Fenómenos embólicos y ecocardiografía transtorácica (ETT) durante cirugía de artroplastía de cadera (AC) / Embolic phenomena in hip Arthroplasty with intraoperative transthoracic echocardiography (TTE)

Embolic event's exist during hip arthroplasty surgery and specially those who had been caused by hip fracture. Complications depends mainly on the preoperative clinical conditions, and may even be subclinical if the patient was previously healthy. Thus, thanks to the technology progress, especially transesophageal echocardiography (TEE), it has been possible to identify these embolic phenomena at an early stage, allowing to be anticipated and treated an eventual cardiorespiratory compromise. A report was made of 2 patients with hip fracture, who underwent hip arthroplasty surgery (HA), in which through transthoracic echocardiography (TTE), it was possible to visualize embolic events, mainly during the acetabular reaming and the press-fit impact of the Cup. One patient presented hemodynamic impact that was early treated. This emphasizes how critical that period of the surgery is, and that when the anesthesiologist must be especially vigilant. There could be different causes: the energy made by the surgeons to make the acetabular reaming or to insert the cup; or even the destruction of the surrounding tissue during the fracture moment. So, in that way blood thrombus, air, fat or bone can get into the blood vessels and produce eventual complications. Therefore, special attention is required to the hemodynamic changes that may occur in these stages of surgery. Particularly, in these cases, in whom the patient's receive regional anesthesia and were positioned on lateral decubitus, it has to monitored by TTE and not by TEE, which gave more limitations at the moment to get the different echocardiograph Windows, thus it was chosen to use the subxiphoid window to see the inferior vena cava. In both cases, it was visualized embolic's events. But as it's said before, only one presented hemodynamic compromised. Also stands out, the relevance that there is more access to TTE in most of the operating centers of the country, unlike the TEE, which the transducer use for it, is more difficult for the anesthesiologist to get access to it and also requires more training.

Durante las cirugías de prótesis de cadera y especialmente aquellas por fractura de cadera pueden presentar eventos embólicos. Las complicaciones dependen principalmente de la condición clínica preoperatoria, pudiendo incluso ser subclínico si el paciente es sano. Así, gracias al progreso de la tecnología, particularmente la ecocardiografía transesofágica (ETE) y transtoraxica (ETT), se ha logrado identificar precozmente dichos fenómenos embólicos, permitiendo anticipar y tratar oportunamente una eventual descompensación cardiorrespiratoria. Se realizó un reporte de 2 pacientes con fractura de cadera, que se sometieron a una cirugía de artroplastía de cadera (AC), en los cuales mediante la vigilancia de ETT, se logró visualizar estos eventos, principalmente durante la fenestración e impactación del cotilo en el acetábulo, presentando uno de estos pacientes un impacto hemodinámico que se trató precozmente. Las causas de las embolías pueden ser variadas, como la presión ejercida por el cirujano para fenestrar e introducir la prótesis o la destrucción del tejido circundante a la lesión durante el momento de la fractura, entre otros. Así, se pueden producir embolias de trombos, grasa, hueso o incluso aire que pueda entrar al torrente sanguíneo y producir eventualmente complicaciones. Con estos hallazgos, ecográficos y en algunas oportunidades clínicos, se podría demostrar lo crítico que es aquel período de la cirugía, en donde se requiere especial atención a los cambios hemodinámicos que se puedan producir, y en el que el anestesiólogo debe estar especialmente vigilante. Particularmente, en estos casos, en que las pacientes recibieron anestesia regional y se intervino en posición de decúbito lateral, se tuvo que realizar monitoreo mediante ETT y no ETE, lo cual entrego más limitantes a la hora de conseguir buena calidad de ventanas cardiacas y por lo tanto, después de visualizar las distintas ventanas se optó por utilizar la ventana subxifoidea para visualizar la vena Cava inferior y así observar los distintos eventos embólicos circulantes. En ambas pacientes se pudieron apreciar eventos embólicos, pero en sólo una paciente tuvo compromiso cardiorrespiratorio con hipotensión, aumento de la frecuencia cardiaca y desaturación. Junto con la demostración de la posibilidad de visualización de embolías con ETT, se destaca la relevancia de que existe mayor acceso a este tipo de ecografía en gran parte de los pabellones de nuestro país, a diferencia de la ETE, en la que la sonda utilizada es de más difícil acceso por parte de los anestesistas y requiere un mayor entrenamiento.

Embolization by Bullet Dislodged from the Heart

Abstract Embolization by a dislodged projectile is a rare complication that may occur in cases of gunshot cardiac injuries. We report a case of a firearm projectile cardiac injury that evolved, with dislocation of the projectile during cardiac surgery, into embolization of the right external carotid artery.

