Surgical Management of Massive Pulmonary Embolism Presenting with Cardiopulmonary Arrest: How Far Is Too Far?

ABSTRACT The incidence of diagnosed massive pulmonary embolism presenting to the Emergency Department is between 3% and 4.5% and it is associated with high mortality if not intervened timely. Cardiopulmonary arrest in this subset of patients carries a very poor prognosis, and various treating pathways have been applied with modest rate of success. Systemic thrombolysis is an established first line of treatment, but surgeons are often involved in the decision-making because of the improving surgical pulmonary embolectomy outcomes.

Vitrectomy with arteriotomy and neurotomy in retinal artery occlusion – A case series

Purpose: This study aimed to investigate the visual outcomes and anatomical changes after vitrectomy for retinal artery occlusion. Methods: Twelve patients with retinal artery occlusion (11 central retinal artery occlusion and 1 branch retinal artery occlusion) were part of this study. Our patients were treated with vitrectomy with arteriotomy or with neurotomy and arteriotomy. Complete ophthalmic examination was performed preoperatively, at 2 weeks, and 1, 3, 6, 9, and 12 months after surgery. Results: The mean preoperative best?corrected visual acuity (BCVA) was 1.94 logMAR, and the final BCVA after 12?months follow?up was 2.04 logMAR. After vitrectomy with arteriotomy, the BCVA in patients treated with neurotomy and arteriotomy was 1.65 and 2.45, respectively (P = 0.038). Conclusion: No benefits have been achieved from using vitrectomy in retinal artery occlusion cases

Surgical Embolectomy in a 34?Week Pregnant Woman with High Risk Pulmonary Embolism and Haemodynamic Instability

Pulmonary embolism represents the leading cause of maternal mortality in developed countries. The optimal treatment of high?risk pulmonary embolism with cardiovascular instability and at high hemorrhagic risk is still debated but surgical embolectomy represents an effective option. We describe the case of a 35?year?old woman in week 34 of pregnancy who was referred to our hospital because of exertional dyspnea and tachycardia and a few hours later became hypotensive and hypoxic. Pulmonary embolism was detected by performing an angio?computed tomography (CT) scan. After a successful cesarean section, emergent embolectomy was performed without inducing uterine hemorrhage. Both mother and the newborn recovered without postoperative sequelae.

Modelo híbrido utilizando placentas humanas para treinamento de Embolectomia Arterial Cerebral / Hybrid model using human placentas for training in Cerebral Arterial Embolectomy

Acidente Vascular Encefálico (AVE) é a doença mais comum do sistema nervoso central, sendo segunda causa de morte e terceira de incapacidade no mundo. Há previsão de que a incidência de AVE dobre até 2050. Melhorias recentes na terapêutica têm demostrado eficácia na redução mortalidade, complicações e sequelas tardias. Trombectomia realizada em caráter urgente é a medida terapêutica mais eficaz para reduzir a mortalidade e as sequelas, permitindo que cerca de 50% dos pacientes retomem vida independente em até 90 dias. OBJETIVO Descrever um simulador sintético e biológico utilizando placentas bovinas e humanas capaz de reproduzir os aspectos técnicos de uma trombose da artéria cerebral média, o local mais comum de AVE de grande impacto funcional, e descrever as nuances e variações da trombectomia que podem ser testadas e validadas. MATERIAIS E MÉTODOS Sete neurocirurgiões participaram da execução dos exercícios de simulação nos quais fora utilizadas 74 placentas humanas, preparadas para simulação de trombectomias em sistema de perfusão aclaradas a manequim. O processo avaliativo constou das seguintes estapas 1 - Validação do simulador: validade de face, conteúdo e construto 2 - Trombectomia microcirúrgica: realização de procedimentos, com arteriotomia longitudinal e com arteriotomia transversal. 3 - Trombectomia endovascular CONCLUSÃO o modelo híbrido desenvolvido mediante à avaliação de Face, Conteúdo e Constructo possua qualidades suficientes que justifiquem sua adoção como subsidio à capacitação de neurocirurgiões em diversas modalidades de treinamento

Stroke is the most common disease of the central nervous system, being the second leading cause of death and third incapacity in the world. The incidence of stroke is predicted to double by 2050. Recent improvements in therapy have been shown to be effective in reducing late mortality, complications and sequelae. Urgently performed thrombectomy is the most effective therapeutic measure to reduce mortality and sequelae, allowing approximately 50% of patients to resume independent life within 90 days. OBJECTIVE To describe a synthetic and biological simulator using bovine and human placentas capable of reproducing the technical aspects of a thrombosis of the middle cerebral artery, the most common site of stroke with great functional impact, and to describe the nuances and variations of thrombectomy that can be tested and validated. MATERIALS AND METHODS Seven neurosurgeons participated in the execution of simulation exercises in which 74 human placentas were used, prepared to simulate thrombectomy in a perfusion system cleared on a mannequin. The evaluation process consisted of the following steps 1 - Simulator validation: face, content and construct validity 2 - Microsurgical thrombectomy: performance of procedures, with longitudinal arteriotomy and transverse arteriotomy. 3 - Endovascular thrombectomy CONCLUSION the hybrid model developed through the evaluation of Face, Content and Construct has sufficient qualities to justify its adoption as a subsidy for the training of neurosurgeons in various training modalities

