Pulmonary thromboembolism: Overview and update from medicolegal aspects

Reporting of Incidental Thrombotic Arteriopathy in Lung Resection Specimens: Examination of Clinical Impact

Pulmonary thrombotic arteriopathy (PTA) can be an incidental finding in lung resections performed for various indications. Historic studies largely examined PTA in autopsies. Thus, the prevalence in surgical samples, particularly in the modern era of lung cancer screening, is poorly defined. Detection of PTA in surgical samples may provide an opportunity for therapeutic intervention, but the impact of this finding on clinical management is unknown. We retrospectively examined consecutive lung surgical resections containing a report of incidental PTA between 2019 and 2022 in our institution. A retrospective chart review was performed to determine the history of systemic thromboembolism and clinical and radiographic follow-up. All slides were reviewed to morphologically characterize the vascular changes. Among 2930 pulmonary resections, 66 (2.3%) reportedly contained PTA. Twenty-four (36.4%) patients had a clinically recognized thromboembolic event either before or after surgical resection. Patients with clinically recognized thromboembolic disease were significantly more likely to have both acute and organized thrombi affecting large arteries. The presence of infarct, chronic hypertensive vasculopathy, or number of vessels with thrombi were not significantly associated with a clinically detected event. Reporting of incidental PTA led to clinical intervention in six patients and confirmed systemic thromboembolic disease in 2. Moreover, 2 patients with no further workup based on the incidental pathology findings subsequently developed pulmonary embolism. PTA is incidentally detected in 2.3% of surgical lung resections, and in two-thirds of cases, there is no clinical suspicion of thromboembolic disease. Pathologic reporting of PTA rarely led to clinical intervention, suggesting a need for improved communication of incidental pathology findings.

Expression of fibroblast activation protein-α in human deep vein thrombosis

BACKGROUND

Fibroblast activation protein-α (FAP), a type-II transmembrane serine protease, is associated with wound healing, cancer-associated fibroblasts, and chronic fibrosing diseases. However, its expression in deep vein thrombosis (DVT) remains unclear. Therefore, this study investigated FAP expression and localization in DVT.

METHODS

We performed pathological analyses of the aspirated thrombi of patients with DVT (n = 14), classifying thrombotic areas in terms of fresh, cellular lysis, and organizing reaction components. The organizing reaction included endothelialization and fibroblastic reaction. We immunohistochemically examined FAP-expressed areas and cells, and finally analyzed FAP expression in cultured dermal fibroblasts.

RESULTS

All the aspirated thrombi showed a heterogeneous mixture of at least two of the three thrombotic areas. Specifically, 83 % of aspirated thrombi showed fresh and organizing reaction components. Immunohistochemical expression of FAP was restricted to the organizing area. Double immunofluorescence staining showed that FAP in the thrombi was mainly expressed in vimentin-positive or α-smooth muscle actin-positive fibroblasts. Some CD163-positive macrophages expressed FAP. FAP mRNA and protein levels were higher in fibroblasts with low-proliferative activity cultured under 0.1 % fetal bovine serum (FBS) than that under 10 % FBS. Fibroblasts cultured in 10 % FBS showed a significant decrease in FAP mRNA levels following supplementation with hemin, but not with thrombin.

CONCLUSIONS

The heterogeneous composition of venous thrombi suggests a multistep thrombus formation process in human DVT. Further, fibroblasts or myofibroblasts may express FAP during the organizing process. FAP expression may be higher in fibroblasts with low proliferative activity.

Comparison of clinical outcomes among patients with isolated axial vs muscular calf vein thrombosis: A systematic review and meta-analysis

OBJECTIVE

Thrombi in the axial calf veins have quite different anatomical and physiological characteristics from that in the muscular calf veins, but their treatment was usually addressed in the same manner. We performed a meta-analysis of randomized and cohort studies to compare clinical outcomes among patients with isolated axial vs muscular calf deep vein thrombosis (DVT).

METHODS

Recurrent venous thromboembolism (VTE) was selected as the primary outcome. Resolution, proximal propagation of calf DVT, pulmonary embolism (PE), major bleeds, and clinically relevant non-major bleeds were separately analyzed as secondary outcomes. Data were pooled and compared with risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Thirteen studies, consisting of 4889 patients, met the inclusion criteria and were included for analysis. A greater rate of recurrent VTE (FE model: RR, 1.23; 95% CI, 1.00-1.53; I2 = 29%), resolution (FE model: RR, 1.32; 95% CI, 1.01-1.72; I2 = 31%), proximal propagation (FE model: RR, 1.63; 95% CI, 1.10-2.41; I2 = 40%), and PE (FE model: RR, 2.79; 95% CI, 1.31-5.95; I2 = 0%) in the axial group compared with the muscular group. There was no difference in the pooled estimates for major bleeds (FE model: RR, 1.09; 95% CI, 0.61-1.95; I2 = 0%), and clinically relevant non-major bleeds (FE model: RR, 1.80; 95% CI, 0.93-3.48) in the axial and muscular arms.

