Clinical Management of Mantle Cell Lymphoma With Concurrent Vascular Complications: A Case Report

This is a case of a 70-year-old patient with no past medical history but a significant family history of cancer, who was admitted with acute pulmonary embolism and left lower extremity deep vein thrombosis concerning malignancy. Further investigations revealed mantle cell lymphoma. This case highlights the complex clinical management of patients presenting with concurrent hematological malignancy and vascular complications.

Recurrent Syncope Unveiling Pulmonary Hypertension Secondary to Pulmonary Artery Thrombi in a Pediatric Patient

We present a case of a nine-year-old female patient who presented with recurrent syncope and was ultimately diagnosed with pulmonary hypertension (PH) secondary to pulmonary artery thrombi in the context of anti-phospholipid syndrome (APS). Extensive investigations including imaging studies revealed PH. Thromboembolic workup confirmed multiple pulmonary artery thrombi, and anti-phospholipid antibody testing confirmed APS. The patient received anticoagulation therapy tailored to APS management. Follow-up assessments demonstrated significant improvement in PH leading to cessation of syncope episodes. In this case, we underscore the importance of considering rare causes of syncope in the pediatric age group, particularly autoimmune disorders. Timely recognition and appropriate management are crucial for favorable outcomes in such cases. This report contributes to understanding the diverse clinical presentations of APS and emphasizes the need for a comprehensive diagnostic approach in patients with unexplained syncope.

Lemierre Syndrome With Streptococcus constellatus Bacteremia

Lemierre syndrome is characterized by thrombophlebitis of the internal jugular vein (IJV) secondary to bacterial pharyngitis or tonsillitis. Though antibiotic use has made this a rarer syndrome, it can nevertheless manifest in patients presenting with pharyngitis. Herein, we describe a 20-year-old male patient with no relevant medical history presenting with signs concerning for pneumonia and was ultimately diagnosed with Lemierre syndrome with Streptococcus constellatus bacteremia. Complications included IJV thrombus with presumed septic emboli to the lungs. The patient was discharged on ampicillin/sulbactam with plans to transition to amoxicillin/clavulanate.

The Development of Fat Embolism Syndrome (FES) and Multiple Small Pulmonary Emboli Following Open Reduction Internal Fixation (ORIF) of a Left Femur Fracture: A Case Report

Fat embolism syndrome (FES) is a rare but potentially life-threatening complication that can occur following orthopedic procedures, such as long bone fracture repairs. FES is caused by the release of fat globules into the bloodstream, leading to the obstruction of blood vessels and subsequent tissue damage. Pulmonary embolism (PE), a condition in which a blood clot travels to the lungs, is another potential complication of orthopedic procedures due to the mobilization of blood clots during surgery. We report the case of a 56-year-old female who presented to the emergency department with a left femur fracture following a mechanical fall and underwent open reduction internal fixation (ORIF) surgery for the fracture. The procedure was complicated by the development of FES and multiple small pulmonary emboli. The patient was managed postoperatively in the ICU, requiring support with multiple vasopressors and mechanical ventilation. She remained in the ICU for three days postoperatively and was discharged on postoperative day six to an inpatient rehabilitation facility.

Bibliometric Analysis of Diagnostic Yield of CT Pulmonary Angiogram (CTPA) in the Diagnosis of Pulmonary Embolism (PE)

CT pulmonary angiography (CTPA) is the investigation of choice for diagnosing pulmonary embolism (PE). Due to the speed and ease of performing the CTPA scans, more clinicians are becoming overly reliant on them, even for patients without strong suspicion of PE. We conducted a bibliometric analysis on the PubMed database from 1990 to 2022 to investigate the literature on the diagnostic yield of CTPA in the diagnosis of PE. A total of 166 articles were published in 98 journals. The number of publications has steadily increased since 2010 and peaked in 2020. Authors from 24 countries contributed to these publications, with the overwhelming majority emanating from United States of America, totaling 66 articles. The authors' contributions were relatively well spread out, with the top four authors publishing the highest number of articles at six each. When we investigated the collaboration between the authors, we found limited multinational and multi-institutional collaborations on this topic. Therefore, more multinational and multi-institutional collaborations will be valuable in future studies. In conclusion, this bibliometric analysis summarizes the literature on diagnostic yield of CTPA in the diagnosis of PE and sheds light on the future pathway that researchers and institutions can focus on.

