Pulmonary embolism from axillosubclavian thrombosis on a rehabilitation unit: case report

This report presents a case of angiogram-confirmed pulmonary emboli (PE) from upper extremity deep venous thrombosis (UE DVT) in a patient with Guillain-Barré syndrome. UE DVT has been rarely reported in the rehabilitation literature and it is not described in many standard references in the field. Risk factors for UE DVT include central venous catheterization (CVC), stasis, and hypercoagulability. Rehabilitation patients commonly demonstrate these risk factors, as well as unilateral limb swelling and pain. Although early reports emphasized the rarity of PE from UE DVT, it is now reported in roughly 12% of cases, and there may be an even higher incidence in CVC-related UE DVT. This report includes a review of etiologic, anatomic, diagnostic, and therapeutic considerations, and concludes with a discussion of the potential underrecognized significance of UE DVT in the general rehabilitation population.

The efficacy of prophylaxis with low-dose warfarin for prevention of pulmonary embolism following total hip arthroplasty

The selection of a prophylaxis regimen and its implementation have been influenced considerably by the decreased duration of hospital stays and the pressures of cost containment. The purpose of the present study was to determine the rate of symptomatic pulmonary embolism both before and after discharge, the number of days required to achieve an adequate level of anticoagulation, and the complications associated with the use of low-dose warfarin after total hip arthroplasty. Between 1987 and 1993, 1099 primary and revision total hip arthroplasties were performed in 940 patients who received low-dose warfarin for prophylaxis against thromboembolic disease. The average duration of prophylaxis was fifteen days (range, one to twenty-nine days). The target level of anticoagulation (as indicated by a prothrombin time of fourteen to seventeen seconds) was achieved an average of three days (range, one to sixteen days) after the operation. The level of anticoagulation was lower than the target range at the time of discharge after 257 total hip arthroplasties (23.4 per cent), and the target level was never achieved during the period of hospitalization after fifty-four such procedures (4.9 per cent). Twelve total hip arthroplasties were associated with a symptomatic pulmonary embolism; the over-all prevalence of this complication therefore was 1.1 per cent (95 per cent confidence interval, 0.4 to 1.9 per cent). Four pulmonary emboli were diagnosed before discharge and eight, after discharge. A fatal pulmonary embolism occurred after one procedure (0.1 per cent). Patients who had a history of symptomatic venous thromboembolic disease had a significantly increased risk of symptomatic pulmonary embolism after total hip arthroplasty (p = 0.001, Fisher exact test). A major bleeding episode occurred after thirty-two total hip arthroplasties (2.9 per cent). Patients who had a prothrombin time of more than seventeen seconds had a significantly increased risk of hematoma formation (p = 0.003, chi-square analysis). Prophylaxis with low-dose warfarin is safe and effective for the prevention of pulmonary embolism after total hip arthroplasty.

[Fatal pulmonary embolism during knee surgery under epidural anesthesia]

A 36 year old male patient suddenly died of pulmonary embolism during the second application of a pneumatic tourniquet undergoing tibial fracture repair. Pulmonary artery angiography using Swan-Ganz catheter demonstrated that the left and right pulmonary arteries were occluded except the partial left upper lobe. PaO2 was below 7 mmHg, and cardiopulmonary resuscitation was not possible. Autopsy showed massive emboli completely blocking the both pulmonary arteries.

Suprarenal inferior vena cava filter placement prior to transcatheter arterial embolization (TAE) of a renal cell carcinoma with large renal vein tumor thrombus: prevention of pulmonary tumor emboli after TAE

To prevent embolization of necrotic renal vein tumor after transcatheter embolization of a left renal cell carcinoma, we placed a suprarenal Bird's nest inferior vena cava filter. The patient tolerated the procedure well and had extensive tumor infarction including the tumor thrombus on 6-month follow-up computed tomography.

Pseudopulmonary embolism: acute respiratory distress in the syndrome of heparin-induced thrombocytopenia

A 73-year-old man with myasthenia gravis was treated with daily plasmapheresis. During the course of treatment, the patient developed progressive thrombocytopenia and an episode of severe acute respiratory distress suggesting pulmonary embolism. The thrombocytopenia and respiratory impairment improved after discontinuation of heparin, and both recurred on heparin rechallenge. The presence of heparin-specific antibodies was confirmed by in vitro assay. The time frame of clinical events suggests a heparin-mediated mechanism for both the thrombocytopenia and respiratory compromise. We conclude that acute respiratory distress may be the presenting manifestation of the syndrome of heparin-associated thrombocytopenia in patients treated with dialysis or apheresis.

Postpartum pulmonary embolectomy; a surgical challenge and favourable outcome

A 23-year-old female underwent uneventful caesarian section, which was followed by massive pulmonary embolism. Pulmonary embolectomy on cardiopulmonary bypass was performed, and was complicated by massive intraabdominal haemorrhage due to a hepatic subcapsular rupture. To our knowledge, this is the first surgically orientated case of postpartum pulmonary embolectomy to be reported in the literature.