CONCLUSIONS

Patients with calf DVT limited to muscular veins might have a lower rate of recurrent VTE, resolution, proximal propagation, and PE vs those with axial calf vein involvement and exhibited similar safety outcomes.

Histopathological Features of Cancer-Associated Venous Thromboembolism: Presence of Intrathrombus Cancer Cells and Prothrombotic Factors

BACKGROUND

Cancer-associated venous thromboembolism (VTE) is a critical complication in patients with cancer. However, the pathological findings of VTE are limited. Here, we investigated the histopathological features of cancer-associated VTE in human autopsy cases.

METHODS

We clinically examined the autopsy cases of VTE with (n=114) and without cancer (n=66) and immunohistochemically analyzed the expression of prothrombotic factors in intrathrombus cancer cells, the thrombus contents of erythrocytes, fibrin, platelets, citrullinated histone H3, and degree of organization.

RESULTS

Vascular wall invasion or small cell clusters of cancer cells was observed in thrombi in 27.5% of deep vein thrombosis and 25.9% of pulmonary embolism cases. The majority of the cancer cells in deep vein thrombi appeared to be invading the vessel wall, whereas the majority of pulmonary thrombi had cancer cell clusters, consistent with embolization via blood flow. These cancer cells were immunohistochemically positive for TF (tissue factors) or podoplanin in up to 88% of VTE cases. The frequency of TF-positive monocyte/macrophages in thrombi was higher in cancer-associated VTE than that in VTE without cancer. Citrullinated histone H3 was predominantly observed in the early stages of organizing thrombi. There was no significant difference in thrombus components between VTE with cancer and without cancer groups.

CONCLUSIONS

Vascular wall invasion or cancer cell clusters in thrombi might influence thrombogenesis of cancer-associated VTE. TF and podoplanin in cancer cells and in monocyte/macrophages may induce coagulation reactions and platelet aggregation. Neutrophil extracellular traps may play a role in the early stages of VTE, regardless of cancer status.

Risk factors and potential predictors of pulmonary embolism in cancer patients undergoing thoracic and abdominopelvic surgery: a case control study

BACKGROUND

Postoperative pulmonary embolism (PE) is a severe complication leading to death and poor prognosis. The present study investigated the risk factors and potential predictors of PE in cancer patients undergoing thoracic and abdominopelvic surgery.

METHODS

A retrospective study was conducted on the patients with cancer who underwent thoracic and abdominopelvic surgery in Sichuan Cancer Hospital from December 2016 to January 2022. A total of 189 patients were included, in which 63 patients diagnosed PE after operation were collected as PE group, and 126 patients matched by age, type of cancer and cancer location were enrolled as control group. Conditional logistic regression was conducted to analyze the association between PE and risk factors. Predictive values of key factors were compared by the area under the curve (AUC) in receiver operating characteristic curve (ROC) curve.

RESULTS

Conditional multivariate logistic regression showed that BMI (odds ratio [OR] 4.065, 95% confidence interval [CI] 1.138-14.527; p = 0.031), intraoperative hypotension time (OR 4.095, 95% CI 1.367-12.266; p = 0.009), same day fluid balance (OR 0.245, 95% CI 0.061-0.684; p = 0.048), and postoperative D-Dimer (OR 1.693, 95% CI 1.098-2.611; p = 0.017) were significantly related to the occurrence of postoperative PE. Postoperative D-Dimer had the maximal AUC value 0.8014 (95% CI: 0.7260-0.8770) for predicting PE, with a cutoff value of 1.505 μg/ml.

CONCLUSIONS

BMI, intraoperative hypotension time, lower same day fluid balance and postoperative D-dimer are independent risk factors associated with PE in cancer patients undergoing thoracic and abdominopelvic surgery. Postoperative D-Dimer seems to be a good indicator to predict postoperative PE for cancer patients.

A novel device for lower leg intermittent pneumatic compression synchronized with active ankle exercise for prevention of deep vein thrombosis

Objective

Intermittent pneumatic compression devices (IPCDs) and active ankle exercises have been shown to be efficacious in preventing venous thromboembolism (VTE) by increasing venous flow velocity and volume. However, IPCDs are expensive and require electricity; therefore, they cannot be used in the event of power loss. We developed a non-powered device that provides lower leg intermittent pneumatic compression synchronized with AAEs (LISA) and compared its efficacy with AAEs alone in increasing the peak velocity in the femoral vein.

Methods

The study population consisted of 20 healthy younger men and 20 healthy older men who performed AAE every 2 s in a sitting posture under four conditions: AAE with LISA (AAE+LISA), AAE alone (AAE), AAE with IPCD, and AAE with a graduated compression stocking.

Results

The PVs under all conditions were significantly higher than those at rest. The PVs in the AAE+LISA condition were significantly higher than those in the AAE alone condition in both younger and older groups (both p < .001).

Conclusions

AAE with LISA significantly increased the PV, suggesting that LISA might be useful for preventing DVT.