Removal of Shield Needles from Graphene Oxide Thrombus and Preparation / 中国医疗器械杂志

Atherosclerosis is a chronic inflammatory disease commonly seen in clinical practice. It can lead to thickening of vascular intima, occlusion of lumen stenosis and thrombosis, leading to angina pectoris, hypertension, myocardial infarction and other diseases, posing a serious threat to human life and health. This study provides a method for removing shield needles from graphene oxide thrombus and its preparation. The graphene oxide shield needle mainly includes flexible rotating shaft, radial flexible rod, rotating needle, adsorption main pipe and dosing main pipe, laser measuring device, high definition camera and other structures, which has the following advantages:firstly, it achieves multi-angle rotation grinding thrombosis, precise rotation grinding, avoids vascular damage and infection; secondly, thrombolytic drugs can be applied in the process of rotary grinding and small thrombus can be adsorbed to effectively avoid secondary embolization of blood vessels; thirdly, it a coating of graphene oxide on a rotating needle, which protects against bacteria and infection. This study has practical reference value for the development of thrombotherapy and the application of graphene in the medical field.

Management of upper extremity peripheral vascular disease: a multimodality approach

Background: It is estimated that more than 200 million people suffer from peripheral vascular disease worldwide. However very few studies are available on upper extremity vascular disease, thus making it an under diagnosed and under treated condition.Methods: In the present study we included 20 participants suffering from upper limb peripheral vascular disease and managed them with multi-modality approach involving general surgeon, interventional radiologist and vascular surgeon for medical line of management, thrombolysis and thrombo-embolectomy procedures.Results: In the present study we observed that early management of these patients with medical management, interventional radiology and embolectomy procedures helped in limb salvage. However alarmingly high number of patients (35%) landed up in amputation because of low index of suspicion and delayed referral.Conclusions: A high level of suspicion and early referral to a tertiary care centre where multi-modality facilities like interventional radiology and vascular surgeon are available should be done.

Clinical experience of upper limb ischemia: a retrospective study

Background: Arterial disorders of the upper extremity are much less common than those of the lower extremity, but when they result in symptoms of acute or chronic ischemia, surgical or endovascular techniques for upper extremity revascularization may be needed. This study presents a review of the epidemiology, aetiology, and clinical characteristics of upper limb ischemia.Methods: The records of 70 patients with upper limb ischemia who underwent treatment from were retrospectively reviewed.Results: A total of 44 patients were diagnosed by CT. Other diagnostic methods and tools used were conventional angiography and duplex ultrasound. Four cases were diagnosed solely on the basis of a medical history and physical examination. A total of 56 surgeries were performed. Rest of the 14 patients went under conservative therapy. The operations included embolectomy and thrombectomy using a Fogarty balloon catheter (n=32), bypass surgery using the great saphenous vein (n=10), percutaneous catheter-directed thrombolysis (n=8), and primary repair (n=4). Patients with Raynaud’s phenomenon or Burger’s disease were either treated with medication only (n=14) or with sympathectomy (n=2).Conclusions: The duration of symptoms in cases of upper limb ischemia may vary from two hours to a year, depending on the aetiology and severity of the illness. Many debates have addressed whether the time gap between the onset of symptoms and treatment predicts long-term arm function.

Resultados do tratamento das oclusões arteriais agudas de membros em hospital universitário - estudo retrospectivo / Results of treatment of acute occlusions of limb arteries at a university hospital - retrospective study

