Successful Surgical Extraction of an Embolized Iliac Vein Stent from the Right Heart: A Case Report.

BACKGROUND Stenting of the iliac vein remains one of the therapeutic options for the treatment of May-Thurner syndrome. Embolization of peripheral venous stents due to improper technique is a feared complication with an estimated incidence of 1% to 3%. Here we describe an interesting case of an embolized iliac vein stent in the right heart that was successfully extracted via a surgical approach. CASE REPORT A 52-year-old woman with a past medical history of hypertension, diabetes mellitus, and iliac vein stent (16×60 mm Zilver Vena) placement for May-Thurner syndrome presented for evaluation of shortness of breath, chest pain, and dizziness. A chest X-ray was performed, revealing a large stent in the cardiac silhouette. An echocardiogram showed a dense material across the tricuspid valve extending from the right atrium into the right ventricle. A percutaneous endovascular attempt to retrieve the stent was unsuccessful and led only to partial stent retrieval. An open sternotomy approach by a cardiac surgeon revealed the embolized stent across the tricuspid valve covered by endothelial tissue. The stent was successfully extracted without any need for tricuspid valve repair or replacement, followed by an uneventful postoperative recovery. CONCLUSIONS The percutaneous approach is the preferred initial option for the extraction of embolized iliac vein stents into the heart. However, when such an approach fails, the surgical approach remains a feasible option. As reported in this case, the surgical retrieval of a stent can be done without any need for either tricuspid valve repair or replacement.

Myocardial infarction due to coronary embolism after mechanical aortic valve replacement: a case report.

Prosthetic valve thrombosis (PVT) in aortic valve and its complication coronary embolism is a very rare condition. Diagnosis and treatment process is challenging. We present a young patient with acute myocardial infarction who underwent mechanical aortic valve replacement (AVR) operation one month earlier. Percutaneous coronary intervention was performed and it was succesful. Transeasophageal ecocardiography (TEE) was performed. Thrombus was seen on the mechanical aortic valve and thrombolytic therapy was initiated. Control TEE was performed and there was no signs of thrombi. The patient was discharged healthfully with anticoagulant and antiaggregan.

Cerebral Embolism and MINOCA Secondary to Left Atrial Myxoma after Occlusion of Atrial Septal Defect by Amplatzer Occluder: A Case Report.

Primary heart tumors are rare, with atrial myxomas being the most common type. Atrial myxomas can lead to embolisms, heart obstruction, and systemic symptoms. Herein, we report a case of 72-year-old woman who presented with a left atrial myxoma at the atrial septal defect occluder, a new acute cerebral infarction, and MINOCA (myocardial infarction with no obstructive coronary atherosclerosis). Left atrial myxoma is a common primary cardiac tumor; however, left atrial myxomas arising after percutaneous atrial septal defect occlusion are rare. Additionally, the patient presented with a new case of multiple systemic emboli. The patient underwent surgical resection of a left atrial myxoma, occluder, and left atrium, and atrial septal repair, and was discharged with good recovery for outpatient follow-up. The possibility of a cardiac tumor, especially an atrial myxoma, which can lead to a series of complications, should be considered at the closure site after percutaneous atrial septal closure. Therefore, active surgical treatment and long-term follow-up are warranted in such cases.

Pre-navigation balloon technique: Distal emboli protection during stent retriever thrombectomy.

OBJECTIVE: During stent retriever thrombectomy, a balloon guide catheter reduces distal emboli and consequently improves clinical outcomes. Because balloons are usually used before stent retrieval, these can affect the thrombus including the distal emboli while performing microcatheter navigation. This study aimed to evaluate the usefulness and safety of the pre-navigation balloon technique during microcatheter and microwire navigation. METHODS: Patients who underwent stent retriever thrombectomy secondary to an anterior circulation large-artery occlusion were retrospectively evaluated. The pre-navigation balloon technique was used, and the number of retrievals, procedure time, final recanalization, presence of distal emboli, first-pass effect (FPE), symptomatic intracranial hemorrhage including procedure-related complications, and clinical outcomes at 3 months were evaluated. RESULTS: In total 123 patients were analyzed, and occurrence of distal emboli was lesser in the pre-navigation balloon than in the non-preballoon group (4.4% vs. 11.5%, p = 0.02). No statistical difference was found in successful recanalization, mortality, and procedure-related complications. Moreover, the pre-navigation balloon group had a higher FPE than the non-balloon group (37.8% vs. 20.5%, p = 0.004). Although no statistical difference was found in the pre-navigation balloon group, a trend toward a higher rate of good clinical outcomes was observed (mRS 0-2 at 3 months, 55.6% vs. 48.7%, p = 0.09). For ICA occlusion(n = 35), significant effects were seen in decreasing distal embolism (0(0%) vs 3(16%), p = 0.01), increasing FPE (8(50%) vs 6(32%), p = 0.003), and improving clinical outcomes (mRS 0-2 at 3 months, 9(56%) vs 7(37%), p = 0.03) in the pre-navigation balloon group. In the multivariate analysis, lesser distal embolism (0.91 [0.80-1.00], p = 0.02), higher successful recanalization (3.52 [1.11-7.03], p = 0.016), and higher FPE (3.17 [1.83-7.37], p = 0.001) secondary to the procedure was a predictor of favorable clinical outcomes. CONCLUSIONS: The pre-navigation balloon technique significantly reduced occurrence of distal embolism and increased the FPE.

