Descending aortic intramural hematoma with pulmonary embolism: A case report / 中国胸心血管外科临床杂志

@#Aortic intramural hematoma and pulmonary embolism are two rapidly progressive and life-threatening diseases. A 65-year-old male patient with descending aortic intramural hematoma and pulmonary embolism underwent pulmonary embolectomy and descending aortic stent-graft placement, with good postoperative results.

Two Cases of Pulmonary Embolectomy Using Retrograde Pulmonary Perfusion for Acute Pulmonary Thromboembolism / 日本心臓血管外科学会雑誌

Pulmonary thromboembolism (PTE) is a life-threatening disease, and in severe cases is required surgical treatment. Emergency pulmonary embolectomy using retrograde pulmonary perfusion (RPP) as an adjunct was successfully performed in 2 patients suffering from massive acute PTE. After removal of the pulmonary thrombus via incision of the pulmonary artery trunk, RPP via the right upper pulmonary vein was performed, which enabled the removal of residual thrombotic material and air from the peripheral branches of pulmonary arteries.

Surgical Treatment for Acute Pulmonary Embolism / 日本心臓血管外科学会雑誌

<b>Background</b> : Acute massive pulmonary embolism is a life-threatening disease. It is often treated with thrombolytic therapy, however, the mortality rates are unsatisfactorily high in patients who developed shock and subsequent cardiac arrest. Surgical pulmonary embolectomy is a last resort for patients with hemodynamic instability. We studied the outcomes of our patients who underwent pulmonary embolectomy for acute pulmonary embolism. <b>Methods</b> : Eight patients who underwent pulmonary embolectomy between January 2011 and December 2014 were studied. Our surgical indications were as follows. Patients who experienced cardiac arrest and treated with PCPS, and those in persistent vital shock, with contraindications of thrombolytic therapy, or with right heart floating thrombus. However, patients with ischemic encephalopathy or acute exacerbation of chronic thromboembolic pulmonary hypertension, and those who had already been treated with thrombolytic therapy were excluded. Preoperative ECMO was indicated for those in sustained shock. Pulmonary embolectomy was performed through median sternotomy and with cardiopulmonary bypass. After antegrade cardiac arrest, all clots were removed with forceps under direct vision through incisions in the bilateral main pulmonary arteries. IVC filter (Günther Tulip) was placed through the right atrial appendage. In our early cases, IVC filter (Neuhaus Protect) was placed after chest closure. Anticoagulation was not administered until hemostasis was achieved. <b>Results</b> : Seven patients underwent pulmonary embolectomy for massive pulmonary embolism, and in one patient pulmonary embolectomy was indicated for right heart floating thrombi although the pulmonary embolism was submassive. Three patients underwent cardiopulmonary resuscitation and were treated with ECMO. Other 3 patients in sustained shock vital were electively treated with ECMO. The other patient developed cardiopulmonary arrest shortly after anesthetic induction and intubation, and suffered disturbance of consciousness postoperatively. All patients were successfully weaned from cardiopulmonary bypass and underwent IVC filter placement (5 Neuhaus Protect, and 3 GProtec Tulip). One patient died due to a vascular complication associated with catheter insertion (retroperitoneal hematoma). No patients developed residual pulmonary hypertension. There were postoperative complications including pneumonia in 5 patients, tracheostomy in 2 patients, atrial fibrillation in 3 patients, and pericardial effusion in 1 patient. One patient who suffered disturbance of consciousness died 2.4 months after the surgery. Other patients had not developed any thrombotic and hemorrhagic complications during a median follow-up of 13.1 months. <b>Conclusions</b> : Pulmonary embolectomy is an effective treatment of acute massive pulmonary embolism. We believe that our strategy is useful, consisting of preoperative hemodynamic stability by an institution of ECMO, complete removal of clots by bilateral main pulmonary incisions, and prevention of recurrence by IVC filter placement.