Investigating the Source of Fatal Pulmonary Thromboembolism in a Coronial Postmortem Population

ABSTRACT

The incidence of how often a deep vein thrombosis is found in the calves of the legs at coronial postmortem examination is unclear. This study retrospectively examined postmortem examination reports from Australian Coronial investigations of sudden death resulting from pulmonary thromboembolism to determine the likelihood of dissection of the deep veins of calves of the legs revealing the source of a pulmonary thromboembolism. From 450 cases taken from the National Coronial Information System (NCIS) for 2016, the postmortem reports of 327 cases were reviewed to provide demographic details of victims of sudden death from pulmonary thromboembolism. In 235 cases, it was possible to determine in 76.6% a thrombus had been found in the deep veins of the calves of the legs after dissection. In 141 cases, it was documented that both sides had been examined. From these, it was determined there was no statistically significant difference in the prevalence of thrombus in either side. However, it was shown that the presence of an abnormality of a lower limb (such as leg or hip infection, burns, surgery and nonoperated fractures, or a larger circumference) increased the likelihood that a deep vein thrombus would be found on that side.

Malignant tumor is the greatest risk factor for pulmonary embolism in hospitalized patients: a single-center study

Background

This study aimed to investigate the background of patients who presented with pulmonary embolism (PE) on contrast-enhanced chest computed tomography (CT) and to explore the risk factors for PE.

Methods

This study included a review of the medical records of all 50,621 patients who were admitted to one community hospital between January 1, 2013 and December 31, 2017. Data on sex, age, risk factors related to blood flow stagnation (obesity, long-term bed rest, cardiopulmonary disease, cast fixation, long-term sitting), risk factors related to vascular endothelial disorder (surgery, trauma/fracture, central venous catheterization, catheter tests/treatments, vasculitis, antiphospholipid antibody syndrome, history of venous thromboembolism (VTE)), and risk factors related to hypercoagulability (malignant tumor, use of oral contraceptives/low-dose estrogen progestin/steroids, infection, inflammatory enteric disease, polycythemia, protein C or protein S deficiency, dehydration) were evaluated.

Results

Of all inpatients, 179(0.35%) out of 50,621 were diagnosed with PE after contrast-enhanced chest CT examination, in which 74 patients were symptomatic and 105 patients had no symptom. Among asymptomatic 105 patients, 71 patients got CT scans for other reasons including cancer screening and searching infection focus, and 34 patients got CT scans for searching PE due to either apparent or suspicious DVT. The rate of discovering PE was significantly greater in women (0.46%, 90/19,409) than men (0.29%, 89/31,212) (P = 0.008). Of the 179 patients with PE, 164 (92%) had some type of risk factor. For both men and women, the most frequent risk factor was a malignant tumor, followed by obesity, long-term bed rest and infection for men and long-term bed rest, obesity and infection for women. The most common malignant tumor was lung cancer. Although taking antipsychotic agent is not advocated as a risk factor, there is a possibility of involvement.

Conclusions

The risk factors for PE were identified in this single-center, retrospective study.

Effects of intermittent pneumatic compression on femoral vein peak venous velocity during active ankle exercise

INTRODUCTION

The risk of developing deep vein thrombosis (DVT) is high even after the period of bed rest following major general surgery including total joint arthroplasty (TJA). Mobile intermittent pneumatic compression (IPC) devices allow the application of IPC during postoperative exercise. Although ambulation included ankle movement, no reports have been made regarding the effects of IPC during exercise, including active ankle exercise (AAE), on venous flow. This study was performed to examine whether using a mobile IPC device can effectively augment the AAE-induced increase in peak velocity (PV).

METHODS

PV was measured by Doppler ultrasonography in the superficial femoral vein at rest, during AAE alone, during IPC alone, and during AAE with IPC in 20 healthy subjects in the sitting position. PV in AAE with IPC was measured with a mobile IPC device during AAE in the strong compression phase. AAE was interrupted from the end of the strong compression phase to minimize lower limb fatigue.

RESULTS

AAE with IPC (76.2 cm/s [95%CI, 69.0-83.4]) resulted in a significant increase in PV compared to either AAE or IPC alone (47.1 cm/s [95%CI, 38.7-55.6], p < 0.001 and 48.1 cm/s [95%CI, 43.7-52.4], p < 0.001, respectively).

DISCUSSION

Reduced calf muscle pump activity due to the decline in ambulation ability reduced venous flow. Therefore, use of a mobile IPC device during postoperative rehabilitation in hospital and activity including self-training in an inpatient ward may promote venous flow compared to postoperative exercise without IPC.

CONCLUSION

Use of a mobile IPC device significantly increased the PV during AAE, and simultaneous AAE with IPC could be useful evidence for the prevention of DVT in clinical settings, including after TJA.