Resumo Contexto As oclusões arteriais agudas (OAA) de membros vêm crescendo paralelemente com a longevidade da população. Objetivos O objetivo deste estudo foi avaliar fatores de risco, salvamento de membros e sobrevida dos pacientes com OAA tratados em instituição universitária. Métodos Este é um estudo coorte retrospectivo de pacientes consecutivos. Os desfechos incluíram: sucesso técnico, sintomas, comorbidades, categoria Rutherford, artérias acometidas, complicações pós-operatórias, taxa de salvamento de membros em 30 dias e óbitos. Resultados Avaliou-se 105 prontuários, havendo predomínio do sexo masculino (65,7%) e idade entre 46 a 91 anos. As etiologias identificadas foram trombóticas (54,3%), embólicas (35,2%) e indefinidas (10,5%). Cerca de dois terços apresentavam-se nas Categorias II e III de Rutherford. Os sintomas associados encontrados foram dor (97,1%), esfriamento (89,5%), palidez (64,7%), parestesias (44,7%), paralisias (30,5%), anestesias (21,9%), edema (21,9%) e cianose (15,2%); e as comorbidades associadas observadas foram hipertensão (65,0%), tabagismo (59,0%), arritmias (26,6%), dislipidemias (24,0%) e diabetes (23,8%). O segmento femoral superficial-poplíteo-distal foi o mais acometido (80%). A tromboembolectomia com cateter Fogarty foi realizada em 73,3% dos casos (81,0% nas embolias, 71,9% nas tromboses e 54,5% nos indefinidos), sendo isoladamente em 41 pacientes (39,05%), nos quais ocorreram 11 reoclusões, 20 amputações e 14 óbitos. A reoclusão arterial foi mais frequente nas tromboses (12,9%; p = 0,054). Até 30 dias após tratamento, o óbito total foi de 14,6% e a amputação maior foi de 19,8%, sendo menos frequente na Classe I Rutherford (p = 0,0179). Conclusão O tratamento da OAA feito prioritariamente por meio de tromboembolectomia com cateter Fogarty, isolado e/ou associado, proporcionou taxas de amputação e complicações compatíveis com as apresentadas na literatura e progressivamente menores nas categorias Rutherford menos avançadas.

Abstract Background Acute arterial occlusions (AAO) in limbs have been increasing in parallel with population longevity. Objective To assess risk factors, limb salvage rates, and survival of patients with AAO treated at a University Hospital. Methods Retrospective cohort study of consecutive patients. Outcomes included: patency, symptoms, comorbidities, Rutherford category, arteries occluded, postoperative complications, and 30-day limb salvage and mortality rates. Results Medical records were evaluated from 105 patients, predominantly males (65.7%), with ages ranging from 46 to 91 years. Etiology: thrombotic (54.3%), embolic (35.2%), and undefined (10.5%). About 2/3 of the patients were assessed as Rutherford category II or III. Associated symptoms: pain (97.1%), coldness (89.5%), pallor (64.7%), sensory loss (44.7%), paralysis (30.5%), anesthesia (21.9%), edema (21.9%), and cyanosis (15.2%). Associated comorbidities: hypertension (65.0%), smoking (59.0%), arrhythmias (26.6%), dyslipidemia (24.0%), and diabetes (23.8%). The distal superficial femoral-popliteal segment was the most affected (80%). Thromboembolectomy with a Fogarty catheter was performed in 73.3% of cases (81.0% of embolic cases, 71.9% of thrombotic cases, and 54.5% of cases with undefined etiology) and was the only treatment used in 41 cases (39.05%), among which there were 11 reocclusion, 20 amputations, and 14 deaths. Arterial reocclusion was more frequent in thrombosis cases (12.9%, p = 0.054). Within 30 days of treatment, total mortality was 14.6%, and 19.8% of cases underwent major amputation, which was less frequent among Rutherford Class I patients (p = 0.0179). Conclusion Treatment of AAO was primarily performed by thromboembolectomy with a Fogarty catheter, either alone or in combination with other treatments, achieving amputation and complication rates compatible with the best results in the literature and were progressively lower in less advanced Rutherford categories.

Cardiac and extra-cardiac pathologies in patients with acute arterial occlusion

SUMMARY OBJECTIVE: We aimed to investigate cardiac and extra-cardiac pathologies in patients who were operated for acute arterial occlusion. METHODS: Between March 2010 and March 2018, a total of 120 patients who underwent surgical treatment for acute arterial occlusion were included in this retrospective study. RESULTS: 84 (70%) and 27 (22. 5%) of the patients had cardiac and extra-cardiac pathologies, respectively. In 9 (7. 5%) of the cases, no reason for arterial occlusion could be found. Pure atrial fibrillation was found in 39 (32. 5%) patients. Atrial fibrillation and cardiac valvular pathologies were detected in 45 patients (37. 5%). Among those with a cardiac valvular pathology, 9 patients (7. 5%) had pure mitral stenosis, 21 patients (17. 5%) had moderate to advanced mitral stenosis with tricuspid regurgitation, 9 patients (7. 5%) had 20-30 mitral regurgitation with 30 tricuspid regurgitation, 3 patients (2. 5%) had moderate mitral stenosis, 30-40 tricuspid regurgitation and 20-30 aortic stenosis, and 3 patients (2. 5%) had 30 mitral regurgitation, 10- 20 tricuspid regurgitation, calcific moderate aortic stenosis, and coronary artery disease. Among those 27 patients with an extra-cardiac pathology, 21 patients (22. 5%) had peripheral artery disease, 3 patients (2.5%) had an abdominal aortic aneurysm, and 3 patients (2. 5%) had Behçet's Disease. CONCLUSION: Cardiac and extra-cardiac pathologies should be kept in mind in patients with acute arterial occlusion. Thus, detected pathologies could be treated, and the development of additional peripheral emboli could be prevented.