Intra-abdominal pressure increases peri-operatively in patients undergoing deep inferior epigastric perforator flap reconstruction: A prospective study linking high intra-abdominal pressure to non-fatal lung embolism within one patient.

BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. The procedure and peri-operative period are associated with the risk of severe post-operative complications, like venous thromboembolic events (VTE) and lung embolism. Whether the intra-abdominal pressure (IAP) increases after the closure of the abdominal defect, thereby potentially affecting the venous backflow and the risk of VTE, is currently not known. AIM: The primary aim is to test if the closure of the abdominal donor site increases the IAP in women undergoing secondary DIEP flap breast reconstruction. MATERIALS AND METHOD: By using a Unometer, we measured the intravesical pressure as a surrogate marker for the IAP, at baseline, immediately after, and 24 h after abdominal skin closure, for 13 patients. RESULTS: The mean IAP increased from 6.1 mmHg (95% CI 4.6-7.7) at baseline to 9.0 mmHg (95% CI 8.0-10.0) immediately after skin closure [mean diff. 2.9 (95% CI 1.0-4.8) (p = 0.007)] and further up to 11.7 mmHg (95% CI 9.0-14.5) 24 h after closure [mean diff. 5.3 (95% CI 1.4-9.1) (p = 0.012)]. We found that IAP varies among the patients, regardless of the tightness of abdominal closure or rectus plication (n = 3). Immediately after closure, none of the isolated patients showed abnormal levels of IAP (>12 mmHg), while eight out of 12 isolated patients (67%) showed IAP levels above the normal range after 24 h. One patient developed a non-fatal lung embolism. CONCLUSION: The mean IAP increases significantly over the post-operative period after DIEP flap reconstruction, although abnormal IAP values are only seen 24 h after the closure of the skin.

[Bullet embolism of internal carotid artery. (A case report and literature review)]. / Pulevaya emboliya vnutrennei sonnoi arterii. (Klinicheskoe nablyudenie i obzor literatury).

Bullet vascular embolism is a rare complication of gunshot wounds with risk of dire consequences and even death. Bullet embolism of internal carotid artery is extremely rare. Therefore, there is no uniform approach to the treatment of these patients. Nevertheless, removal of embolus through available surgical approach and arterial reconstruction with restoration of blood flow seems optimal. The authors present a 14-year-old patient with a wound to the left half of the chest from pneumatic gun complicated by bullet migration to the right ICA. Surgical intervention made it possible to remove the bullet from the artery and eliminate the risk of thrombosis and embolism. This case demonstrates the possibilities of open reconstructive surgery of supra-aortic vessels.

Hepatic Hypertrophy in Normal and Cirrhotic Livers Following Portal Vein Embolization: Comparative Assessment of 2 Different Embolic Regimens in a Large Animal Model.

PURPOSE: To compare the mechanistic effects and hypertrophy outcomes using 2 different portal vein embolization (PVE) regimens in normal and cirrhotic livers in a large animal model. METHODS AND MATERIALS: The Institutional Animal Care and Use Committee approved all experiments conducted in this study. Fourteen female Yorkshire pigs were separated into a cirrhotic group (CG, n = 7) and non-cirrhotic group (NCG, n = 7) and further subgrouped into those using microspheres and coils (MC, n = 3) or n-butyl cyanoacrylate (nBCA, n = 3) and their corresponding controls (each n = 1). A 3:1 ethiodized oil and ethanol mixture was administered intra-arterially in the CG to induce cirrhosis 4 weeks before PVE. Animals underwent baseline computed tomography (CT), PVE including pre-PVE and post-PVE pressure measurements, and CT imaging at 2 and 4 weeks after PVE. Immunofluorescence stainings for CD3, CD16, Ki-67, and caspase 3 were performed to assess immune cell infiltration, hepatocyte proliferation, and apoptosis. Statistical significance was tested using the Student's t test. RESULTS: Four weeks after PVE, the percentage of future liver remnant (FLR%) increased by 18.8% (standard deviation [SD], 3.6%) vs 10.9% (SD, 0.95%; P < .01) in the NCG vs CG. The baseline percentage of standardized future liver remnant (sFLR%) for the controls were 41.6% for CG vs 43.6% for NCG. Based on the embolic agents used, the sFLR% two weeks after PVE was 58.4% (SD, 3.7%) and 52.2% (SD, 0.9%) (P < .01) for MC and 46.0% (SD, 2.2%) and 47.2% (SD, 0.4%) for nBCA in the NCG and CG, respectively. Meanwhile, the sFLR% 4 weeks after PVE was 60.5% (SD, 3.9%) and 54.9% (SD, 0.8%) (P < .01) and 60.4% (SD, 3.5%) and 54.2% (SD, 0.95%) (P < .01), respectively. Ki-67 signal intensity increased in the embolized lobe in both CG and NCG (P < .01). CONCLUSIONS: This preclinical study demonstrated that MC could be the preferred embolic of choice compared to nBCA when a substantial and rapid FLR increase is needed for resection, in both cirrhotic and non-cirrhotic livers.