Fluoroscopic Guided Fogarty Embolectomy for an Angio-Seal Embolism in the Popliteal Artery

The Angio-Seal is a widely used arterial closure device that helps achieve faster hemostasis and provide early ambulation to patients. However, it can cause various complications in clinical practice. We present the uncommon complication of popliteal artery occlusion following Angio-Seal deployment, and describe an effective interventional approach to its treatment. Because fluoroscopy-guided Fogarty embolectomy has the advantages of complete removal of the embolus without fragmentation, and clear visualization of the exact location of the embolus during the procedure, it is a suitable method for treating this complication.

Diagnostic yield and therapeutic impact of transthoracic echocardiography in patients with potential cardiac sources of cerebral embolism

To explore the diagnostic yield of transthoracic echocardiography [TTE], and assess the effect of echocardiographic findings on subsequent therapy. In this retrospective study, we reviewed TTE reports and hospital records of patients diagnosed with a stroke or transient ischemic attack [TIA], screening for potential cardiac sources of embolism [CSE] from January 2006 to December 2008 at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia by considering at least 15 predefined TTE criteria. The therapeutic interventions employed as a consequence of the TTE findings were sought. We analyzed 240 patients [mean patient age 58.5 +/- 14] out of 10563 TTEs. While only one patient exhibited a definite CSE on TTE, potential CSEs were found in 35 patients [14.6%], most commonly caused by left ventricular [LV] systolic dysfunction [31.4%], followed by LV regional wall motion abnormalities [25.7%]. Multivariate analysis revealed 2 independent predictors for identifying a CSE on TTE: history of coronary artery disease [odds ratio [OR] 6.2, 95% confidence interval [CI]:2.6-14.8, p=0.0001], and nationality [OR 0.16, 95% CI: 0.3-0.7, p=0.019]. The TTE findings affected therapy in only 3 patients [1.2%]. The TTE performed to exclude a CSE in patients with stroke or TIA resulted in low diagnostic yield, and had little impact on therapeutic decisions. Future refinement of clinical strategies to predict a CSE is needed to improve diagnosis, and possibly cost-effectiveness, of TTE

Acute Embolic Occlusion of the Left Common Iliac Artery Treated With Intra-Arterial Thrombolysis and Percutaneous Thrombectomy

Acute embolic occlusion of the common iliac artery is a rare medical emergency that is not only limbthreatening, but also potentially life-threatening. Several treatment options exist for acute limb ischemia, although no treatment is clearly best. We report a case of acute embolic occlusion of the left common iliac artery in a patient with atrial fibrillation who was treated successfully using mechanical thrombectomy following intra-arterial thrombolysis.

new method to decrease the occurrence of embolic events during total hip replacement

The goal of this study is to assess the efficacy of a modified surgical technique, designed to limit the increase in intramedullary pressure during insertion of the prosthesis and to reduce intra-operative embolic events. Forty patients treated with total hip replacement in Tanta university hospitals divided into 2 groups [group 1] treated with conventional cementing technique and [group 2] treated with a modified cementing technique with a cannula inserted into the intertrochanteric region of the femur to decrease the intramedullary pressure to avoid the increase of the intramedullary pressure after application of the cement and insertion of the stem. There was a significant difference between the incidence of embolism and increased pulmonary artery pressure [detected by trans-thoracic Echocardiography] between both groups of patients where the incidence of both were found to be much lower when the modified technique was used. Also the changes in the hemodynamic parameters [heart rate, blood pressure, and central venous pressure] accompanying the appearance of emboli in Echocardiography especially grades 2 and 3 embolism were found to be significant in the conventional cementing group [p<0.05]. The changes in the respiratory parameters [decreased oxygen saturation, decreased arterial oxygen tension, decreased end tidal CO2, and increased arterial CO2] accompanying the appearance of emboli in Echocardiography especially grades 2 and 3 embolism were found to be significant in the conventional cementing group [p<0.05]. Modified surgical technique [A vacuum drainage of the proximal femur along the linea aspera] was found to be effectively reducing the incidence of embolization during cemented hip arthroplasty

Value of transesophageal echocardiography and routine peripheral doppler study in the detection of silent embolism

25 patients with known cardiac disease and no signs and symptoms of peripheral embolism were included in this study. Peripheral Doppler study could demonstrated obstruction in the peripheral arterial tree of the lower limb in 8 of them. Transthoracic echocardiography fail to demonstrate the source of emboli in any of these cases while transesophageal study could detect source of emboli in 6 of the 25 cases included in the study. Only 2 of these cases had such positive finding in transthoracic study and 3 of these cases had silent arterial obstruction on peripheral Doppler study. It was concluded that routine periodic Doppler study of the peripheral arterial tree of the lower limbs is needed to detect cases with silent emboli. These cases should be selected and subjected to transesophageal echocardiography to determine the source of the embolism and its nature aiming at early diagnosis and prevention of major acute leg ischemia or stroke