Acute Portal Vein Thrombosis as an Initial Presentation of Protein C Deficiency: A Case Report

Protein C (PC) is an essential vitamin K-dependent protein that regulates thrombosis and hemostasis in the body. A mutation in the PROC gene on chromosome 2q14.3 results in PC deficiency. The clinical presentation of PC deficiency can vary, ranging from a single vein thrombosis to disseminated intravascular coagulation, purpura fulminans, or even life-threatening complications such as sepsis. Here, we present a case of a 37-year-old female who was found to have acute portal vein thrombosis as an initial presentation of PC deficiency. She presented to the hospital with acute onset of abdominal pain associated with nausea, blood-streaked emesis, and bloody bowel movement.

Recurrent Thromboembolic Events While on Anticoagulation Lead to the Diagnosis of Metastatic Lung Adenocarcinoma: A Case Report

Lung cancer can lead to hypercoagulability that causes thromboembolic events such as pulmonary emboli, deep vein thrombosis, ischemic strokes, and non-bacterial thrombotic endocarditis. While it is not uncommon for cancer to cause thromboembolic events, it is unusual for thrombotic events to be the first manifestation of cancer. In the following report, we review the case of a 59-year-old woman who presented with melena and abdominal pain. She had a pertinent history of multiple thromboembolisms while on anticoagulation four months before this presentation. Upon admission, it was discovered that the patient had new pulmonary emboli, and further workup revealed that her gastrointestinal symptoms were due to ischemic colitis. While initial imaging showed no evident masses that would heighten suspicion of cancer, she had persistent abdominal lymphadenopathy. Therefore, she also underwent an abdominal lymph node biopsy which revealed metastatic lung adenocarcinoma, a possible cause of her hypercoagulable state. This case report highlights the importance of considering malignancy in the differential of a patient with recurrent thromboembolism and raises the question of whether standardized screening for malignancy in patients with multiple thromboembolic events would be beneficial.

May-Thurner Syndrome: A Suspicion That Led to an Incidental Discovery

May-Thurner syndrome (MTS)/Iliac vein compression syndrome is characterized by left iliac vein stenosis secondary to compression by the right common iliac artery against the fifth-lumbar vertebra. It increases the incidence of deep venous thrombosis (DVT). We had a 43-year-old female presenting with left leg swelling and was found to have extensive DVT provoked by a long history of travel. Because of the extension of her thrombus, a catheter-guided thrombectomy (CDT) was planned and findings of MTS were identified incidentally. She had an endovascular stent placed and was discharged on long-term anticoagulation.

Role of extracorporeal membrane oxygenation and surgical embolectomy in acute pulmonary embolism

PURPOSE OF REVIEW

Surgery is an important option to consider in patients with massive and submassive pulmonary emboli. Earlier intervention, better patient selection, improved surgical techniques and the use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) have contributed to improve the safety of surgery for pulmonary emboli.

RECENT FINDINGS

VA ECMO is rapidly changing the initial management of patients with massive pulmonary emboli, providing an opportunity for stabilization and optimization before intervention. The early and long-term consequences of acute pulmonary emboli are better understood, in particular with regard to the risks of chronic thromboembolic pulmonary hypertension (CTEPH), an entity that should be identified in the acute setting as much as possible. The presence of chronic thromboembolic pulmonary disease can be associated with persistent haemodynamic instability despite removal of the acute thrombi, particularly if pulmonary hypertension is established. The pulmonary embolism response team (PERT) is an important component in the management of massive and submassive acute pulmonary emboli to determine the best treatment options for each patient depending on their clinical presentation.