Characteristics and risk factors of deep vein thrombosis in hemiplegic, healthy and bilateral limbs of hemiplegic patients: a 10-year retrospective study

Deep vein thrombosis (DVT) in hemiplegic patients mainly affects hemiplegic limbs, DVT can also occur only in healthy limbs, and some hemiplegic patients have DVT in both limbs. Characteristics and risk factors of DVT in hemiplegic, healthy, and bilateral limbs are unknown. To describe the proportion, risk factors, extent, and timing of DVT in hemiplegic, healthy and bilateral limbs. A 10-year retrospective review of consecutive patients was performed. DVT affected hemiplegic limbs in 34 (62%), healthy limbs in 11 (20%), and was bilateral in 10 (18%). DVT was more likely to develop in healthy limbs of hemiplegic patients without surgery (odds ratio (OR) 0.022; 95% confidence interval (CI) 0.001-0.922), and without diabetes (OR 0.023, 95% CI 0.001-0.853). Among the veins at the level of which DVT occurred, intermuscular veins represented 20 (45%) in hemiplegic, 5 (37%) in healthy, and 6 (74%) in bilateral limbs. The median time that DVT occurred after hemiplegia onset was 18 days (interquartile range [IQR] 9-79) in hemiplegic, 17 days (IQR 10-56) in healthy, and 21 days (IQR 8-27) in bilateral limbs. Early and effective prevention of DVT after surgery and optimal management of diabetes may reduce the risk of DVT in bilateral limbs. It's important to prevent proximal extension of calf vein DVT. DVT prophylaxis should be started early and continued for at least 3 weeks after hemiplegia onset.

High Signal Intensity on Diffusion-Weighted Images Reflects Acute Phase of Deep Vein Thrombus

The effects of antithrombotic therapy on deep vein thrombosis (DVT) can be affected by thrombus age, which cannot be reliably determined by noninvasive imaging modalities. We investigated whether magnetic resonance (MR) diffusion-weighted imaging (DWI) can localize and determine the age of venous thrombus in patients with DVT, animal models, and human blood in vitro. Signal intensity (SI) on DWI and the apparent diffusion coefficient (ADC) of thrombi were assessed in eight patients with DVT using a 1.5-T MR imaging (MRI) system. We assessed the organizing processes as venous thrombus developed in the rabbit jugular vein using a 3.0-T MRI system over time. We also assessed MRI signals of human blood in vitro using the 1.5-T MRI system. Venous thrombi were detected by DWI as areas of high or mixed high and iso SI in all patients. The ADCs were lower in the proximal, than in the distal portion of the thrombi. The thrombi of rabbit jugular veins histologically organized in a time-dependent manner, with high SI on DWI at 4 hours, mixed high and iso SI at 1 and 2 weeks, and iso SI at 3 weeks. The ADC correlated negatively with erythrocyte content, and positively with smooth muscle cells, macrophages, hemosiderin, and collagen content. MRI signals of human blood in vitro showed that ADCs were affected by erythrocyte content, but not by blood clotting. MR-DWI can detect venous thrombus, and high SI on DWI accompanied by a low ADC might reflect erythrocyte-rich, acute-phase thrombi.

A retrospective observational study investigating the factors associated with right heart failure in patients with primary acute pulmonary embolism and deep vein thrombosis

BACKGROUND

The relationship between the risk of right heart failure in primary acute pulmonary embolism after embolization and the residual thrombus sites in the pelvis and lower limbs is not clear.

METHODS

This single-center retrospective observational study examined the results of contrast-enhanced computed tomography and venous ultrasonography of patients with primary acute PE and DVT. We assessed the association between the occurrence of right heart failure and age; gender; pulmonary thrombosis distribution; most proximal site of deep vein thrombosis in the soleal vein, inferior vena cava (IVC), or common iliac vein (CIV); DVT distribution; and malignancy using univariate and multivariate logistic regression.

RESULTS

In all, 77 of 165 patients were male (mean age: 65.1 ± 13.7 years). Right heart failure occurred in 53 patients (32.1%). Multivariate analysis revealed that the odds ratio (OR) for right heart failure was significantly lower in patients with the most proximal site of DVT in the IVC/CIV (OR = 0.07, 95% confidence interval [CI] 0.01-0.62, P = .017), while it was significantly higher in females (OR = 2.51, 95% CI 1.05-6.01, P = .039), and in patients who exhibited the presence of bilateral venous thrombosis (OR = 3.89, 95% CI 1.60-9.48, P = .003).

CONCLUSION

A significant factor involved in PE without right heart failure was the most proximal site of DVT in the IVC/CIV, and significant risk factors associated with PE with right heart failure were more prevalent in females and in patients who exhibited the presence of bilateral venous thrombosis.

Relationship between the site of thrombosis and the prevalence of pulmonary embolism in acute lower extremity deep venous thrombosis

OBJECTIVE

Lower extremity deep venous thrombosis (LEDVT) is common and can lead to pulmonary embolism (PE). Currently, the mechanism of how LEDVT causes PE is unclear. The aim of this study was to explore the relationship between the thrombus sites and PE in LEDVT patients.