[Apical hypertrophic cardiomyopathy with right ventricular involvement]

We report right ventricular involvement in apical hypertrophic cardiomyopathy (HCMP) in two women and one man, aged from 19 to 44 years-old, who presented different signs from those with left ventricular disease (who have good clinical evolution), with signs and symptoms of severe diastolic restriction, showing great atrial enlargement and two with atrial fibrillation and death due to thromboembolism. The right ventricular involvement in apical HCMP leads to a worst prognosis than isolated left ventricular disease, does not have the typical electrocardiographic changes and presents with ventricular restriction and tricuspid regurgitation.

[An autopsy case of pulmonary thromboembolism: a delayed complication of a victim by traffic accident]

A 35-year-old male had fallen down from his motor bike caused a fracture of the medial condyle of the right tibia and the acromion of the left scapula. He had received screw fixed operation for his right tibia and had been in the hospital for one month. He died suddenly in the hospital and was autopsied to find out the cause of death. On external examination, it was found that affected leg was bruised and swollened. Partially organized thrombosis in the posterior tibial vein was revealed and bilateral pulmonary arteries were packed with reddish massive thromboemboli. The causes of the posterior tibial vein thrombosis were intimal damage and decreased venous flow, attributable to bed rest for long days and external fixation of the lower extremity. We presumed that direct cause of death was a large thromboemboi which were migrated from posterior tibial vein and lodged at the bifurcation of the pulmonary artery causing obstruction of pulmonary blood flow. Finally we opened the direct cause of death was pulmonary thromboembolism due to leg injury. Clinical instability may hinder the diagnostic elevation and delay therapeutic intervention, it is the most often happened in sudden death cases within the hospital. The importance of early diagnosis and early prevention is underscoped, because the symptoms of pulmonary thromboembolism are not always produced. To prevent fatal pulmonary thromboembolism in trauma, prophylactic use of low-dose heparin therapy and/or the use of oral anticoaglant (warfarin) have been effective and recommended in USA and Western Europe. The routine use of these therapy has not yet been spread in Japan, because the incidence is still apparently lower than in USA and Western Europe as well as the risk of hemorrhage. If the victims of road traffic accident receive the prophylactic use of low-dose heparin and/or oral anticoaglant (warfarin), it might be an effective way to reduce mortality.

Perioperative pulmonary tumor embolus: a case report

A 64-year-old white female underwent an elective exploratory laparotomy, right radical nephrectomy, and excision of a vena cava tumor for renal cell carcinoma. Preoperatively, the patient was diagnosed with a right kidney mass that was invading the right renal artery and vena cava. The patient had received a general endotracheal anesthetic consisting of O2, N2O, forane, fentanyl, pentothal, vecuronium, and hydromorphone. The right nephrectomy was completed by the urologist without incident. Following the nephrectomy, the right renal artery and vein were dissected, and the vena cava was exposed. When a temporary clamp was placed on the vena cava, there was a sudden onset of tachycardia, right bundle branch block with (transient) inversion of the QRS complex, hypotension, decreased end-tidal CO2 and decreased O2 saturation, and increased pulmonary inspiratory pressures that did not resolve when the clamp was removed. The diagnosis of tumor embolus was made and the incision was closed. As arrangements were made to transfer the patient to a nearby hospital with facilities to perform cardiopulmonary bypass and pulmonary embolectomy, the patient was supported with 100% oxygen, intermittent boluses of epinephrine, sodium bicarbonate, and titrated inotropic infusions (dopamine, dobutamine, and epinephrine). Successful embolectomy was accomplished. The patient was discharged on postoperative day 9 in good condition.

Molecular characterization of a type I quantitative factor V deficiency in a thrombosis patient that is "pseudo homozygous" for activated protein C resistance

Resistance to activated protein C (APC), which is associated with the FV Leiden mutation in the large majority of the cases, is the most common genetic risk factor for thrombosis. Several laboratory tests have been developed to detect the APC-resistance phenotype. The result of the APC-resistance test (APC-sensitivity ratio, APC-SR) usually correlates well with the FV Leiden genotype, but recently some discrepancies have been reported. Some thrombosis patients that are heterozygous for FV Leiden show an APC-SR usually found only in homozygotes for the defect. Some of those patients proved to be compound heterozygotes for the FV Leiden mutation and for a type I quantitative factor V deficiency. We have investigated a thrombosis patient characterized by an APC-SR that would predict homozygosity for FV Leiden. DNA analysis showed that he was heterozygous for the mutation. Sequencing analysis of genomic DNA revealed that the patient also is heterozygous for a G5509-->A substitution in exon 16 of the factor V gene. This mutation interferes with the correct splicing of intron 16 and leads to the presence of a null allele, which corresponds to the "non-FV Leiden" allele. The conjunction of these two defects in the patient apparently leads to the same phenotype as observed in homozygotes for the FV Leiden mutation.