SUMMARY

Three types of surgery can be performed for pulmonary emboli depending on the extent and degree of organization of the thrombi (pulmonary embolectomy, pulmonary thrombo-embolectomy and pulmonary thrombo-endarterectomy). Other treatment options in the context of acute pulmonary emboli include thrombolysis and catheter-directed embolectomy. Future research should determine how best to integrate VA ECMO as a bridging strategy to recovery or intervention in the treatment algorithm of patients with acute massive pulmonary emboli.

Aspirin Administered for Venous Thromboembolism Prophylaxis May Protect Against Stiffness Following Total Knee Arthroplasty

BACKGROUND

Aspirin has become the main agent for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA). This study assessed whether aspirin is associated with less knee stiffness compared to warfarin and other chemoprophylaxis agents.

METHODS

This is a retrospective review of all primary and revision TKAs performed between January 2009 and October 2020 at a high volume institution. Demographics, comorbidity data, and operative variables were extracted from medical records. VTE prophylaxis administered during this time period included aspirin, warfarin, and "others" (factor Xa, unfractionated heparin, low-molecular-weight heparin, fondaparinux, adenosine diphosphate receptor inhibitor, and direct thrombin inhibitor). The primary outcome assessed was manipulation under anesthesia (MUA) performed within 6 months of index surgery. Secondary outcome included major bleeding events. Univariate followed by multivariate regression analyses were performed.

RESULTS

A total of 15,903 cases were included in the study, of which 531 (3.3%) patients developed stiffness that required MUA. The rates of MUA were 2.7% (251/9223) for patients receiving aspirin, 4.2% (238/5709) for patients receiving warfarin, and 4.3% (42/971) for all others (P's < .001). Multivariate regression analysis confirmed that aspirin is associated with lower rates of VTE compared to warfarin (adjusted odds ratio 1.423, 95% confidence interval 1.158-1.747, P < .001) and compared to other anticoagulation medications (adjusted odds ratio 1.742, 95% confidence interval 1.122-2.704, P = .013). Major bleeding events were also significantly lower in patients who received aspirin compared to the other 2 groups (P's = .001).

CONCLUSION

Aspirin prophylaxis is associated with lower rates of MUA following TKA compared to warfarin and other VTE chemoprophylactic agents when grouped together.

Pulmonary endarterectomy in severe chronic thromboembolic pulmonary hypertension: the Toronto experience

BACKGROUND

Pulmonary endarterectomy (PEA) in severe chronic thromboembolic pulmonary hypertension (CTEPH) is associated with higher risks. However, recent evidence suggests that these risks may be mitigated with the use of extracorporeal membrane oxygenation (ECMO).

METHODS

We performed a retrospective analysis of 401 consecutive patients undergoing PEA at the Toronto General Hospital between August 2005 and March 2020. Patients with severe CTEPH defined by pulmonary vascular resistance (PVR) >1,000 dynes.s.cm-5 at the time of diagnosis were compared to those with PVR <1,000 dynes.s.cm-5.

RESULTS

The New York Heart Association (NYHA) functional class, brain natriuretic peptide (BNP) and 6-minute walk distance were worse in patients with PVR >1,000 dynes.s.cm-5. A greater proportion of patients with PVR >1,000 dynes.s.cm-5 was treated with targeted pulmonary hypertension (PH) medical therapy (38% vs. 18%, P<0.001) and initiated on inotropic support (7% vs. 0.3%, P<0.001) before PEA. Since 2014, the ECMO utilization rate increased in patients with PVR >1,000 dynes.s.cm-5 compared to those with PVR <1,000 dynes.s.cm-5 (18% vs. 3.1%, P<0.001). The hospital mortality in patients with PVR >1,000 dynes.s.cm-5 decreased from 10.3% in 2005-2013 to 1.6% in 2014-2020 (P=0.05), while the hospital mortality in patients with PVR <1,000 dynes.s.cm-5 remained stable (1.2% in 2005-2013 vs. 2.7% in 2014-2020, P=0.4). The overall survival reached 84% at 10 years in patients with PVR >1,000 dynes.s.cm-5 compared to 78% in patients with PVR <1,000 dynes.s.cm-5 (P=0.7).