METHODS

A retrospective study that included the medical data of 3101 patients aged >18 years who were diagnosed with LEDVT by duplex ultrasound was performed at The First Affiliated Hospital of Wenzhou Medical University from 2008 to 2017. The clinical information of the patients was collected. According to the thrombosis sites, the patients were divided into three groups. We determined the cumulative prevalence and prevalence rate of PE between the groups and used Cox proportional hazard regression models, which were stratified on matched sets, to calculate the hazard ratios (HRs) for all of the outcomes of interest. We focused on the relationship of proximal or isolated distal LEDVT with PE and also analyzed the relationship of the left side or right side of LEDVT with PE.

RESULTS

A total of 1629 (52.5%) patients had left LEDVT (group 1), 912 (29.4%) patients had right LEDVT (group 2), and 560 (18.1%) patients had bilateral LEDVT (group 3). The rate of PE was higher in group 2 than in group 1, although there were more patients suffering from LEDVT in group 1 than in group 2 (P < .001). The patients with proximal LEDVT in group 3 exhibited a greater risk of PE compared with those with isolated distal LEDVT (adjusted HR, 2.79; 95% confidence interval, 1.42-5.49). We also observed that the proportion of patients with proximal LEDVT who were receiving treatment was much higher than that of patients with distal LEDVT (P < .05). The patients with right LEDVT had a higher risk of PE than the patients with left LEDVT (adjusted HR, 1.60; 95% confidence interval, 1.15-2.21), and the patients with right LEDVT had more comorbidities, such as malignant neoplasms, hypertension, and diabetes (P < .001).

CONCLUSIONS

Patients with proximal bilateral LEDVT had a higher likelihood for development of PE than did patients with distal LEDVT, which may be associated with inadequate therapy for proximal bilateral LEDVT. PE was more likely to develop with right-sided LEDVT because these patients had more comorbidities in our study.

The dating of thrombus organization in cases of pulmonary embolism: an autopsy study

Background

Pulmonary embolism (PE) is associated to high mortality rate worldwide. However, the diagnosis of PE often results inaccurate. Many cases of PE are incorrectly diagnosed or missed and they are often associated to sudden unexpected death (SUD). In forensic practice, it is important to establish the time of thrombus formation in order to determine the precise moment of death. The autopsy remains the gold standard method for the identification of death cause allowing the determination of discrepancies between clinical and autopsy diagnoses. The aim of our study was to verify the morphological and histological criteria of fatal cases of PE and evaluate the dating of thrombus formation considering 5 ranges of time.

Methods

Pulmonary vessels sections were collected from January 2010 to December 2017. Sections of thrombus sampling were stained with hematoxylin and eosin. The content of infiltrated cells, fibroblasts and collagen fibers were scored using a semi-quantitative three-point scale of range values.

Results

The 30 autopsies included 19 males (63.3%) and 11 females (36.7%) with an average age of 64.5 ± 12.3 years. The time intervals were as follows: early (≤1 h), recent (> 1 h to 24 h), recent-medium (> 24 h to 48 h), medium (> 48 h to 72 h) and old (> 72 h). In the first hour, we histologically observed the presence of platelet aggregation by immunofluorescence method for factor VIII and fibrinogen. The presence of lymphocytes has been identified from recent thrombus (> 1 h to 24 h) and the fibroblast cells were peripherally located in vascular tissue between 48 and 72 h, whereas they resulted central and copious after 72 h.

Conclusions

After a macroscopic observation and a good sampling traditional histology, it is important to identify the time of thrombus formation. We identified histologically a range of time in the physiopathology of the thrombus (early, recent, recent-medium, medium, old), allowing to determine the dating of thrombus formation and the exact time of death.

Clinical trial number

NCT03887819.

Trial registration

The trial registry is Cliniclatrials.gov, with the unique identifying number NCT03887819. The date of registration was 03/23/2019 and it was “Retrospectively registered”.

Effect of resistance of the exercise band on the peak femoral vein velocity during active ankle flexion

Objective

To examine the resistance effect of using an exercise band on the lower extremity venous velocity during active ankle flexion.

Methods

Twenty healthy young adult men performed active ankle flexion every 2 s either with no band or with two exercise bands, marked red and silver in the order of increasing tension. They held the band in its natural length with an elbow in extension and an ankle in maximal dorsiflexion at initiation of each active plantar flexion in each posture. The peak velocity in the right superficial femoral vein was measured in each condition.

Results

Holm’s multiple comparisons revealed significant increases in the mean (individual 95% confidence intervals) peak velocities (cm/s) with no, red, and silver bands (35.8 (28.9–42.7), 46.5 (38.8–54.3), and 56.9 (47.0–66.8), respectively, in the sitting posture, and 50.7 (39.2–62.3), 60.7 (46.8–74.6), and 69.0 (55.3–82.7), respectively, in the supine posture; all p < 0.01).

Conclusion

Resistance with the exercise bands efficiently enhanced the femoral venous velocity during active ankle plantar flexion.