RESUMO OBJETIVO: O objetivo do estudo é investigar patologias cardíacas e extracardíacas em pacientes operados por oclusão arterial aguda. MÉTODOS: Entre março de 2010 e março de 2018, um total de 120 pacientes submetidos a tratamento cirúrgico para oclusão arterial aguda foram incluídos neste estudo retrospectivo. RESULTADOS: Dos pacientes incluídos, 84 (70%) e 27 (22.5%) apresentavam, respectivamente, patologias cardíacas e extracardíacas. Em 9 (7.5%) dos casos, nenhuma cause para a oclusão arterial foi encontrada. Fibrilação atrial isolada foi encontrada em 39 (32.5%) pacientes. Fibrilação atrial e valvopatias cardíacas foram detectadas em 45 pacientes (37.5%). Entre aqueles com valvopatias cardíacas, 9 (7.5%) tinham estenose mitral isolada, 21 (17. 5%) tinham estenose mitral moderada a avançada com regurgitação tricúspide, 9 (7. 5%) tinham 2°-3° de regurgitação mitral com 3o regurgitação tricúspide, 3 (2. 5%) tinham estenose mitral moderada, 3°-4° regurgitação tricúspide e 2°-3° estenose aórtica, e 3 (2.5%) tinham 3o mitral, 1°- 2° regurgitação tricúspide moderada, estenose aórtica moderada calcificada e doença coronariana. Entre os 27 pacientes com patologia extracardíaca, 21 (22.5%) tinham doença arterial periférica, 3 (2,5%) tinham aneurisma da aorta abdominal, e 3 (2.5%) tinham Doença de Behçet. CONCLUSÃO: Patologias cardíacas e extracardíacas devem ser consideradas em pacientes com oclusão arterial aguda. Assim, patologias detectadas podem ser tratadas e o desenvolvimento de trombos periféricos adicionais pode ser evitado.

Replacement of the native mitral valve due to endocarditis caused by stenotrophomonas maltophilia

Abstract We report a case of a 59-year-old female patient with vegetative native mitral valve endocarditis caused by Stenotrophomonas maltophilia (SM). She had hemodialysis-dependent chronic renal failure, but no immunosuppressive disease. Echocardiography showed mobile vegetation on her native mitral valve. Right femoral artery embolectomy and mitral valve replacement were performed simultaneously. She awakened from anesthesia, but she passed away due to septic shock complications. To the best of our knowledge, this was the first case in whom native mitral valve endocarditis caused by SM was observed (despite of absence of any immunosuppressive event) and needed to undergo valve replacement.

Comparison of different types of endovascular mechanical embolectomy in acute ischemic stroke

SUMMARY Background: To compare the treatment efficacy of different types of endovascular mechanical embolectomy in acute ischemic stroke (AIS). Material and Methods: A total of 89 patients with AIS were selected in our hospital from January 2014 to January 2016 and divided into tPA group (n=27), tPA+Trevo group (n=30) and tPA+Solitaire FR group (n=32) for different treatments. Treatment effectiveness was evaluated using NIHSS and mRS system. The NIHSS score, vascular recanalization rate and postoperative complications were compared among groups. Results: The NIHSS score of the tPA group was significantly lower than that of other two groups at 1 d after the operation (p < 0.05), but it was significantly higher than that of other two groups at 3 d and 3 w after the operation (p < 0.05). After the treatment, no significant difference in NIHSS score was found between the tPA+Trevo and tPA Solitaire FR groups. The revascularization rate was significantly higher, but the mortality rate in 90 d was significantly lower in the tPA+Trevo and tPA+Solitaire FR groups than that in the tPA group (p < 0.05), and no significant difference was found between the tPA+Trevo and tPA+Solitaire FR groups. The incidence rate of symptomatic intracranial hemorrhage was significantly lower in the tPA+Solitaire FR group than that in tPA+Trevo group (p < 0.05) or tPA group (p < 0.01). Significantly more patients with mRS no higher than 2 points were found in the tPA+Trevo and tPA+Solitaire FR groups than those in tPA group (p < 0.05), and no significant difference was found between the tPA+Trevo and tPA+Solitaire FR groups. Conclusion: TPA+Solitaire FR is a type of thrombectomy that is superior to tPA and tPA+Trevo in the treatment of patients with AIS.