CONCLUSIONS

The early and long-term results of PEA in patients with severe CTEPH are excellent despite greater postoperative risks. ECMO as a bridge to recovery after PEA can be useful in patients with severe CTEPH.

COVID-19 and renal infarct: To be or not to be on anticoagulation

We present a unique case of a male veteran with a history of Castleman disease, presenting with multiple arterial and venous vascular thromboses in the setting of recent Coronavirus (COVID-19)-disease diagnosis. We explore this patient’s morbidity related to thrombotic complications of his COVID-19 diagnosis that were potentially avoidable with a comprehensive outpatient evaluation of his risk for thrombosis, as well as the initiation of anticoagulation and/or antiplatelet therapy given his high risk. Our case highlights the need for a standardized clinical workup of patients in the outpatient setting for risk assessment of vascular thrombosis associated with COVID-19 infection to direct medical management, in order to minimize adverse outcomes, complications requiring inpatient admission, and the need for additional yet limited medical resources and interventions. We propose a minimum of low-dose aspirin 81 mg daily as a reasonable approach for outpatient clinicians to consider, based on their best clinical judgement, when managing mild COVID-19, while other options, such as novel oral anticoagulants, are undergoing further investigation.

Incidental Finding of Bilateral Acute Pulmonary Emboli in a Patient With Asymptomatic COVID-19 Infection

A 58-year-old male with a history of hypertension, dyslipidemia, osteoarthritis of both knees, and morbid obesity presented to the emergency department for opioid detoxification. He complained of generalized soreness, anxiety, and difficulty sleeping but denied signs and symptoms suggestive of coronavirus disease 2019 (COVID-19) infection. His COVID-19 polymerase chain reaction (PCR) result came back positive, and his D-dimer level was 5373 ng/mL. A computed tomography pulmonary angiogram showed a moderate burden of bilateral acute pulmonary emboli. He was managed with enoxaparin sodium subcutaneous therapeutic dose for three days, followed by oral apixaban 10 mg twice a day for seven days and then 5 mg twice a day for six months. To date, the rate of venous thromboembolism (VTE) in nonhospitalized patients with COVID-19 has not been reported, and current guidelines do not recommend thromboprophylaxis for these patients.

Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT

ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.

Third-Degree Heart Block Associated With Saddle Pulmonary Embolism: A Rare Sequelae of COVID-19-Induced Hypercoagulable State

The pathophysiology of coronavirus disease 2019 (COVID-19) involves multi-organ dysfunction, particularly involving the respiratory, cardiovascular and hematological systems. This dysfunction is partly due to systemic inflammation causing a wide array of pathological sequelae thus posing a significant challenge to management despite the advances in treatment made thus far. In this report, we present a COVID-19 patient who developed a transient complete heart block and was temporarily paced as a complication of a saddle pulmonary embolus (PE). The mechanism of complete heart block is unclear, may be related to strain, ischemia, or vagal response. We believe that this is a unique sequence of events in a COVID-19 patient and, to our knowledge, is the first of its kind to be reported.

Post-mortem cardiac magnetic resonance parameters in normal and diseased conditions

Background

Post-mortem cardiac magnetic resonance (CMR) is a non-invasive alternative to conventional autopsy. At present, diagnostic guidelines for cardiovascular conditions such as hypertrophic cardiomyopathy have not been established. We correlated post-mortem CMR images to definite conventional autopsy findings and hypothesed that elevated T2-weighted signal intensity and RV to LV area ratios can identify myocardial infarction and pulmonary emboli respectively.