Tromboembolismo pulmonar masivo de alto riesgo asociado a foramen oval permeable / High-risk massive pulmonary thromboembolism associated with patent foramen ovale

La alta mortalidad de los pacientes con tromboembolismo pulmonar masivo de alto riesgo amerita un enfoque terapéutico enérgico e invasivo que incluya la embolectomía pulmonar quirúrgica en aquellos pacientes con contraindicación para trombolisis o trombolisis fallida. Describimos un caso de tromboembolismo pulmonar masivo de alto riesgo que recibió tratamiento quirúrgico en vez de trombolisis debido a que al momento del diagnóstico presentaba un trombo móvil a través de un foramen oval permeable con altísima posibilidad de embolismo paradójico arterial.

High mortality rate associated with massive pulmonary embolism requires an aggressive invasive approach including surgical pulmonary embolectomy when thrombolytic therapy has failed or is contraindicated. We describe a case of high-risk massive pulmonary embolism who underwent surgical treatment due to the presence of a mobile intracardiac clot in a patent foramen ovale, and the possible risk of paradoxical arterial embolism.

Anesthetic Management of Acute Massive Pulmonary Embolism after Intracerebral Hemorrhage: A case report / 대한마취과학회지

Acute massive pulmonary embolism after intracerebral hemorrhage (ICH) is rare but associated with a high mortality rate. A 44-year-old man presented with acute pulmonary embolism on 38th day after onset of ICH. We tried off-pump pulmonary embolectomy with CPB on stand-by. But, hemodynamic deterioration occurred when right pulmonary artery was clamped after removal of some clots, therefore CPB was rapidly instituted under normothermic beating heart with full heparinization. On pump beating, heart pulmonary embolectomy was performed successfully without adverse events. On postoperative 2nd day, the patient was started on anticoagulation therapy and recovered favorably without any neurologic sequelaes.

A Case of Primary Unknown Squamous Cell Carcinoma Incidentally Found in the Thrombus After Pulmonary Embolectomy / 결핵

A thromboembolic event in patients later given a diagnosis of cancer is the result rather than the cause of the cancer. The risk of hidden cancer is significantly higher for patients with recurrent idiopathic thromboembolism compared to those with secondary deep vein thrombosis. Microemboli from hepatic or adrenal metastases and large-sized emboli from the great veins invaded by the tumor are the sources of tumor embolization. The intraarterial tumor emboli less likely invade the arterial wall. Thrombus formation and organization may be capable of destroying tumor cells within pulmonary blood vessels. Therefore, all tumor emboli are not true metastases. The treatment of deep vein thrombosis and pulmonary embolism in patients with cancer consists of anticoagulation with heparin and warfarin, venacaval filters, appropriate anti-neoplastic agents, and surgical methods(embolectomy, thromboendarterectomy). However, considerable literatures suggest that oral anticoagulant such as warfarin is ineffective in the treatment of those. We report a case of primary unknown squamous cell carcinoma incidentally found in the thrombus after pulmonary embolectomy.

Acute Massive Pulmonary Thromboembolism Occupying both Whole Pulmonary Arteries

Massive pulmonary embolism is a major cause of morbidity and death in hospital. Most episodes of acute pulmonary embolism occurred from multiple emboli. When pulmonary embolism is suspected, the definitive diagnosis is pulmonary arteriography, but high degree of certainty can also be achieved with ventilation-perfusion scanning. The therapeutic modalities available for patients with acute pulmonary embolism are prophylatic and definitive therapy. Prophylatic therapy including anticoagulant with heparin is used to prevent further emboli episodes that might be fatal. Definitive therapy for pulmonary embolism including thrombolytic agents and pulmonary embolectomy attempts to dissolve and remove the resolution of the pathophysiologic sequelae of pulmonary embolism. We experienced a case of acute massive pulmonary embolism which occupied the pulmonary arteries bilaterally. Patient with orthopedic surgery one month before developedd dyspnea and chest tightness. Eventhough continuing enough amount of anticoagulant therapy, rapid hemodynamic deterioration and severe hypoxia occurred progressively. Urgent pulmonary embolectomy was succeeded and he has been followed up at out patient department.