Venous thromboembolism in patients with cancer: design and rationale of a multicentre, prospective registry (Cancer-VTE Registry)

INTRODUCTION

Patients with cancer are at higher risk of venous thromboembolism (VTE) than the general population as the malignancy itself and treatment modalities, including medication and surgery, contribute to the risk of developing VTE. Furthermore, patients with cancer developing VTE have a worse prognosis than those without cancer. There are no multicentre prospective data on the occurrence and treatment of VTE in patients with cancer in Japan, and data on the outcomes, complications and incidence of VTE in these patients have not been reported. In addition, Japanese patients with cancer are traditionally treated with unfractionated heparin or warfarin; however, the use of direct oral anticoagulants, which became available in 2014, has not been sufficiently examined in this patient group. Therefore, this multicentre, prospective registry has been designed to capture VTE data from Japanese patients presenting with six cancer types.

METHODS AND ANALYSIS

This registry will enrol 10 000 patients with colorectal, lung, stomach, breast, gynaecological (including endometrial, cervical, ovarian, fallopian tube and peritoneal) or pancreatic cancer between March 2017 and March 2019 and follow them for 1 year. We plan to collect data on the incidences of symptomatic VTE, bleeding events, stroke, systemic embolic events, incidental VTE requiring treatment in patients, overall survival and symptomatic VTE event-free survival.

ETHICS AND DISSEMINATION

All patients will provide written informed consent. Data will remain anonymous and will be collected using an online electronic data capture system. Study protocol, amendments and informed consent forms will be approved by the institutional review board/independent ethics committee at each site prior to study commencement. Results will be disseminated at national meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

UMIN000024942.

Incidence of venous thromboembolism in psychiatric inpatients: a chart review

PURPOSE

Venous thromboembolism (VTE) is the combination of pulmonary embolism (PE) and deep vein thrombosis. In recent years, VTE has been gaining attention in the field of psychiatry as it can cause sudden deaths in patients hospitalized in psychiatric departments. The purpose of this study was to investigate the incidence of VTE in psychiatric inpatients using contrast-enhanced computed tomography (CT).

PATIENTS AND METHODS

At the psychiatric department of the Akita University Hospital, NANOPIA^® D-dimer was measured in patients with suspected symptomatic VTE or believed to be at risk for asymptomatic VTE. A follow-up contrast-enhanced CT was also performed in cases of D-dimer values over 1 µg/mL. Patients diagnosed with VTE based on contrast-enhanced CT during hospitalizations between May 1, 2009 and April 30, 2017 were analyzed. VTE incidence was compared in restrained and unrestrained catatonic and noncatatonic patients. We also investigated whether VTE was symptomatic or asymptomatic as well as its outcomes.

RESULTS

The overall incidence of VTE was 2.3% (39/1,681) in the 8-year period. VTE was observed in 61.1% (11/18) of catatonic patients, 4.1% (11/270) of noncatatonic restrained patients, and 1.2% (17/1,393) of noncatatonic unrestrained patients. PE was observed in 76.9% (30/39) of VTE patients and 97.4% (38/39) of VTE patients were asymptomatic. Recovery was achieved in all cases of VTE treated with anticoagulation therapy.

CONCLUSION

These results indicate that the risk of VTE is high in psychiatric inpatients and that PE is common in these population. The data may also suggest that contrast-enhanced CT is important in surveying thrombus in suspected cases of VTE. In the psychiatric field, proper attention must be given to VTE, regardless of the presence or absence of catatonia or restraint, particularly given that PE was observed in more than 75% of cases of VTE.

The utility of on-site ultrasound screening in population at high risk for deep venous thrombosis in temporary housing after the great East Japan Earthquake

BACKGROUND

To evaluate the diagnostic performance of ultrasonography for screening of a population at risk for deep vein thrombosis (DVT) in a post-disaster setting.

METHODS

Ultrasonography was applied as a screening technique to the residents of a temporary housing facility who were displaced following the Great East Japan Earthquake. Thirty DVT screening sessions were held from April 2013 to June 2015. Individuals were invited to participate if they were identified as "high risk" for DVT, defined as those with low activity levels, a history of lower limb trauma, baseline lower limb pain or swelling, a cancer-bearing status, or a history of venous thromboembolic event. Ultrasonographic examinations were performed from the calf to the popliteal veins using portable devices.

RESULTS

Of the 3,316 subjects screened (682 men and 2,634 women) with a mean age of 71 ± 9.7 years, DVT was diagnosed in 382 (11.5%). DVT was more likely in older, symptomatic, or female patients with a history of venous thromboembolism and attempting to perform daily exercise. The rate of DVT diagnosis increased from 9.9% in 2013 to 13.5% in 2015.

CONCLUSIONS

Ultrasonography is efficient for screening at-risk populations in challenging settings. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:566-574, 2017.