RESUMO OBJETIVO Comparar a eficácia do tratamento de diferentes tipos de embolectomia mecânica endovascular em acidente vascular cerebral isquêmico agudo (AIS). MATERIAL E MÉTODOS Um total de 89 pacientes com AIS foi selecionado em nosso hospital de janeiro de 2014 a janeiro de 2016, e os pacientes foram divididos em: grupo tPA (n = 27), tPA + grupo Trevo (n = 30) e grupo tPA + Solitaire FR (n = 32) para diferentes tratamentos. A eficácia do tratamento foi avaliada usando NIHSS e sistema mRS. Escore NIHSS, taxa de recanalização vascular e complicações pós-operatórias foram comparados entre os grupos. RESULTADOS A pontuação NIHSS do grupo tPA foi significativamente menor do que a dos outros dois grupos em um dia após a operação (p < 0,05), mas foi significativamente maior do que nos outros dois grupos em três dias e três semanas após a operação (p < 0,05). Após o tratamento, não houve diferença significativa no escore NIHSS entre o grupo tPA + Trevo e o grupo tPA Solitaire FR. A taxa de revascularização foi significativamente maior, mas a taxa de mortalidade em 90 dias foi significativamente menor nos grupos tPA + Trevo e tPA + Solitaire FR do que no grupo tPA (p < 0,05) e não houve diferença significativa entre os grupos tPA + Trevo e tPA + Solitaire FR. A taxa de incidência de hemorragia intracraniana sintomática foi significativamente menor no grupo tPA + Solitaire FR do que no grupo tPA + Trevo (p < 0,05) ou no grupo tPA (p < 0,01). Significativamente mais pacientes com mRS não maiores que 2 pontos foram encontrados no grupo tPA + Trevo e tPA + Solitaire FR do que no grupo tPA (p < 0,05), e nenhuma diferença significativa foi encontrada entre os grupos tPA + Trevo e tPA + Solitaire FR. Conclusão O tPA + Solitaire FR é um tipo de trombectomia superior ao tPA e tPA + Trevo no tratamento de pacientes com EIA.

The Application of Multi-modal CT in Stent Embolectomy for Acute Ischemic Stroke / 中山大学学报(医学科学版)

@#【Objective】To explore the image evaluation value of multi-model CT in the treatment of acute ischemic stroke with Solitaire stent embolectomy. 【Methods】 A total of 62 patients diagnosed with acute ischemic stroke from January 2015 to June 2016 in Guangdong Second Provincial General Hospital were included in this study. Multi- model CT inspection，including CT scan（NCCT），CT angiography（CTA）and CT perfusion imaging（CTP），was performed in all patients within 3~8 h. The improved vascular TICI classification standard（mTICI）was used to assess vascular embolization，and we evaluated the responsible vessels and blood perfusion state by CTA and CTP blood vessels ，to determine the feasibility of embolectomy with Solitaire stent preliminarily. The patients underwent multi-mode CT examination 24 h after stent embolization to evaluate the responsible vessels. NIHSS was used to assess the neurological function at admission and 72 h after stent embolization.【Results】A total of 34 patients with indication of stent thrombus removal were selected by multi-mode CT examination from 62 patients. Re-examination of multi-mode CT after stent thrombus removal showed that 30 of the 34 cases（30/34，the successful rate was 88.2%）gained success in vascular recanalization. Before the stent thrombus removal of the 34 patients，CTP imaging showed ischemic penumbra（IP），and there was significant decrease in cerebral blood flow（CBF）and slight decrease in cerebral blood volume（CBV），significantly prolonged peak time （TTP） and mean transit time （MTT） compared with the contralateral image area. The difference is statistically significant（P < 0.01）. After the stent thrombus removal，the relative cerebral blood flow（rCBF）and relative cerebral blood volume（rCBV）were elevated，the relative peak time（rTTP）and relative mean transit time（rMTT）were shortened. The difference is statistically significant（P < 0.01）. Compared with admission，there is significant statistical difference in the NIHSS score of patients 72 h after operation（P < 0.01）.【Conclusion】Multi-model CT has guiding effect and important evaluation value in the treatment of acute ischemic stroke patients with Solitaire stent thrombolysis.

Cilioretinal artery branch avulsion secondary to surgical embolectomy: management and outcome. Case report / Avulsão do ramo da artéria ciliorretiniana secundária à embolectomia cirúrgica: manejo e desfecho. Relato de caso

ABSTRACT We report the trans-operative approach and short-term outcome for a patient who suffered a traumatic avulsion of the cilioretinal artery branch during the surgical management of a cilioretinal arterial branch occlusion with intraocular embolectomy. The patient underwent a pars plana vitrectomy with in situ embolectomy. The blocked artery was incised using 25 Ga vertical scissors, and embolus manipulation was performed using microsurgical forceps. During embolus extraction, the occluded cilioretinal artery and its branch were inadvertently avulsed and torn with subsequent intense bleeding. Laser and endodiathermy were used for acute hemostasis. The maneuvers created an unintended retinochoroidal anastomosis. Visual-field improvement was noted three months after the surgery. In the event of a complicated surgical embolectomy with the avulsion of the artery, the formation of a retinochoroidal anastomosis and reperfusion of the occluded artery may occur along with the improvement of the visual field in some cases.