Clinical Characteristics of Acute Lower Extremity Ischemia Due to Left Atrial Myxoma: A Rare Case Report with Review of Literature.

Emboli caused by cardiac myxomas mostly occur in the cardiovascular or cerebrovascular systems and rarely in the lower extremity vasculature. We introduce the rare case of a patient with left atrial myxoma (LAM) whose right lower extremity (RLE) suffered from acute ischemia due to tumor fragments, along with a review of the relevant literature, and highlight the clinical characteristics of LAM. An 81-year-old female presented with acute ischemia of RLE. Color Doppler ultrasound showed no blood flow signal far from the RLE femoral artery. Computed tomography angiography showed an occlusion of the right common femoral artery. A transthoracic echocardiogram revealed a left atrial mass. Femoral artery embolectomy was performed under local anesthesia, followed by thoracotomy with tumor resection under general anesthesia on postoperative day seven. The tumor was pathologically confirmed as an atrial myxoma. A literature search of the PubMed database returned 58 cases of limb ischemia due to LAM, and the conclusions drawn from the statistical analysis were that emboli from LAM occurred most commonly in the aortoiliac and bilateral lower limb vasculature and were rarely associated with upper extremity and atrial fibrillation. Multisystem embolism is characteristic of cardiac myxoma. The removed embolus should be examined pathologically for signs of a cardiac myxoma. Lower-limb embolisms should be promptly diagnosed and treated to avoid osteofascial compartment syndrome.

[Idiopathic Ascending Aortic Thrombosis with Multiple Embolism:Report of a Case].

Ascending aorta thrombosis unaccompanied by an aneurysm or a primary hypercoagulable state is rare. We report a surgical case of ascending aorta thrombosis with multiple emboli. A 44-year-old woman visited the hospital for evaluation of dysarthria and was diagnosed with multiple cerebral infarcts. Contrast-enhanced computed tomography (CT) revealed a mass in the ascending aorta and the brachiocephalic artery. We performed emergency removal of the masses and endarterectomy with cardiopulmonary bypass under hypothermic circulatory arrest. Histopathological examination of the resected specimen showed thrombi. The patient had an uneventful recovery and was discharged 12 days postoperatively. No recurrent thrombus or hypercoagulable state was observed for 3 years postoperatively.

Management of Venous and Arterial Bullet Emboli.

Gunshot wounds account for significant morbidity and mortality in the United States. A rare and potentially fatal complication of a gunshot wound is bullet embolus. Potential complications include distal limb ischemia, coronary infarct, renal infarction, stroke, pulmonary embolization, cardiac valvular injury, thrombophlebitis, and dysrhythmias. Overall, surgical embolectomy and endovascular retrieval are the preferred treatments for bullet emboli. We report one case of venous bullet embolus and one case of arterial bullet embolus, both of which were successfully treated with endovascular retrieval. A thorough physical exam and appropriate imaging are vital to prompt identification and treatment of bullet emboli, as the repercussions of missed injuries can be devastating.

Ventricular Embolization of Mitral Valve in Valve Rescued With a Second Valve.

Valve embolization is a catastrophic complication of mitral valve-in-valve and valve-in-ring procedures and occurs due to inadequate ventricular positioning, undersizing, or insufficient anchoring. Emergent cardiac surgery to retrieve the embolized valve is usually required for overt embolization. In the situation described herein, a decision was made to attempt to deploy a second valve at a proper depth to anchor the embolized valve and prevent further migration. This case highlights the technique of deploying a second valve to anchor the embolized valve if valve migration has occurred with minimal movement.

Percutaneous mechanical thrombectomy in the management of early acute superior mesenteric artery embolism.

