presentation, V/Q scan, and pulmonary angiogram were consistent with pulmonary embolus. No improvement occurred despite therapy with heparin. When sent for surgical embolectomy, sarcoma of the pulmonary artery was diagnosed. This entity, though rare, should be considered in the differential diagnosis of pulmonary vascular disease.

Diagnosis, Differential↗
PubMed1988

In vivo right heart thrombus. Precursor of life-threatening pulmonary embolism.

This report describes three cases of massive mobile right heart thrombus and reviews the available literature to better define the pathophysiology, natural history and most appropriate therapy of the syndrome. The clinical presentation of most patients has been severe cardiopulmonary dysfunction and the diagnosis has been made by echocardiographic study. The most likely source of these cardiac thrombi is the large systemic veins. The associated mortality risk is very high. Therapy has, heretofore, been individualized. Embolectomy has been most favored, with a survival rate of 80 percent. The role of thrombolytic therapy remains to be delineated. Therapy should, however, be initiated rapidly because of the precipitous nature of the mortality risk.

Aged↗
PubMed1989

Left ventricular thrombus in the absence of detectable heart disease.

A woman presented with acute left leg pain requiring urgent left femoral embolectomy. Echocardiography showed a large, pedunculated left ventricular mass, but no additional cardiac abnormality. Clinical evaluation including cardiac catheterization and open heart surgery demonstrated no cardiac pathologic findings. At surgery, a large thrombus was removed from the left ventricle. We suggest that all patients with arterial embolic disease have echocardiography, even if heart disease is not suspected.

Adult↗
PubMed2006

Techniques and outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

Cardiopulmonary function in patients with chronic thromboembolic pulmonary hypertension can almost be normalized by pulmonary endarterectomy. The procedure involves the removal of organized and incorporated fibrous obstructive tissue from the pulmonary arteries during circulatory arrest under deep hypothermia. Mortality rates reported for patients who have undergone pulmonary endarterectomy range from 4 to 24%. The operation is not an embolectomy but a true endarterectomy. After proximal intrapericardial pulmonary artery incision, the correct endarterectomy plane is established and circumferentially followed down to the lobar, segmental, and sometimes subsegmental pulmonary artery branches in each lobe. Completion of the endarterectomy procedure in one lung is usually possible within a 15-min period of circulatory arrest. This is followed by reperfusion and another period of circulatory arrest for the endarterectomy on the contralateral side. Additional cardiac procedures can be performed after arteriotomy closure, during the rewarming period, if necessary. The outcomes with regard to functional status, quality of life, hemodynamics, right-ventricular function, and gas exchange are very favorable. After surgery, significant and persistent decreases of pulmonary artery pressures and pulmonary vascular resistance are observed in a large majority of patients. Cardiac output is increased and right-heart function is persistently improved. Postoperative management of patients undergoing pulmonary endarterectomy can be challenging. Important complications are persistent pulmonary arterial hypertension due to inadequate endarterectomy or significant secondary vasculopathy, and reperfusion edema in the endarterectomized parts of the lung. Adequate postoperative care is therefore essential. Preoperative hemodynamic severity and the site of anatomic obstruction are believed to be key predictors of postoperative outcome.

Chronic Disease↗
PubMed2007

Massive bilateral pulmonary emboli complicating coronary artery bypass grafting: a case report.

We report an unusual case of massive bilateral pulmonary emboli following single coronary artery bypass grafting on cardiopulmonary bypass. The patient was admitted electively, received deep vein thrombosis prophylaxis, and had no clinical evidence of deep vein thrombosis in the perioperative period. On the tenth postoperative day he developed sudden dyspnea and a diagnosis of pulmonary embolus was made with computed tomography. Despite full anticoagulation he continued to deteriorate, and despite attempts at pulmonary embolectomy he died of right-sided heart failure. Post-mortem confirmed the diagnosis, but there was no evidence of thrombi in the pelvic and leg veins.

Aged↗
PubMed1999

Sequential retroperitoneal venous hemorrhage and embolism of an angio-seal puncture closure device complicating iliac artery angioplasty.