Methods

For this unblinded pilot sub-study, we selected cases from the original blinded study that compared post-mortem imaging to conventional autopsy in patients referred for coronial investigation between October 2014 to November 2016. Three groups of scans were selected based on the cause of death identified by conventional autopsy: non-cardiovascular causes of death with no structural cardiac abnormality i.e., control cases, acute/subacute myocardial infarction and pulmonary emboli. Left ventricular (LV) wall thickness, LV myocardial signal intensity and ventricular cavity areas were measured.

Results

Fifty-six scans were selected [39 (69.6%) males]: 37 (66.1%) controls, eight (14.3%) acute/subacute myocardial infarction and eleven (19.6%) pulmonary emboli. The median age was 61 years [Interquartile range (IQR) 50-73] and the median time from death to imaging and autopsy was 2 days (IQR 2-3) and 3 days (IQR 3-4). The septal and lateral walls were thicker {15 mm [13-17] and 15 mm [14-18]} on post-mortem CMR than published ante-mortem measurements. Areas of acute/subacute myocardial infarction had significantly higher T2-weighted signal intensity (normalised to skeletal muscle) compared to normal myocardium in those who died from other causes {2.5 [2.3-3.0.] vs. 1.9 [1.8-2.3]; P<0.001}. In cases with pulmonary emboli, there was definite RV enlargement with a larger indexed RV to LV area ratio compared to those who died from other causes {2.9 [2.5-3.0] vs. 1.8 [1.5-2.0]; P<0.001}.

Conclusions

We present potential post-mortem CMR parameters to identify important cardiovascular abnormalities that may be beneficial when conventional autopsy cannot be performed. In patients without cardiovascular disease, LV wall thickness was found to be unreliable in diagnosing hypertrophic cardiomyopathy without histological and/or genetic testing. Elevated T2 signal intensity and RV to LV area ratios may be useful markers for acute/subacute myocardial infarction and pulmonary emboli. Larger studies will be necessary to define cut-offs.

Intraoperative Hypotension in a Patient with Antithrombin Deficiency, Bilateral Pulmonary Emboli, and Cefazolin Allergy

In medicine, the search for a clear answer can at times be elusive. However, this does not necessarily preclude the administration of intelligent and thoughtful therapeutic treatments. Here, we describe a complicated emergent event of severe hypotension and near-arrest that occurred in the operating room in a young, healthy woman undergoing outpatient thyroid surgery. We detail the situation as it presented in the operating room and the measures taken to rule out potential life-threatening diagnoses and develop a thoughtful treatment plan. We further describe the evidence for and against the two remaining diagnostic possibilities: anaphylaxis versus acute pulmonary embolism.

Preoperative cardiac and respiratory investigations do not predict cardio-respiratory complications after pancreatectomy

BACKGROUND

The process of undergoing a pancreatic resection places a patient under notable physiologic strain throughout the perioperative journey, with well recognized risks of postoperative cardiopulmonary complications. Preoperative preparations and screening often incorporate a barrage of testing, including electrocardiograms, transthoracic echocardiography, chest X-rays and spirometric evaluations. However, the current literature does not demonstrate whether these common tests provide any predictive correlation with postoperative cardiopulmonary complications. This retrospective study is structured to identify complications in post-pancreatic resection patients and assess for a predictive correlation with preoperative test results.

METHODS

A retrospective analysis of all patients having undergone a pancreatic resection at a single tertiary centre, between 2014 and 2016. The inpatient medical records were reviewed for 30-day postoperative complications, including acute myocardial infarction, cardiac dysrhythmia, pulmonary embolism, pneumonia or pleural effusions. The results of routine preoperative diagnostic tests and complication rates were analysed.

