within the right atrium (Fig. 2). Due to the suboptimal contrast within the pulmonary arteries, evaluation for pulmonary thromboembolism can be incomplete, which can lead to misdiagnosis of pulmonary thromboembolism when no thromboembolism is present (31). In a recent case series, Prabhu et al. (31) described their experience in evaluating 5 pediatric patients who had Fontan procedure and multidetector CT (MDCT) for suspected pulmonary thromboembolism. Three of the patients were initially misdiagnosed as having pulmonary thromboembolism due to suboptimal contrast-enhancement technique using a single injection of contrast material through an upper extremity vein. They described the following three technical parameters that could be used to optimize CTPA in those patients with a Fontan: simultaneous injection of contrast material through lower- and upper-extremity veins, the usage of a delayed second-phase scan if there is a suboptimal contrast enhancement on the initial images or in patients with bilateral Glenn shunts with sluggish blood flow in the Fontan circulation or in the pulmonary arteries (Fig. 2), and employing bolus tracking with optimal contrast enhancement within the Fontan pathway and the pulmonary arteries (31). Alternatively, an additional useful technique for assessing Fontan pathway thromboembolism is to give patient a single intravenous injection of the leg at a slow injection rate with a single delay-phase scan at 1–3 minutes (32).
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An acute massive pulmonary thromboembolism, i.e., high risk PE, represents the most severe form of pulmonary embolism with mortality rates exceeding 20% irrespective of treatment [1, 2]. High-risk PE can ultimately result in sudden death secondary to massive obstruction of the pulmonary bed (approximately 10% of PE cases). Clin- ical presentation of high-risk PE is associated with hemodynamic instability, persistent hypotension (with hypotension defined as a sudden fall in systolic blood pressure to <90 mmHg or more, or by ≥40 mmHg from baseline) and cardiogenic shock [3, 4]. Standard manage- ment of PE involves anticoagulant treatment, though sys- temic thrombolysis is considered as a treatment of choice in cases of worsening cardiovascular instability or rapid respiratory failure [5–7]. Catheter-based approaches or open surgical embolectomy are usually considered when the thrombolytic therapy fails or it is contraindicated and a patient has persisting hemodynamic compromise [8– 11]. PMT involves use of certain mechanical devices, ultrasound, pressurized saline injection or suction to as- pirate fragments of macerated emboli following other thrombectomy techniques [12–16]. Mechanical thromb- ectomy exposes a thrombus surface area after fragmenta- tion and enables local intra-clot thrombolytic agents to augment thrombolysis [17–24]. Although thrombolysis and PMT facilitate rapid improvement in haemodynamics, serious complications may occur, including bleeding, per- foration or dissection of cardiovascular structures as well as failure to respond to initial immediate management . Currently, selection criteria for PE treatment options, i.e., systemic thrombolysis, PMT or open surgical embol- ectomy, are based mostly on the assessment of patient’s history.
Case presentation: A male in his early 40s began to complain of hallucinations. He was admitted to a psychiatric hospital as an emergency case 4 days before death. He was physically restrained to control agitation and aggressiveness. The patient was severely obese (BMI 36.45). At autopsy, large thromboembolic masses filled the pulmonary trunk and both pulmonary arteries. Thrombi were also noted in the right popliteal vein and bilateral gastrocnemius and soleus veins, suggesting bilateral lower extremity deep vein thrombosis. Dissection of the brain, which weighed 1457 g, revealed no noteworthy macroscopic findings. Histological examination showed lymphocyte infiltration into the perivascular space of the brain tissue with no vasculitis. Immunohistochemical staining of T. pallidum was negative, the fluorescent treponemal antibody-absorption test was positive, the rapid plasma reagin titer was 1:4, and the T. pallidum hemagglutination assay titer was 1:10,240. Real-time PCR assay of the brain tissue detected low copy numbers of T. pallidum genes. Altogether, the cause of death was acute pulmonary thromboembolism resulting from bilateral lower extremity deep vein thrombosis. The patient also had early-stage meningovascular neurosyphilis.
The child was in his usual state of health until he was found unresponsive on the floor near his bed one morning. Paramedics were summoned to the scene and, despite resuscitation efforts, the patient was pronounced dead. An autopsy revealed the cause of death to be massive, acute, pulmonary thromboembolism result- ing from acute left leg thrombosis. The family stated that the child had been asymptomatic, without recent complaints, pain, or clin- ical changes in his vascular malformation.