Catheter fragments embolization

Although the use of central venous silicone catheters is widespread, little is known about the incidence of catheter rupture and embolization. Over a three-year period, 3916 silicone catheters were inserted in 3672 patients in the authors' hospital. Catheter or catheter fragments embolism occurred in 4 patients (1.2 embolizations per 1000 patients treated). Inappropriate mechanical deobstruction attempts resulted in 2 embolizations, and hence, these should be avoided. Chest roentgenography failed to detect the small fragments within the heart silhouette in 2 cases. Two-dimensional echocardiography showed the separated catheter fragment in all 4 cases. All four catheter fragments were subsequently removed from the right-heart chambers.

Low-dose warfarin prophylaxis to prevent symptomatic pulmonary embolism after total knee arthroplasty

Pulmonary embolism poses a risk to patients undergoing total knee arthroplasty. The selection of an appropriate prophylaxis agent and its implementation have been influenced by decreased duration of hospital stay and the pressures of cost containment. The purpose of this study was to determine the inpatient and outpatient pulmonary embolism rates, the number of days required to attain the target level of anticoagulation, and complications associated with the use of a low-dose warfarin prophylaxis protocol after primary and revision total knee arthroplasty. Between 1984 and 1993, there were 815 primary and revision total knee arthroplasties that received low-dose warfarin prophylaxis at our institution. The average time to attainment of the target level of anticoagulation was 3 days. The average duration of warfarin prophylaxis was 12 days. Overall, there were a total of three symptomatic pulmonary embolisms (0.3%; 95% confidence interval, 0.08%-1.1%). There were eight (1%) symptomatic deep vein thromboses (all distal). There were two deaths (0.3%), but neither one was secondary to a pulmonary embolism. Seventeen knees (2.5%) developed a hematoma after surgery, and two of these patients required drainage of the knee. Low-dose warfarin prophylaxis is safe and effective in preventing symptomatic pulmonary embolism after total knee arthroplasty.

Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications

BACKGROUND

Little is known about the clinical, diagnostic, and prognostic aspects of upper-extremity deep vein thrombosis (UEDVT).

OBJECTIVES

To identify the clinical and laboratory parameters associated with this disease, to assess the diagnostic accuracy of ultrasonographic methods for its detection, and to establish the frequency of both early and late complications.

PATIENTS AND METHODS

After a careful history was taken, 58 consecutive patients with signs and symptoms that were clinically suggestive of UEDVT underwent the determination of antithrombin III and protein C and S levels and resistance to activated protein C and lupuslike anticoagulants. Compression ultrasonography, color flow Doppler imaging, and Doppler ultrasonography were performed prior to venography. Patients with confirmed UEDVT underwent objective tests to detect a pulmonary embolism and were followed up prospectively to record recurrent thromboembolic events and postthrombotic sequelae.

RESULTS

Findings from venography confirmed UEDVT in 27 patients (47%). Central venous catheters, thrombophilic states, and a previous leg vein thrombosis were statistically significantly associated with UEDVT. Sensitivity and specificity of compression ultrasonography (96% and 93.5%, respectively) and color flow Doppler imaging (100% and 93%, respectively) were comparable and better than those of Doppler ultrasonography (81% and 77%, respectively). Objective findings suggestive of a pulmonary embolism were recorded in 36% of the patients with UEDVT. After a mean follow-up of 2 years, 2 patients with UEDVT experienced recurrent thromboembolic events, and 4 had postthrombotic sequelae.

CONCLUSIONS

Symptomatic UEDVT is associated with central venous catheters, thrombophilic states, and a previous leg vein thrombosis. Both compression ultrasonography and color flow Doppler imaging are accurate methods for its detection. A pulmonary embolism is a common complication of the disease. Finally, this disorder may recur and may be followed by postthrombotic sequelae.

Role of early diagnosis for a noninvasive treatment of pulmonary thromboembolism in leukemic children