RESULTS

A total of 244 patients, median age of 66 years (range 18-88 years) were included in the study. Of these, 11 patients experienced a cardiac complication and 16 patients experienced a respiratory complication. Among those who experienced cardiac events, only two patients had abnormalities in their preoperative electrocardiograms. Patients who sustained a cardiac or respiratory event did not have any evidence of abnormality in their preoperative transthoracic echocardiography or respiratory investigations, respectively.

CONCLUSION

Despite the recommendation that high-risk procedures such as pancreatic resections warrant thorough, routine, preoperative cardiac and respiratory investigation, a more functional preoperative assessment should be considered to stratify and predict postoperative outcomes.

Relation between dynamic change of red cell distribution width and 30-day mortality in patients with acute pulmonary embolism

INTRODUCTION AND OBJECTIVES

Recent studies suggest that an increase in red cell distribution width (RDW) levels have a better prognostic value than a single measurement. In the current study, we investigated the predictive value of increasing RDW levels for mortality in acute pulmonary emboli (APE) patients.

MATERIALS AND METHODS

For the study, 199 APE patients who were hospitalized were enrolled. Patients were divided into three groups according to their admission and 24th hour RDW values. Patients for whom both RDW values normal were put in group 1 (normal); patients with admission RDW > 14.5% and decreased 24th hour RDW values were in group 2 (decreased); patients whose 24th hour RDW levels were >14.5% and increased compared to their baseline RDW measurement were in group 3 (increased). Clinical and laboratory findings and 30-day mortality of these groups were compared.

RESULTS

Mean patient age was 68 ± 16, and 48% of the patients were male. There were 98 patients (49%) in group 1, 59 patients (30%) in group 2, and 42 patients (21%) in group 3. Patients in group 3 were older, had lower eGFR and hemoglobin values, and had higher brain type natriuretic peptide values. Mortality rate was higher in group 3 (0%, 3.4%, 19%, respectively, P < .0001). Increase in RDW was independently related to mortality [HR: 4.9, (95%CI: 1.2-18, P = .02)].

CONCLUSION

APE patients with increasing RDW levels have higher mortality rates. Serial measurements of RDW may help us determine patients with high risk for mortality.

Thrombus entrapped in patent foramen ovale: a rare form of thrombus in transit

In rare cases, thrombus in transit can be entrapped in a patent foramen ovale (PFO). A patient with this condition is at high risk of embolic stroke and death. Early diagnosis and treatment is essential to help prevent stroke and death in these cases. There is no universal management guideline for this rare condition. The decision between medical versus surgical treatment should be made individually for each patient. We present a case of thrombus in transit entrapped in a PFO that was treated medically by lifelong anticoagulation.

Pulmonary artery sarcoma: a rare thoracic tumor frequently misdiagnosed at presentation

This case illustrates a rare but important differential diagnosis of pulmonary emboli in the field of thoracic oncology, that of pulmonary artery sarcoma. It describes particular clinical features that may raise suspicion of this tumor in cases of suspected pulmonary emboli, and highlights novel radiological modalities and tissue sampling techniques in such cases. Surgical resection, as part of multi-modality therapy, is the cornerstone of treatment that has seen survival dramatically improve in recent years for patients with this rare cancer.

Acute pulmonary emboli due to internal jugular vein thrombosis in papillary thyroid carcinoma, a case report and literature review

Upper extremity deep vein thrombosis (UEDVT) is a life threatening rare condition. Among the patients with UEDVT, internal jugular vein is accepted as uncommon thrombosis. Since internal jugular vein thrombosis (IJVT) is mostly underdiagnosed, a great attention is needed to diagnose the disease. A 75-year-old woman with history of dyspnea on exertion (DOE), weight loss and anorexia with the stable vital sign and right-sided cervical adenopathy with suspected thyroid nodule was admitted. One day after admission, sudden dyspnea was occurring with unstable vital sign and hypotension. Chest X-ray showed a bilateral pleural effusion. Pleural tap was exudative, CT scan showed bilateral pulmonary emboli. CT scan of the neck showed right-sided cervical adenopathy, heterogeneous thyroid and internal jugular vein thrombosis concomitant with superior thyroid vein thrombosis. The patient was treated with thrombolytic agent and enoxaparin followed by warfarin. Thyroid FNA revealed papillary thyroid carcinoma that followed by total thyroidectomy, histopathological examination verified papillary thyroid carcinoma. Although lower extremity DVT is the main cause of pulmonary emboli, but IJVT may be proceed by pulmonary embolism. Due to fatal outcome of pulmonary emboli in IJVT, color duplex sonography, is recommended in documented tumors or suspected history of malignancy.