Purpose: We retrospectively analyzed open pulmonary thromboembolectomy in patients with acute and chronic pulmonary thromboembolism. Materials and Methods: Between August 1990 and May 2005, 12 consecutive patients with acute and chronic pulmonary thromboembolism underwent open pulmonary thromboembolectomy at Yonsei Cardiovas- cular Center. Their mean age was 47.5 years, and 7 of the patients were female. Among 12 patients, 5 had acute onset, and 7 had chronic disease, and 9 patients were associated with deep venous thrombosis. Extent of pulmonary embolism was massive in 3 patients with hemodynamic instability, and sub- massive in 8 patients. Preoperative echocardiogram revealed elevated right ventricular pressure in all patients, and 7 patients were in NYHA functional class III or IV. Pulmonary thromboembolectomy was performed in all patients under total circulatory arrest. Results: There were 2 hospital deaths (16.7%). Among the patients who survived, mean right ventricular pressure was decreased significantly from 64.3 mmHg to 34.0 mmHg with improvement of NYHA functional class. Conclusion: Open pulmonary thromboembolectomy is thought to be an immediate and definitive treatment for massive pul- monary embolism with optimal results. Even though operative mortality is still high, early diagnosis and immediate surgical intervention in highly selective patients may improve the clinical outcome.
Symptomatic pulmonary thromboembolism (PTE) is rare in neonates, and the diagnosis is often made only postmortem. The true incidence is probably underestimated because of its varying presentations, ranging from mild respiratory distress to acute right-heart failure and cardiovascular collapse. We report a sudden cardiorespiratory collapse on day 10 of life in a preterm neonate who was subsequently diagnosed as having a saddle pulmonary embolus. The patient underwent an emergency surgical embolectomy as a salvage procedure. Considering the potentially lethal complications of PTE, neonatologists and pediatricians should maintain a high degree of suspicion in infants with sudden inexplicable deterioration in cardiorespiratory status. Surgical removal of the thrombus is an invasive procedure and potentially carries a high mortality rate. Two term neonatal survivors of surgical intervention have been reported in the medical literature so far. However, we believe that this is the ﬁrst documented preterm neonatal survivor after surgical intervention for a massive saddle PTE.
Background: Systemic lupus erythematous (SLE) can involve any organ in body, but pulmonary vascular system involvement is usually in the latter course of the disease. Case Report: Here we are submitting a case of SLE who was presented with massive pulmonary thrombosis as a presenting symptom. A 25 year old unmarried female patient presented to us with complaints of sudden onset breathlessness and retrosternal chest pain. On the basis of examination and investigations SLE with Pulmonary thromboembolism was diagnosed. She was treated with Immunosuppressive and anticoagulant therapy and showed a dramatic good response. Conclusion: Patient comes with sign and symptoms of Pulmonary thromboembolism as a first manifestation, should also be evaluated for SLE and Anti phospholipid antibody.
Methods: In this cross-sectional study, the patients being referred to 3 of teaching hospitals of Tehran from March 2015 to March 2016 because of trauma and died in hospital due to the diagnosis of pulmonary embolism (PE) were recruited. Then the patients were autopsied and the cause of death was evaluated and the frequency of PE was compared before and after the autopsy.
elicited. Laboratory investigations and complete haema- tological profile was within normal limits (no features of hypercoagulable disorders). Echocardiography showed dilated right atrium and right ventricle with impaired right ventricular systolic function. The pulmonary valve appeared thickened with possible mass attached to it, with turbulence and gradient in the main pulmonary artery. A contrast enhanced CT was performed which revealed a hypodense filling defect in the main and bilateral pulmo- nary arteries which did not exhibit any significant post contrast enhancement (Fig. 1). Based on the clinical and radiological findings a diagnosis of pulmonary thrombo- embolism was made and pulmonary thromboendarter- ectomy was planned. Under GA, midline sternotomy was performed and main pulmonary artery was opened. Grey white organised mass with thrombosed areas was removed by separating it from the main pulmonary artery, bilateral pulmonary artery branches and pulmonary valves. On his- topathology the tumor was composed of spindle to epithe- lioid cells exhibiting moderate to marked pleomorphism
Spiral CT Scan (Fig.3) showed no other pulmonary paranchymal lesions and the pulmonary arteries CT angiography (Fig.4), as the most validated test for PTE diagnosis in our region, reported as “after injection of contrast medium with power injection with the rate of 4 ml/s, pulmonary arteries were opacified. The main trunk of pulmonary artery and the left main pulmonary arteries had normal course with no evidence of any stenosis or pathologic dilatation or thrombosis. Filling defects are evident in distal of right pulmonary artery that is extended to all lobar branches of right lung. Small filling defects are also noted in distal branches of pulmonary arteries of the left lower lobe. Above descriptions were consistent with the diagnosis of pulmonary
In addition, the amounts of apoptotic type II pneumocytes have negative correlation trend with the arterial blood PaO2/FiO2 because the apoptotic pneumocytes are of insufficience for the surfactant secretion, preventing lung collapse, improving oxygenation. These findings are in accord with a randomized controlled clinical study on PTE, lung transplantation and the mechanisms [30,42]. The mechanisms of injury may involve neutro- phil activation, oxygen radicals, cytokines, complement, arachidonic acid derivatives, platelet activating factor . The LIRI can be effectively blunted by the reduction of macrophage- dependent injury by gadolinium while inhaled NO also will attenuate injury by reducing pulmonary hypertension and minimizing neutrophil sequestration . Study has also found that inspired NO promoted the integrity of pulmonary endothelium, increased the vascular density and alleviated the lung histological injury compared to ARDS by aug- menting the mRNA expression of Endothelial Progenitor Cells (EPC) surface markers CD34 and CD133 in lung tissue .