PURPOSE: To present a case of iatrogenic puncture closure device embolization complicating surgery for retroperitoneal hemorrhage (RPH) secondary to angioplasty-induced common iliac vein trauma. METHODS AND RESULTS: A 78-year-old woman with rest pain underwent successful kissing balloon dilation of her aortoiliac bifurcation for a calcified ostial stenosis of the left common iliac artery. Hemostatic puncture closure devices (Angio-Seal) were used to secure both femoral punctures. A right-sided retroperitoneal hematoma developed, and during surgical exploration of the right groin, the Angio-Seal device was removed. The only bleeding site found was the external iliac artery puncture and it was repaired. She again became hypovolemic 18 hours later and was returned to surgery, where bilateral groin explorations and laparotomy by the vascular surgical team found a tear in the left common iliac vein. After repair, the patient was stable for 48 hours when the left leg became critically ischemic. Angiography detected a new high-grade stenosis in the left profunda femoris artery; embolectomy retrieved a footplate from the left puncture closure device. The patient died 11 days later from multiorgan failure. CONCLUSIONS: RPH should be considered early as an occult cause of hypovolemic shock developing soon after even technically straightforward iliac angioplasty. Interventionists should be aware that using the Angio-Seal device risks acute limb ischemia if footplate embolization occurs.

Aged↗
PubMed2006

Over 14 years of experience with cardiac myxomas.

Atrial myxomas are the most commonly encountered tumours of the heart and can present at different ages with different clinical symptoms. They are one of the curable tumours of the heart. Appropriate surgical treatment and surgery must be performed with great precautions in order to prevent fatal systemic embolizations. In this retrospective study we will present our experience of 14 years, between 1990 and 2004, in 27 patients who had been operated for cardiac myxomas. Diagnosis of the myxomas were made by echocardiography in all cases. Surgical approach to the tumour was biatrial in nine, left atrial in II, and transseptal in seven patients. Associated procedures included coronary artery bypass grafting in one, mitral valve repair with tricuspid annuloplasty in two patients, mitral valve replacement in one and bilateral femoral embolectomy in one patient. One hospital mortality occurred as a result of multiorgan failure in a patient with peripheral embolization. None of the patients required recurrent operation, however, mitral valve insufficiency was surgically corrected in one patient.

Adolescent↗
PubMed1976

Pulmonary embolism: current therapeutic concepts.

Pulmonary thromboembolism is a widespread problem and is an important cause of death in patients with a variety of medical and surgical conditions. There have been few significant advances in the understanding of the aetiology beyond additional evidence confirming the importance of Virchow's triad. An impressive list of epidemiological associations has been compiled, however. Some knowledge of the natural progression of the disease is required as an aid in the understanding of the application of the therapeutic and prophylactic measures available in the management of pulmonary embolism. It would seem that at least two-thirds of pulmonary emboli are non-fatal, and in these cases the natural resolution, even of comparatively large embolic masses, is very efficient in patients without pre-existing cardiopulmonary disease. Diagnosis may prove difficult and most ancillary investigations are of questionable value. On the other hand, pulmonary radio-isotope scanning is far more specific and pulmonary angiography is a comparatively simple and complication-free diagnostic procedure. Prophylaxis is a real and practical aim, especially following surgery or myocardial infarction. In these groups widespread clinical trials of prophylactic measures have been made possible by the objective radio-iosotope screening techniques. Mechanical means of preventing venous stasis and anticoagulation appear effective. In addition, low-dose subcutaneous heparin seems to be as useful as heparin in conventional dosage. Apart from conventional supportive therapy, there are three major approaches to the treatment of pulmonary embolism. Heparin remains the mainstay, particularly in the less severe cases, hopefully preventing propogation of thrombosis and recurrence of embolism, thus allowing resolution to take place. Thrombolytic therapy with streptokinase or urokinase is capable of producing far more rapid dissolution of pulmonary emboli with consequent theoretical advantages over heparin. No reduction in mortality has been shown using thrombolytic therapy. Patients who fail to respond satisfactorily to acute resuscitative measures may require pulmonary embolectomy.

Chronic Disease↗
PubMed1999

Treatment of pulmonary thromboembolism.