RESUMO Relatamos a abordagem transoperatória e o desfecho em curto prazo de um paciente que sofreu uma avulsão traumática do ramo da artéria ciliorretiniana durante o tratamento cirúrgico de uma oclusão do ramo arterial ciliorretiniano com embolectomia intraocular. O paciente foi submetido a uma vitrectomia pars plana com embolectomia in situ. A artéria bloqueada foi incisada com uma tesoura vertical de 25 Ga e a manipulação do êmbolo foi feita com pinça microcirúrgica. Durante a extração do êmbolo, a artéria ciliorretiniana ocluída e seu ramo foram inadvertidamente avulsionados e rasgados com sangramento intenso subsequente. Laser e endodiatermia foram utilizados para hemostasia aguda. As manobras criaram uma anastomose retinocoroidiana não intencional. Melhora do campo visual foi observada três meses após a cirurgia. No caso de uma embolectomia cirúrgica complicada com a avulsão da artéria, a formação de uma anastomose retinocoroidiana e reperfusão da artéria ocluída pode ocorrer juntamente com a melhora do campo visual em alguns casos.

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.

Embolectomía tardía en isquemia aguda de miembros inferiores / Late embolectomy in acute lower limb ischemia

La isquemia aguda es la interrupción brusca del aporte sanguíneo a un determinado territorio del organismo. Su causa más frecuente, la embolia arterial, consiste en la oclusión también brusca de una arteria sana por material trombótico formado en un territorio proximal al del accidente y que desencadena un cuadro que, de no diagnosticarse y tratarse adecuadamente, puede comprometer la vida del paciente. Existe una estrecha relación entre la gravedad del cuadro isquémico y el tiempo transcurrido de manera que si no se toman medidas agresivas a tiempo raramente se resuelve de manera satisfactoria. La revascularización es considerada menos efectiva después de 8 a 10 h de isquemia, tiempo después del cual muchos se abstienen de operar debido al temido síndrome de reperfusión; sin embargo, algunos refieren éxitos con embolectomías tardías. Se presenta un caso de embolismo arterial a miembro inferior derecho por arritmia cardiaca, que llegó al servicio de Cirugía Vascular del Hospital Provincial "Dr. Antonio Luaces Iraola", con 72 h de evolución. Se le realizó embolectomía femoral con catéter de Fogarty con resultados satisfactorios, lo que apoya la hipótesis de que se debe intentar reperfundir la extremidad siempre que se demuestre viabilidad de los tejidos y no exista gangrena, independientemente del tiempo transcurrido(AU)

Acute ischemia is the sudden interruption of the blood flow in a specific area of the body. Its most common cause is arterial embolism consisting of abrupt occlusion of a healthy artery by thrombotic residues formed in an area near the stroke and unleashing a clinical picture that should be adequately diagnosed and treated to avoid death. There is close relationship between the severity of ischemia and the time elapsed because if no aggressive actions are taken in due time, the results are rarely satisfactory. Revascularization is considered less effective 8 to 10 hours after ischemia. After this time many surgeons refrain from performing surgery due to the frightening reperfusion syndrome. However some had documented successful results with late embolectomy. Here is a case of arterial embolism in right lower limb owing to cardiac arrhythmia. The patient arrived to the Vascular Surgery service after 72 hours of the event; he was performed femoral embolectomy with Fogarty catheter and the achieved results were satisfactory, which supports the hypothesis of trying to reperfusing the affected limb whenever tissue viability exists and gangrene is not present, regardless of time elapsed(AU)

Tratamiento neuroquirúrgico de la isquemia cerebral / Neurosurgical treatment of cerebral ischemia

Introducción: El manejo actual de la isquemia cerebral aguda (IA) contempla el uso de r-tPA y terapia endovascular, mientrasque en la isquemia cerebral crónica (IC) la mejor terapia aún no está definida. La revascularización cerebral microquirúrgicaha sido descrita como tratamiento alternativo para pacientes con IA y contraindicación para r-tPA o terapia endovascular, asícomo para pacientes con IC en quienes la terapia médica ha fracasado. Objetivo: Comunicar la experiencia inicial en cirugíade revascularización cerebral, con énfasis en la utilidad de la embolectomía microquirúrgica y del bypass cerebral comoterapia de rescate en IA, así como del bypass cerebral en IC. Pacientes y Método: Serie prospectiva de 5 pacientes conisquemia cerebral tratados con cirugía de revascularización cerebral en el período 2013 a 2016. Se describe la técnica y resultadosquirúrgicos, así como el estado funcional a los 3, 6 y 12 meses de seguimiento según modified Rankin Scale (mRS)...