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an independent risk factor for thrombosis. Antiretroviral therapy does not appear to significantly increase risk of venous thromboembolism in HIV-positive patients . The prothrombotic state in HIV-positive patients correlates with the severity of HIV-associated immunosuppression. The mechanism of this increased prothrombotic state in HIV patients is unknown. However, various abnormalities predisposing to a prothrombotic state have been reported, including the presence of antiphospholipid antibodies and lupus anticoagulant, deficiencies of protein C, protein S, heparin cofactor II, and antithrombin, and increased levels of von Willebrand factor and D-dimers [2, 3].
It is recognised that this study has limitations. This investiga- tion was designed as a pilot study, with a small planned enroll- ment, but clearly represents a small sample of the dogs treated at the institution. All dogs in this study were deemed high-risk for PTE. Although this increased the pretest probability of PTE, it did enable evaluation of the feasibility of CTPA for PTE diag- nosis in dogs. The study was also limited by the lack of a gold- standard against which to compare CTPA. V/Q scintigraphy and selective pulmonary angiography have previously been used for PTE diagnosis in dogs (Suter 1984, Bunch et al. 1989, Johnson et al. 1999), but V/Q scanning was not available and selective pulmonary angiography is an invasive and potentially high-risk procedure in unstable cases.
Case presentation: A 27-year-old Greek woman, gravida 2 para 1, presented at 10 weeks ’ gestation to the Emergency Unit of our hospital complaining of diffuse abdominal pain which deteriorated the last 3 days, which was localized in her right iliac fossa, along with vomiting. She had undergone open laparotomy and right salpingo-oophorectomy at the age of 23 due to an ovarian cyst. Besides this, her personal and family medical history was unremarkable. She had never received oral contraceptives or any hormone therapy. On arrival, a clinical examination revealed tenderness on palpation of her right iliac fossa, without rebound tenderness or muscle guarding. Within 10 hours of hospitalization, her symptoms deteriorated further with rebound tenderness during the examination, tachycardia, and a drop of 12 units in her hematocrit value. An emergency laparotomy was performed. Two mesenteric cysts and a 60 cm necrotic part of her intestine were revealed intraoperatively. In the postoperative period, she complained of acute abdominal pain, tachycardia, and dyspnea. Computed tomography imaging revealed mesenteric vein thrombosis and pulmonary thromboembolism. She was treated with low molecular weight heparin and she was discharged on the 11th
Venous thromboembolism (VTE) is considered as one of the leading causes of maternal mortality during pregnancy and postpartum period. In this retrospective study the medical records of 81 women diagnosed with Pulmonary thromboembolism (PTE) and Deep venous thrombosis (DVT) between 2009 and 2012 in Tabriz Al-Zahra hospital was participated. These cases were evaluated regarding frequency, maternal and fetus risk factors associated with VTE. During 3 years 33 patients were diagnosed as PTE; 7 women were diagnosed as DVT and PTE; and 41 women were diagnosed as DVT. Most frequent underlying disease was hypertension (13.5%) and most frequent symptoms of PTE and DVT were dyspnea (100%) and swelling of lower limb (100%) respectively. 93% of PTE and 79% of DVT incidences occurred during and after the third trimester of pregnancy. Additionally, 38% of PTE occurred during or after childbirth (33% following cesarean and 5% following vaginal delivery). Therefore, it seems that vaginal delivery is safer than cesarean surgery. In addition, the importance of third trimester of pregnancy and postpartum period is obvious.
