Mechanical thrombectomy in patients with deep venous thrombosis.

PURPOSE: To report our experience with mechanical thrombectomy in proximal deep vein thrombosis (DVT). METHODS: Eighteen patients with a mean (+/- SD) age of 37.6 +/- 16.1 years who presented with DVT in the iliac and femoral vein (n = 3), inferior vena cava (n = 5), or inferior vena cava and iliac vein (n = 10), were treated with the Amplatz Thrombectomy Device after insertion of a temporary caval filter. RESULTS: Successful recanalization was achieved in 15 of 18 patients (83%). Overall, the percentage of thrombus removed was 66 +/- 29%: 73 +/- 30% at caval level and 55 +/- 36% at iliofemoral level. Complementary interventions (seven patients) were balloon angioplasty (n = 2), angioplasty and stenting (n = 2), thrombo-aspiration alone (n = 1), thrombo-aspiration, balloon angioplasty, and permanent filter (n = 1), and permanent filter alone (n = 1). There was one in-hospital death. Follow-up was obtained at a mean of 29.6 months; three patients had died (two cancers, one myocardial infarction); 10 had no or minimal sequelae; one had post-phlebitic limb. CONCLUSION: Mechanical thrombectomy is a potential therapeutic option in patients presenting with proximal DVT.

Endovascular treatment for dissection of the descending aorta.

Surgery for acute ischaemia complicating dissection of the descending aorta is associated with high mortality. We used an endovascular fenestration approach (scissor technique) to treat seven of 12 patients with ischaemic complications of descending aortic dissection; the remaining five patients were treated by stent implantation. Four of the 12 patients died (two in the fenestration group and two in the stenting group) in the days after the procedure. The remaining eight were symptom-free a mean of 9.4 (SD 8) months later. We suggest that the fenestration approach is a promising addition to endovascular treatment for patients with ischaemic complications of descending aortic dissection.

Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients.

BACKGROUND: Floating right heart thrombi (FRHTS) are a rare phenomenon, encountered almost exclusively in patients with suspected or proven pulmonary embolism and diagnosed by transthoracic echocardiography. Their management remains controversial. METHODS AND RESULTS: We report on a series of 38 consecutive patients encountered over the past 12 years. Thirty-two patients were in NYHA class IV, 20 in cardiogenic shock. Echocardiography usually demonstrated signs of cor pulmonale: right ventricular overload (91.7% of the population), paradoxical interventricular septal motion (75%), and pulmonary hypertension (86. 1%). The thrombus was typically wormlike (36 of 38 patients). It extended from the left atrium through a patent foramen ovale in 4 patients. Pulmonary embolism was confirmed in all but 1. Mortality was high (17 of 38 patients) irrespective of the therapeutic option chosen: surgery (8 of 17), thrombolytics (2 of 9), heparin (5 of 8), or interventional percutaneous techniques (2 of 4). The in-hospital mortality rate was significantly linked with the occurrence of cardiac arrest. Conversely, the outcome after discharge was usually good, because 18 of 21 patients were still alive 47.2 months later (range, 1 to 70 months). CONCLUSIONS: Severe pulmonary embolism was the rule in our series of FRHTS (mortality rate, 44.7%). The choice of therapy had no effect on mortality. Emergency surgery is usually advocated. However, thrombolysis is a faster, readily available treatment and seems promising either as the only treatment or as a bridge to surgery. In patients with contraindications to surgery or lytic therapy, interventional techniques may be proposed.

Angiographically documented late reocclusion after successful coronary angioplasty of an infarct-related lesion is a powerful predictor of long-term mortality.

BACKGROUND: Late reocclusion of an infarct-related artery (IRA) that was patent in the early days after acute myocardial infarction (MI) is a frequent event; the reocclusion rate may be as high as 30%. Few studies have been designed to analyze the impact of late reocclusion of the IRA on late survival. METHODS AND RESULTS: We studied 528 patients who all had a patent IRA after a successful PTCA procedure 10+/-6 days after MI and who underwent systematic 6-month angiographic follow-up to assess late patency of the IRA. We compared long-term survival of patients with and without late reocclusion. Based on the results of 6-month follow-up angiography, 2 groups of patients were defined: (1) 90 patients (17%) with reocclusion (Thrombolysis In Myocardial Infarction [TIMI] flow 0 or 1) and (2) 438 patients (83%) without reocclusion. Long-term clinical follow-up was obtained for all 528 patients at a median of 5.7 years after follow-up angiography (6.4 years after PTCA). The overall actuarial 8-year total mortality rate was 13%. At the end of follow-up, there were 35 deaths (8%) among the 438 patients without reocclusion and 18 deaths (20%) among the 90 patients with reocclusion (P=0.002). The actuarial 8-year total mortality rate was 10% in patients without reocclusion and 28% in patients with reocclusion (P=0.0003). The actuarial cardiovascular mortality rate was 7% in patients without reocclusion and 25% in patients with reocclusion (P<0.0001). The impact of reocclusion on long-term mortality was greater in patients with anterior MI. CONCLUSIONS: Late IRA patency is strongly associated with long-term survival after MI. These observations should encourage prospective studies to evaluate the impact of strategies designed to prevent late reocclusion in postinfarction patients.

[Pheochromocytoma simulating myocardial infarct. Apropos of a case]. / Phéochromocytome simulant un infarctus du myocarde. A propos d'un cas.

The authors report the case of a pheochromocytoma in a 67 year old man in whom the initial clinical presentation suggested myocardial infarction. Pheochromocytoma is usually an adrenal tumour with a very variable clinical symptomatology. It is very rare for cardiac disease to be a presenting symptom. The diagnosis was suggested by major blood pressure abnormalities occurring after starting medical treatment for infarction. Pheochromocytomas may cause serious cardiovascular disorders. The diagnosis must be suspected in the presence of atypical signs, an essential requirement to reduce the mortality of the disease.