Background: Tissue Plasminogen Activator (t-PA) and mechanical thrombectomy are today the best treatment approachfor acute ischemic stroke (AIS). However, the best management for chronic cerebral ischemia (CCI) is still debated. Microsurgicalrevascularization has been described as alternative treatment for patients with AIS and contraindication for t-PA orendovascular therapy, and for patients with CCI and failure of maximal medical therapy. Aim: To describe the effectiveness ofmicrosurgical embolectomy and cerebral bypass as salvage therapy in AIS, as well as cerebral bypass in CCI. Methods: Fivepatients were treated by cerebral revascularization between 2013 and 2016. Surgical and functional results were analyzed.Neurological outcomes were assessed by modified Rankin Scale (mRS) at 3, 6 & 12 months...

Embolectomía pulmonar quirúrgica en el manejo del tromboembolismo pulmonar agudo: reporte de caso / Surgical pulmonary embolectomy for the management of acute pulmonary embolism: a case report

RESUMEN Introducción: El tromboembolismo pulmonar es una patología que compromete la vida y requiere tratamiento inmediato. De esta manera, para obtener los mejores resultados debe existir un alto grado de sospecha clínica que permita realizar el diagnóstico de manera temprana. Su manejo es farmacológico con anticoagulación, pero en ciertas ocasiones requiere de tratamiento quirúrgico. El objetivo de este reporte de caso es describir las indicaciones actuales para embolectomía pulmonar quirúrgica en un paciente con tromboembolismo pulmonar. Presentación del caso: Se presenta un caso de una paciente con tromboembolismo pulmonar, inestabilidad hemodinámica y foramen oval permeable, en el cual se encontraba atrapado un trombo en silla de montar con extensión a las dos aurículas, quien fue tratada con embolectomía pulmonar quirúrgica. Posterior a la embolectomía pulmonar quirúrgica la paciente presentó un episodio de tromboembolismo pulmonar recurrente que fue manejado nuevamente con embolectomía quirúrgica previo a la implantación de un filtro de vena cava por vía percutánea. Su evolución fue satisfactoria permitiendo suspender el soporte ventilatorio y hemodinámico de manera temprana. Conclusiones: La embolectomía pulmonar quirúrgica se mantiene vigente como manejo del tromboembolismo pulmonar en pacientes con inestabilidad hemodinámica que tienen contraindicación para trombolisis o en quiénes esta terapia ha fallado, así como en pacientes que tienen un trombo intracardíaco o en un foramen oval permeable. MÉD.UIS. 2017;30(1):93-7.

ABSTRACT Introduction: The pulmonary embolism is a pathology that endangers life and it requires an immediate treatment. In order to get the best results there should be a high degree of clinical suspicion that allows us to make an early diagnosis. It requires a pharmacological treatment with anticoagulation but in certain cases there is necessary a surgical treatment. The objective of this case report is to describe the current indications for the surgical pulmonary embolectomy in a patient with pulmonary embolism. Case Presentation: This is the presentation of a case in a patient with pulmonary embolism, haemodynamic instability and a horse saddle thrombus located in a patent foramen ovale which was expanded on the both heart atriums. This patient was treated with surgical pulmonary embolectomy. Following the surgical pulmonary embolectomy the patient had a recurrent pulmonary embolism episode that was treated with the insertion of a percutaneous vena cava filter and a newly surgical pulmonary embolectomy. The patient had a satisfactory postoperative evolution with an early discontinuation of the ventilatory and haemodynamic support. Conclusion: The surgical pulmonary embolectomy is still an applicable treatment for the pulmonary embolism in patients with haemodynamic instability, absolute contraindication to systemic thrombolytic therapy or failure to this therapy, patent foramen ovale and an intracardiac floating thrombus. mÉD.uIs. 2017;30(1):93-7.