For patients who are not suitable candidates for aggres- sive surgical intervention, transcatheter arterial emboli- zation, being a less invasive procedure, offers a suitable and effective alternative in HSS . Furthermore, since aneurysms in HSS are usually bilateral and multifocal at the time of diagnosis, embolization is a preferred modal- ity in such patients . Arterial embolization is also an acceptable therapeutic option in patients with severe or recurrent hemoptysis . Authors have performed embolization with several agents including steel coils, ethibloc and an epoxy, isobutyl cyanoacrylate . Asso- ciated complications of arterial embolization include arteriovenous fistulae, pulmonary infarction, abscess for- mation, oesophageal necrosis, bronchial necrosis, and spinal ischemia [70,71]. Rarely, the patients may require repeat embolization because the arterial lesions may become recanalized or revascularized . Balloon veno- plasty may be used in patients with vena caval thrombo- sis. However, it is only safe to perform this procedure in the early stages .
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Background: In patients hospitalized over a 4 year period for pulmonary embolism (PE), we assessed relationships of testosterone (TT) and estrogen therapy (ET) anteceding PE in patients found to have familial-acquired thrombophilia. Methods: From 2011 through 2014, 347 patients were hospitalized in Cincinnati Mercy Hospitals with PE. Retrospective chart review was used to identify patients receiving TT or ET before PE; coagulation studies were done prospectively if necessary.
To confirm dissection, MDCT pulmonary angiography was performed using a Somatom Sensation Open 64 CT scanner (Siemens, Germany). We acquired MDCT data during an IV injection of 100 ml of the iodinated contrast agent iomeprol (Iomeron 400, Bracco Imaging, Germany) at a rate of 4 mL/sec. The following scanning protocol was used: collimation, 4 × 1 mm; gantry rotation time, 500 msec; and table feed, 1.5 mm/rotation. The tube current was 150 mA at 140 kV to keep the radiation dose within a reasonable range. The scan delay was determined using bolus tracking. Multiplanar reformation (MPR) images in sagittal, coronal, oblique sagittal, and curved projections were generated.
Study Design: Retrospective review. Summary of Background Data: Deep vein thrombosis (DVT) and pulmonary embolism (PE) are potential complications following major orthopaedic surgical procedures. Venous thromboembolism (VTE) is the disease process underlying DVT and PE. Pharmacological options can be use low-molecular-weight heparin (LMWH). Objective: The purpose of this study is to evaluate the hemorrhage risk when LMWH is started after 24 hours from surgery and to assess venous thromboembolism and pulmonary embolism risk in patients undergoing early prophylaxis after spine surgery. Methods: A consecutive cohort of 100 patients undergoing spinal surgery. Diagnosis was multilevel lumbar spinal stenosis in 46 cases and, degenerative thoracolumbar kypho-scoliosis in 54 cases. Starting on the first postoperative day, patients were routinely administered daily prophylactic enoxaparin at 8 pm (40 mg). Analysis was performed to identify risk factors of VTE among five independent variables (age, sex, obesity defined as body mass index > 30 kg/m 2 , smoking, duration of surgery), with statistical significance
Elective TKA and revision showed incidence rates of 1.3% and 14.2% in subjects who were placed in inten- sive care, respectively. In addition, there were differences in the mean length of ICU stay, 1.83 days in the group of Elective TKA vs. 3.5 days in the group of revision, indicating that the difference in VTE incidence is because of intensive care placement status as well as the duration of the stay based on the type of surgery. The factors that are most commonly reported as risk factors, including long-term hospitalization (more than 2 weeks), fe- male, elderly (older than 65 years), cardiovascular disease, and malignant tumors were shown to be weakly as- sociated based on the results of this study. Unexpectedly, BMI was smaller in the DVT group; this may be a sta- tistical error due to the considerably low DVT incidence, unlike other studies, especially due to the relatively lower morbid obesity rate compared to the West. According to a SMART study  and Markovic-Denic et al. , chronic heart failure, varicose veins, and a history of VTE were independent risk factors. In an ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting) study , the primary risk factor for DVT in surgical patients prior to hospitaliza- tion was obesity (10%), followed by chronic heart failure (9%), chronic pulmonary disease (8%), and presence of varicose veins or venous insufficiency (7%); following hospitalization, the highest risk factors were complete immobilization (39%) followed by ICU stay (23%). Our results support that motor impairments and ICU stay after orthopedic surgery are the most significant risk factors for VTE.