PURPOSE: This study was performed to summarize our experience in the management of early-stage acute superior mesenteric artery embolism (ASMAE) by percutaneous mechanical thrombectomy (PMT). METHODS: The clinical data of 12 patients with early-stage ASMAE treated by PMT in our institution from November 2019 to September 2021 were retrospectively analyzed. The patients had no obvious evidence of bowel infarction as shown by peritoneal puncture and computed tomography angiography. Thrombectomy of the superior mesenteric artery was performed using a 6F AngioJet catheter. RESULTS: The emboli were completely removed in 10 (83.3%) patients. Six patients were treated only by the AngioJet device. The other six patients underwent combined treatment with a 6F multipurpose drainage catheter after PMT, including one patient who underwent simultaneous stent implantation. Two patients showed no significant improvement in their symptoms after the operation; one was found to have intestinal necrosis and underwent resection by exploratory laparotomy, and the other died of septic shock 3 days after PMT (further intervention had been discontinued because of complications with multiple underlying diseases). No other PMT-related complications occurred. Only one patient was found to have a pseudoaneurysm of the superior mesenteric artery 1 week after PMT and underwent resection by exploratory laparotomy. The 11 surviving patients were smoothly discharged from the hospital after their symptoms were relieved. At a mean follow-up of 13.2 months, computed tomography angiography showed smooth patency of the superior mesenteric artery. No patients developed serious symptoms during follow-up. CONCLUSIONS: PMT by the AngioJet device is a minimally invasive, safe, and effective technique to remove ASMAE. Early application of PMT can avoid acute intestinal necrosis. Combining the AngioJet device with a 6F multipurpose drainage catheter might be more helpful to remove residual emboli.

Embolism After Injection of a Calcium Sulfate Bone Graft Substitute: A Case Report.

CASE: A 66-year-old man presented with new left hip pain after total hip arthroplasty 21 years earlier. Computed tomography imaging revealed massive osteolysis involving the ileum behind the well-fixed acetabular component. The patient was indicated for head and liner exchange with grafting of the osteolytic lesion. Surgery was complicated by cardiopulmonary arrest after injection of a bone graft substitute into the lesion. Despite resuscitation attempts, the patient died. CONCLUSION: Embolism is a rare complication of bone graft substitute injection for pelvic osteolysis. This material can extravasate from bone and deposit in the pulmonary and cerebral microcirculation.

Effect of catheter ablation combined with left appendage occlusion for non-valvular atrial fibrillation: a meta-analysis.

OBJECTIVE: To estimate the effect of catheter ablation combined with left appendage occlusion in the treatment of non-valvular atrial fibrillation (NVAF) by a method of meta-analysis. METHODS: Pubmed, Embase, and Cochrane Library were searched for the studies about catheter ablation combined with left appendage occlusion in treating NVAF. The data analysis was performed using R 4.0.5 software. The retrieval time was from inception to May 12, 2021. RESULTS: A total of 18 published studies were identified in the meta-analysis, including 1385 participants. During the perioperative period of catheter ablation combined with left appendage occlusion in treating NVAF, the pooled incidences of pericardial effusion, major or minor bleeding events, and residual flow documented were 0.5%(95%CI 0.0002-0.0099), 1.42%(95% CI 0.00-0.04), 7.24%(95% CI 0.0447-0.0975), respectively. During the follow-up, the incidences of all-cause mortality, embolism events, and bleeding events were 0.32%(95%CI 0.0000-0.0071), 1.29%(95%CI 0.0037-0.0222), 2.07%(95% CI 0.0075-0.0339), respectively. In the follow-up period of the transesophageal echocardiography, the most complication was residual flow event with an incident rate of 10.80%(95% CI 0.054-0.1620). The maximum occurrence probability of residual flow events was 17.92% (95% CI 0.1133-0.2452). Moreover, the incident rate of NVAF recurrence was 29.23% (95% CI 0.2222-0.3623). CONCLUSION: The meta-analysis suggests that the "one-stop" procedure is effective for those patients undergoing NVAF. However, Patients with more residual blood flow have a higher incidence of bleeding complications. More studies are warranted to verify the safety and efficacy of catheter ablation combined with left appendage occlusion in terms of the "one-stop" procedure.

Extended Use of Distal Embolic Protection Devices in Treatment of Distal Embolism During Lower Extremity Arterial Endovascular Interventions.

There is no consensus on the best treatment modality for acute distal embolization complications during endovascular interventions for peripheral arterial diseases. We report on 3 patients who underwent mechanical embolectomy using a distal embolic protection device (EPD). All patients showed angiographic evidence of distal embolism, which occurred during lower extremity limb salvage endovascular procedures. After embolectomy, all had complete recanalization of the involved vessel on completion angiogram, and none had any device-related complications or adverse outcomes from the embolization. This initial experience suggests that EPD can be used for both the prevention and treatment of intraoperative distal embolization during endovascular intervention of lower extremity arterial disease.