The epidemiology, diagnosis, treatment, and prophylaxis of PE are rapidly advancing. Our array of diagnostic imaging tools has expanded to include echocardiography and spiral chest CT with contrast. We have also gained a keen appreciation for the importance of risk stratification of our patients. The decision to administer thrombolysis or undertake embolectomy may now depend upon the presence of right ventricular dysfunction even if systemic arterial pressure is normal. Finally, the availability of low molecular weight heparins broadens our options for pharmacologic management.

Anticoagulants↗
PubMed1978

Complications of catheter cerebral arteriography: analysis of 5,000 procedures. I. Criteria and incidence.

Computer analysis of complications of 5,000 catheter cerebral arteriograms performed at four hospitals (two training and two nontraining) revealed a total of 68 complications (1.4%). Eight (0.16%) of these complications were major: five patients required thrombectomy or embolectomy, two had permanent neurologic deficits, and one patient died. The complication rate for the training hospitals (3.9%) was significantly higher than that for the nontraining hospitals (0.9%), but the rates of permanent complications were identical in both groups (0.1%). Reporting criteria and complication types are described.

Adult↗
PubMed1983

Intraarterial infusion of urokinase in the treatment of acute pulmonary thromboembolism: preliminary observations.

Eleven patients were treated for acute pulmonary thromboembolism by perfusion of urokinase in the main pulmonary artery for a period of 12 hr with angiographic control. Clinical and radiologic improvement was achieved in all patients except for one in whom an embolectomy was later performed. The complications were similar to those for intravenous urokinase treatment, the most frequent being hemorrhage.

Aged↗
PubMed1985

Radiographic findings in pulmonary hypertension from unresolved embolism.

Pulmonary artery hypertension with chronic pulmonary embolism is an uncommon entity that is potentially treatable with pulmonary embolectomy. Although the classic radiographic features have been described, several recent investigators report a significant percentage of these patients with normal chest radiographs. In a series of 22 patients, no normal radiographs were seen. Findings included cardiomegaly (86.4%) with right-sided enlargement (68.4%), right descending pulmonary artery enlargement (54.5%), azygos vein enlargement (27.3%), mosaic oligemia (68.2%), chronic volume loss (27.3%), atelectasis and/or effusion (22.7%), and pleural thickening (13.6%). Good correlation with specific areas of diminished vascularity was seen on chest radiographs compared with pulmonary angiograms.

Adult↗
PubMed2004

Hybrid treatment of acute massive pulmonary thromboembolism: mechanical fragmentation with a modified rotating pigtail catheter, local fibrinolytic therapy, and clot aspiration followed by systemic fibrinolytic therapy.

OBJECTIVE: We sought to evaluate the efficacy and safety of a hybrid treatment for acute massive pulmonary thromboembolism in patients with hemodynamic impairment by combining mechanical fragmentation, local thrombolysis, and clot aspiration. SUBJECTS AND METHODS: Within a period of 35 months, 25 patients with hemodynamic impairment (eight men and 17 women; age range, 35-77 years) were treated with mechanical thrombus fragmentation using a modified rotating pigtail catheter. After embolus fragmentation, all patients received an intrapulmonary injection of recombinant human-tissue plasminogen activator and then underwent manual clot aspiration with a large-lumen percutaneous transluminal coronary angioplasty guide catheter. RESULTS: All the patients survived, and their clinical status improved. Posttreatment angiography showed an improvement in pulmonary perfusion in all patients (mean Miller score before treatment, 22.2; after treatment, 13.6; p < 0.01). Mean pulmonary artery pressure decreased from 32.6 to 23.4 mm Hg (p < 0.01). Mean treatment time was 124.6 min. CONCLUSION: Hybrid treatment with mechanical fragmentation using a rotating pigtail catheter combined with local fibrinolysis and manual clot aspiration resulted in a rapid and safe improvement in the hemodynamic condition of patients with acute massive pulmonary thromboembolism. This hybrid treatment appears to be especially useful in patients at high risk for right ventricular failure and is a minimally invasive alternative to surgical embolectomy.

Acute Disease↗