Outcomes-based systematic review for management of massive intra-cardiac or pulmonary thrombotic emboli during surgery

INTRODUCTION

The management of massive intra-operative embolism remains controversial. Our hypothesis was that either surgical or medical thrombectomy offers survival benefit in these patients.

METHODS

Published case reports were reviewed for intra-operative intra-cardiac or pulmonary embolism and outcomes for the following four intervention groups were evaluated for mortality benefit: surgical embolectomy; thrombolysis; anticoagulation; supportive care alone. We also assessed whether the use of diagnostic modalities prior to each embolism event resulted in a mortality benefit and, separately, whether post-intervention improvement in physiologic parameters resulted in improvement in outcomes. Univariate analyses and logistic regression were performed to assess the impact of the four primary interventions on mortality, the primary outcome.

RESULTS

Seventy-eight cases were reviewed and therapeutic interventions resulted in improved survival (70%) compared to supportive care (45%), odds ratio=0.38[0.15-0.98], p=0.04. Univariate analysis of primary interventions with death as a primary outcome resulted in a lack of significantly different outcomes (p=0.08). Mortality rates were 71% in the thrombolytic; 28% in surgical embolectomy; 18% in anticoagulation and 43% in the supportive care groups. The routine pre-event use of trans-esophageal echocardiography was not related with improved outcomes (p=0.36) but the use of pulmonary artery or central venous catheters was (p=0.035). Post-intervention improvements in the physiologic parameters of each diagnostic modality were associated with an improvement in mortality (p<0.05).

CONCLUSIONS

Our data present some important trends among the intervention groups, raising significant concerns about the safety for the use of thrombolytics in the management of intra-operative embolism.

Bilateral shotgun pellet pulmonary emboli

Intravascular migration of bullets and other foreign bodies is a rare but known complication of penetrating trauma. Missile embolization can represent a diagnostic challenge because it may present in various and unexpected ways. We present the case of a 54-year-old female who sustained shotgun pellet emboli to the pulmonary arteries following a left upper extremity gunshot wound and related vascular surgery. The case illustrates bilateral embolization, and the embolic events occurred following surgery. Embolization should be considered in evaluating patients with gunshot wounds, particularly if there are anomalous symptoms or the projectile is not found in the original, or expected, location. Close attention to the location of the foreign bodies on serial radiographs may reveal the diagnosis of intravascular embolization.

Primary tibial vein aneurysm: a source of pulmonary emboli

OBJECTIVE

To describe a case of a rare type of venous aneurysm (posterior tibial) with associated pulmonary embolus. We will discuss options and considerations germane to the diagnostic evaluation and possible interventions for this challenging clinical scenario.

METHODS

Case presentation and literature review.

RESULTS

A 36-year-old man presented to an outside hospital with a three-day history of left calf pain, acute shortness of breath and syncope elicited by exercise. Work-up demonstrated a pulmonary embolus and a posterior tibial venous aneurysm with mural thrombus. The patient presented to us 18 months later with persistent calf pain seeking an alternative to recommendations of lifelong anticoagulation. The patient was treated with surgical resection of the venous aneurysm with subsequent discontinuation of his anticoagulation. There were no surgical or thrombotic complications of this treatment course and the patient's discomfort improved.