Pulmonary thromboembolism (PTE) in leukemic children undergoing intensive chemotherapy should be promptly recognized so that specific therapy can be started. Our experience with the two cases reported here has led us to propose guidelines for the treatment of initial PTE in a pediatric hematology unit. Two children with leukemia developed PTE, the first during the relapse for acute lymphoblastic leukemia and the second at the onset of acute promyelocytic leukemia. In both cases, the diagnosis of PTE was based on clinical assessment of sudden acute respiratory failure with positive pulmonary perfusional scintigraphy in spite of a negative chest X-ray. The subintensive supervision consisted of instrumental monitoring with the assistance of an intensive care anesthetist. The clinical monitoring was based on the serial registration of respiratory rate, cardiac rate, SaO2 and body temperature. The thrombolytic therapy, together with heparin prophylaxis, was successfully administered in the hematology ward without the need for intensive care support (i.e. mechanical ventilation). The success of the treatment was documented by the criterion of a return to the normal cardiorespiratory parameters a few hours after the start of the thrombolytic treatment. Furthermore, a chest CT scan in case 1 and an arteriography in case 2 confirmed the PTE-related hypoperfusion. On the basis of this experience, the authors point out that in the course of acute respiratory failure in leukemic children, the combination of a negative chest X-ray and a positive pulmonary perfusional scintigraphy (compared whenever possible with ventilatory scintigraphy) in the presence of a negative CT scan could be a reliable diagnostic tool for PTE. This pathology should be treated promptly and with specific therapy to avoid progression to a severe, massive PTE.

The role of ultrasonography and inferior vena cava filter placement in high-risk trauma patients

Undetected lower-extremity deep-vein thrombosis (LEDVT) in the trauma patient can lead to significant morbidity and mortality. The purpose of this study was to: 1) evaluate the role of ultrasonography in the early detection of LEDVT in high-risk trauma patients; 2) identify prognostic indicators that predict LEDVT; and 3) evaluate the efficacy of selected inferior vena cava (IVC) filter placement in the prevention of pulmonary emboli. From October 1993 through December 1994, all adult multiple-trauma patients admitted to the Trauma Service who required prolonged bed rest (>3 days) or sustained a lower-extremity, pelvic, or spinal fracture with paralysis were prospectively studied with serial physical examinations and lower-extremity venous ultrasounds within 72 hours of admission and then weekly until discharge. Two hundred twenty-eight patients were entered into the study. Thirty-nine patients (17%) developed ultrasound evidence of LEDVT; of these, only seven (18%) were evident on physical examination. This allowed 32 patients (82%) with unsuspected LEDVT to receive earlier definitive therapy. Multivariate logistic regression analysis of LEDVT with various predictors found age, hospital length of stay, and lower-extremity trauma to be significant predictors of LEDVT (P < 0.05). Twenty-nine patients (74%) had immediate IVC filter placement upon ultrasound identification of proximal LEDVT. None of these patients developed pulmonary emboli. Ten patients (26%) with a LEDVT were treated with systemic anticoagulation alone. One of these patients sustained a fatal pulmonary embolus. In a historic control group of 234 high-risk trauma patients admitted in the 14 months prior to implementing screening ultrasounds, six patients sustained pulmonary emboli (P < 0.05). Screening ultrasounds combined with selective placement of IVC filters play an important role in reducing the morbidity and mortality associated with LEDVT in high-risk trauma patients.

Pre-clinical evaluation of technetium-99m platelet receptor-binding peptide

P748 is a dimeric peptide which incorporates two high affinity GPIIb/IIIa receptor-binding domains and a novel 99mTc binding sequence, which provides the platelet imaging agent 99mTc-P748. The aim of this study was to evaluate 99mTc-P748 preclinically for use as a hot spot scintigraphic thrombus imaging agent.

METHODS

Technetium-99m-P748 was prepared by either a ligand exchange or a one-vial kit. The oxorhenium congener, [ReO]P748, was prepared by ligand exchange from Bu4NReOBr4. The binding of P748 peptide and [ReO]P748 to GPIIb/IIIa receptors on activated platelets was assessed by their inhibition of ADP stimulated human platelet aggregation in platelet rich plasma (PRP). The localization of 99mTc-P748 in deep vein and pulmonary thrombi was assessed in a canine thrombosis model and the biodistribution of 99mTc-P748 was determined in rats.

RESULTS

P748 peptide inhibited the aggregation of human platelets in PRP by 50% at a concentration (IC50) of 28 nM and [ReO]P748 had an IC50 of 36 nM showing the high in vitro receptor binding affinity of both the peptide and its rhenium complex (and by analogy its technetium complex). Technetium-99m-P748 was readily prepared at room temperature in 15 min in > or = 90% radiochemical yield and purity and provided definitive images of femoral vein thrombi within 20 min and pulmonary thrombi, within 1 hr in the canine model. Femoral vein thrombus-to-blood and thrombus-to-muscle ratios at 4 hr averaged 6.7 and 46, respectively. Pulmonary thrombus-to-blood and thrombus-to-normal lung ratios at 4 hr averaged 29 and 27, respectively. Dog and rat studies both showed rapid clearance of the radiotracer from the blood and with no significant hepatobiliary excretion but with notable early kidney retention.

CONCLUSION

The combination of high in vitro receptor-binding affinity, high thrombus uptake and definitive in vivo images of both femoral vein and pulmonary thrombi show that 99mTc-P748 has considerable potential as a clinical imaging agent for the detection of venous thromboembolism.