Histological criteria for age determination of fatal venous thromboembolism

In clinical and forensic practice, fatal thromboembolism is a major problem, particularly in a patient with no pre-existing risk factors. Out of a recent case, we discuss here the criteria for age determination of venous thrombi in a 46-year-old female with concomitant deep vein thrombosis in the common femoral left vein and in the right heart and fatal pulmonary embolism. At autopsy, histopathology and immunohistochemistry evidenced the different composition of thrombi in different sites and permitted to define the different timing. We discuss and review the histopathological criteria for age estimation of venous thrombi starting from the case and in relation to the acquired and inherited thrombophilic risk factors. The appropriateness of clinical management is also discussed.

Medico-Legal Aspects of Pulmonary Thromboembolism

Pulmonary ThromboEmolism (PTE) is an important disease for legal medicine. Because of their sudden lethal onset, generally medicolegal autopsies show few clinical information when PTE is the cause of death. During medicolegal autopsies, the autopsy operator must answer to important questions. For example, autopsy operator can need to assess the casual relationship between PTE and recent accident, such as trauma or long air travel. Furthermore, the autopsy operator needs to investigate the pathology of PTE as a cause of sudden cardiovascular death. It is relatively simple to confirm a fatal massive thromboembolus in the initial stage of thoracic investigations, but sometimes it might be difficult to distinguish this from postmortem clot. In such cases histopathological examination can help in the differentiation. Histological examination is also required for observation of chronological changes of the thrombi. Chronological evaluation is an important factor especially to determine whether the death coincides with the date of a specific accident/event or instead there is an earlier onset of PTE. In addition, histological sections sometimes show additional information, such as tumor fragments in cases of malignancy or small fragments of bone marrow in cases of active resuscitation, that can be useful in a medicolegal scenario. Furthermore, new diagnostic tools are arising, which they can be very helpful in the individuation of this frequently underdiagnosed disease. The goal of our work is to investigate these aspects through the review of the recent literature.

Intense Triceps Surae Contraction Increases Lower Extremity Venous Blood Flow

Objective

Venous thromboembolism can be prevented by physical prophylaxis, such as active ankle exercise (AAE), in addition to pharmacological treatment. However, the relationship between the intensity of triceps surae (TS) exercise and venous flow is unclear, and physical thromboprophylaxis has not been established for patients with leg cast immobilization. The goals of the current study were to clarify the degree of intensity of TS isotonic contraction required to increase peak blood velocity (PV) in the superficial femoral vein to higher than that at no resistance and to determine if TS isometric contraction can increase PV.

Methods

A prospective, nonrandomized, controlled trial was performed in 20 healthy young adult men. PVs at rest and during one TS isotonic or isometric contraction were measured using Doppler ultrasonography. Isotonic contraction intensity was defined as no resistance with contraction of maximum effort and 25%, 50%, 75%, and 100% of one repetition maximum (1RM). Isometric contraction intensity was defined as 15-35%, 40-60%, 65-85%, and 90-100% of the maximal voluntary contraction.

Results

Isotonic contraction at 75% 1RM (51.4 cm/s [95% CI, 40.1-62.6]) and 100% 1RM (54.9 cm/s [95% CI, 43.1-66.7]) significantly increased PV compared to that with no resistance (41.0 cm/s [95% CI, 32.2-49.8]) (P=0.005, 0.001, respectively). Isometric contraction increased PV significantly at all intensities (all P≤0.002).

Conclusions

Applying resistance at ≥75% 1RM increases venous flow and enhances the effect of AAE with TS isotonic contraction. TS isometric contraction may serve as thromboprophylaxis for patients undergoing leg cast immobilization.

Surgical Embolectomy for Acute Pulmonary Thromboembolism

Acute pulmonary thromboembolism is a catastrophic event, especially for hospitalized patients. The prognosis of pulmonary thromboembolism depends on the degree of pulmonary arterial occlusion. The mortality of massive pulmonary embolism is reportedly as high as 25% without cardiopulmonary arrest and 65% with cardiopulmonary arrest. In patients with unstable hemodynamics due to pulmonary thromboembolism, surgical pulmonary embolectomy is indicated for patients with a contraindication to thrombolysis, failed catheter therapy, or failed thrombolysis. Thrombolytic therapy adds an additional burden on patients who are at risk of potential hemorrhagic complications. It is also indicated if patients are already on a veno-arterial extra-corporate membrane oxygenator for circulatory collapse or cardiopulmonary arrest. The outcome for patients who require cardiopulmonary resuscitation for longer than 30 minutes is poor. Therefore, early triage for massive and sub-massive pulmonary embolism is crucial. A team approach including a cardiovascular surgeon may be effective to save critically ill patients. Prompt removal of emboli reduces the right ventricular load with quick recovery of cardiopulmonary function in the early postoperative period. A recent series reported excellent results, with in-hospital mortality of less than 10%. Surgical pulmonary embolectomy is an effective, safe, and easy procedure to save critical patients due to pulmonary thromboembolism.