CONCLUSION

Primary aneurysms of the tibial veins as a cause of pulmonary emboli are rare. A review of the literature suggests that anticoagulation alone does not provide effective amelioration of thromboembolic risk from lower extremity venous aneurysms. We have reported a case of successful surgical treatment of a posterior tibial venous aneurysm and recommend that surgical correction be strongly considered for accessible venous aneurysms.

Intrapulmonary artery infusion of urokinase for treatment of massive pulmonary embolism: a review of 26 patients with and without contraindications to systemic thrombolytic therapy

BACKGROUND

Pulmonary emboli (PE) are a common event seen in over 600,000 patients a year. Occurring suddenly, PE often result in a high rate of mortality. To combat the high rate of mortality, more aggressive therapies including the use of thrombolytics are often indicated. The use of intrapulmonary artery infusion of urokinase has been shown to promote rapid resolution of emboli and restoration of normal pulmonary hemodynamics.

HYPOTHESIS

The study was undertaken to review the effectiveness and safety of pulmonary artery infusion of urokinase in 26 patients with and without contraindications to the use of systemic thrombolytic therapy.

METHODS

We reviewed the outcomes of 26 patients who received infusion of urokinase, using a usual loading dose of 4,000 U/kg body weight given as a bolus, followed by 4,000 U/kg/h for 12 to 24 h, using either/or unilateral or bilateral infusions. Pulmonary angiograms were obtained prior to and following the urokinase infusions.

RESULTS

Intrapulmonary artery infusion of urokinase was given to 26 patients, 9 of whom had contraindications to the use of systemic thrombolytic therapy. Six patients were recent post operative, one was receiving oral anticoagulants, one was receiving chemotherapy with bleeding complications, and one had received cardiopulmonary resuscitation. Twenty of the patients returned to their baseline state (normal heart rate, blood pressure, and p02), one was minimally improved, and five deaths occurred. Of the five deaths, three occurred within 1 h of starting urokinase infusion, the remaining two died more than 36 h after treatment with urokinase as a result of their basic underlying disease. Minor bleeding occurred from puncture sites, two hematomas occurred at the puncture site, and there were two gastrointestinal bleeds, one of which occurred a week post urokinase therapy while the patient was receiving heparin and coumadin. No central nervous system bleeds occurred and no transfusions were required as a result of urokinase intrapulmonary artery infusions. The overall mortality rate in this series was 11.5%.

CONCLUSIONS

Intrapulmonary artery infusion of urokinase in extensive pulmonary embolism is a safe and efficient treatment in patients with and without contraindication to the use of systemic thrombolytic therapy. With a usual loading dose of 4,000 U/kg body weight, followed by an infusion of 4,000 U/kg/h for 12 to 24 h, it produces significant and rapid resolution of pulmonary emboli with a low morbidity and mortality rate. In our series, the mortality rate was 11.5%, and none of the deaths was the direct result of urokinase therapy.

Combined MR proton lung perfusion/angiography and helium ventilation: potential for detecting pulmonary emboli and ventilation defects

Three-dimensional (3D) perfusion imaging allows the assessment of pulmonary blood flow in parenchyma and main pulmonary arteries simultaneously. MRI using laser-polarized (3)He gas clearly shows the ventilation distribution with high signal-to-noise ratio (SNR). In this report, the feasibility of combined lung MR angiography, perfusion, and ventilation imaging is demonstrated in a porcine model. Ultrafast gradient-echo sequences have been used for 3D perfusion and angiographic imaging, in conjunction with the use of contrast agent injections. 2D multiple-section (3)He imaging was performed subsequently by inhalation of 450 ml of hyperpolarized (3)He gas. The MR techniques were examined in a series of porcine models with externally delivered pulmonary emboli and/or airway occlusions. With emboli, perfusion deficits without ventilation defects were observed; airway occlusion resulted in matched deficits in perfusion and ventilation. High-resolution MR angiography can unambiguously reveal the location and size of the blood emboli. The combination of the three imaging methods may provide complementary information on abnormal lung anatomy and function.