Relationship between the times of endovascular thrombectomy and the prognosis of acute ischemic stroke / 中国脑血管病杂志

Objective To investigate the relationship between the times of thrombectomy and the prognosis of acute ischemic stroke. Methods From June 2014 to June 2016,the clinical data of 61 consecutive patients with ischemic stroke treated with emergency endovascular thrombectomy in Jinling Hospital,Medical School of Nanjing University were collected retrospectively. According to the times of thrombectomy,they were divided into either a routine thrombectomy group ( <3, n =48 ) or a multiple thrombectomy group (≥3,n=13). The modified Rankin scale (mRS) was used to evaluate the neurological function prognosis at 90 d in both groups of patients. The mRS score 0-2 was defined as good prognosis,3-6 were defined as poor prognosis,and 6 was death. Univariate analysis was used to compare the differences between the groups (excluding the patients whose DSA data missing or of poor quality). Spearman correlation analysis was used to evaluate the relationship between the times of thrombectomy and prognosis and fatality rate. Results Univariate analysis showed that the recanalization rate of the patients in the routine thrombectomy group (73. 9%[34/46] vs. 25. 0%[3/12],P =0. 005) and the rate of good collateral compensatory (55. 6%[25/45] vs. 8. 3%[1/12],P =0. 004) were higher than those in the multiple thrombectomy group. The incidence of symptomatic intracranial hemorrhage in the routine thrombectomy group was lower than that in the multiple thrombectomy group (14. 6%[7/48] vs. 53. 8%[7/13],P =0. 003). The mortality rate at 90 days was 18. 0%(n=11). Further Spearman correlation analysis showed that the times of thrombectomy were moderately positive correlated with the mortality rate ( r=0. 517,P=0. 000). There was no significant correlation between the times of thrombectomy and the good function prognosis (r=0. 076,P=0. 560). However,the effects of the differences between recanalization rate,collateral compensation and symptomatic intracranial hemorrhage could not be ruled out. Conclusion Emergency intravascular interventional therapy of multiple thrombectomy is positively related to the mortality rate at 90 d in patients with acute ischemic stroke,however,a study with larger sample is needed to confirm it.

Relationship between the times of endovascular thrombectomy and the prognosis of acute ischemic stroke / 中国脑血管病杂志

Objective To investigate the relationship between the times of thrombectomy and the prognosis of acute ischemic stroke. Methods From June 2014 to June 2016,the clinical data of 61 consecutive patients with ischemic stroke treated with emergency endovascular thrombectomy in Jinling Hospital,Medical School of Nanjing University were collected retrospectively. According to the times of thrombectomy,they were divided into either a routine thrombectomy group ( <3, n =48 ) or a multiple thrombectomy group (≥3,n=13). The modified Rankin scale (mRS) was used to evaluate the neurological function prognosis at 90 d in both groups of patients. The mRS score 0-2 was defined as good prognosis,3-6 were defined as poor prognosis,and 6 was death. Univariate analysis was used to compare the differences between the groups (excluding the patients whose DSA data missing or of poor quality). Spearman correlation analysis was used to evaluate the relationship between the times of thrombectomy and prognosis and fatality rate. Results Univariate analysis showed that the recanalization rate of the patients in the routine thrombectomy group (73. 9%[34/46] vs. 25. 0%[3/12],P =0. 005) and the rate of good collateral compensatory (55. 6%[25/45] vs. 8. 3%[1/12],P =0. 004) were higher than those in the multiple thrombectomy group. The incidence of symptomatic intracranial hemorrhage in the routine thrombectomy group was lower than that in the multiple thrombectomy group (14. 6%[7/48] vs. 53. 8%[7/13],P =0. 003). The mortality rate at 90 days was 18. 0%(n=11). Further Spearman correlation analysis showed that the times of thrombectomy were moderately positive correlated with the mortality rate ( r=0. 517,P=0. 000). There was no significant correlation between the times of thrombectomy and the good function prognosis (r=0. 076,P=0. 560). However,the effects of the differences between recanalization rate,collateral compensation and symptomatic intracranial hemorrhage could not be ruled out. Conclusion Emergency intravascular interventional therapy of multiple thrombectomy is positively related to the mortality rate at 90 d in patients with acute ischemic stroke,however,a study with larger sample is needed to confirm it.

Development of Mycotic Aneurysm of the Internal Iliac Artery Following Embolectomy of the Common Iliac Artery : Report of a Case Complicating Infective Endocarditis / 日本心臓血管外科学会雑誌

<p>A 23-year-old woman with mitral valve infective endocarditis complicated by embolism of the right common iliac artery underwent transfemoral embolectomy by a Fogarty catheter and mitral valve replacement. She developed occlusion of the right internal iliac artery, that was revealed by computed tomography on the 9th postoperative day. The occlusion was considered to result from migration of a part of the emboli from the right common iliac artery into the right internal iliac artery during the procedure of embolectomy. On the 16th postoperative day, she underwent repeat mitral valve replacement because of perivalvular leakage. Furthermore, after 2 weeks from the diagnosis of embolism of the right internal iliac artery, the embolic site showed aneurysmal formation finally requiring aneurysmectomy. Her recovery was uneventful. Our case is considered to be rare in that serial observations on computed tomography indicated the development of mycotic aneurysm at the site of septic embolism. In addition, care must be taken to prevent migration of emboli into branched arteries during the procedure of embolectomy for peripheral arterial septic embolism caused by infective endocarditis.</p>