Pathophysiology of Venous Thromboembolism with Respect to the Anatomical Features of the Deep Veins of Lower Limbs: A Review

Here the pathophysiology of venous thromboembolism is reviewed with respect to the anatomical features of the deep veins of lower limbs. A thrombus is less likely to form in the thigh veins compared with that in the calf veins; however, clinical symptoms are more likely to appear in the thigh veins owing to vascular occlusion. When a patient is bedridden, thrombosis is more likely to occur in the intramuscular vein, which mainly depends on muscular pumping and the venous valve, rather than in the three crural branches, which mainly depends on the pulsation of the accompanying artery. Thrombi are prone to be generated in the soleal vein compared with those in the gastrocnemius vein because of the vein and muscle structures. A soleal vein thrombosis grows toward the proximal veins along the drainage veins. To prevent a sudden pulmonary thromboembolism-related death in bedridden patients, preventing soleal vein thrombus formation and observing the thrombus proximal propagation via the drainage veins are clinically important. When deep vein thrombosis occurs, avoiding embolization and sequela caused by the thrombus organization is necessary.

Clinical Significance of the Soleal Vein and Related Drainage Veins, in Calf Vein Thrombosis in Autopsy Cases with Massive Pulmonary Thromboembolism

OBJECTIVE

To clarify the histopathological characteristics of deep vein thrombosis (DVT) resulting in lethal pulmonary thromboembolism (PE).

SUBJECTS AND METHODS

We investigated 100 autopsy cases of PE from limb DVT. The distribution and chronology of DVT in each deep venous segment were examined. Venous segments were classified into three groups: iliofemoral vein, popliteal vein and calf vein (CV). The CV was subdivided into two subgroups, drainage veins of the soleal vein (SV) and non drainage veins of SV.

RESULTS

Eighty-nine patients had bilateral limb DVTs. CV was involved in all limbs with DVT with isolated calf DVTs were seen in 47% of patients. Fresh and organized thrombi were detected in 84% of patients. SV showed the highest incidence of DVTs in eight venous segments. The incidence of DVT gradually decreased according to the drainage route of the central SV. Proximal tips of fresh thrombi were mainly located in the popliteal vein and tibioperoneal trunk, occurring in these locations in 63% of limbs.

CONCLUSIONS

SV is considered to be the primary site of DVT; the DVT then propagated to proximal veins through the drainage veins. Lethal thromboemboli would occur at proximal veins as a result of proximal propagation from calf DVTs.

Deep venous thrombosis in the nonoperated leg after primary major lower extremity arthroplasty: a retrospective study based on diagnosis using venography

Venous thromboembolism (VTE) is a common complication after major orthopedic surgery. However, the reported rates of deep venous thrombosis (DVT) vary widely. Our aim was to study the incidence of DVT in the nonoperated leg after primary major lower extremity arthroplasty using bilateral venography. The records of patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) at our institution between August 2013 and August 2014 were reviewed. We examined the records for a total of 380 patients, of which 244 had undergone bilateral venography 3-5 days after THA or TKA. A total of 244 patients undergoing TKA (n = 119) or THA (n = 125) were recruited for this study. DVT was diagnosed in 42 (17.2%) of the 244 patients; nine patients developed DVT in both legs, and four developed DVT only in the nonoperated leg. All of the DVTs were located in calf veins. DVT occurred more frequently after TKA than THA, especially in muscular veins. Female sex and older age were found to be positive risk factors for DVT after THA. The incidence of DVT after major lower arthroplasty is high. DVT in nonoperated legs should be carefully considered because of its potential risks, especially in left. Distal DVT also has a high risk to develop pulmonary embolism (PE). The combination of anticoagulant and pneumatic compression is a good measure to avoid proximal DVT, and it is well tolerated to stop anticoagulant if the patients were diagnosed as having no DVT.

Multi-phase postmortem CT angiography (MPMCTA): a new axillary approach suitable in fatal thromboembolism

Postmor tem computed tomography is widely used in the forensic pathology setting as supplementing medico-legal investigations and being capable of providing significant data that affect final conclusions and adding new quality to recording postmortem observations. The integration with angiographic methods [postmortem computed tomography angiography and multiphase postmortem CT angiography (MPMCTA)] allows the examination of the cardiovascular system and it is increasingly being utilised in the field of forensic pathology. However, using the standardised procedure that establishes the femoral vessels on one side of the corpse as an access point to the vascular system, visualisation of the vascular tree below the cannula insertion site is excluded. Consequently, visualisation of the vascular anatomy and morphology of the lower limbs is impossible and lesions such as thrombosis of the superficial and deep venous system may remain elusive. Bearing in mind the high incidence of pulmonary thromboembolism in forensic case studies and the difficulties in postmortem diagnosis, we propose a new axillary approach for MPMCTA that allows the full detection of the vascular system of the lower limbs.

Relationship between Specific Distributions of Isolated Soleal Vein Thrombosis and Risk Factors

OBJECTIVE

The relationship between specific distributions of isolated soleal vein thrombosis (SVT) and risk factors was investigated.

SUBJECTS AND METHODS

The subjects included 93 patients with SVT diagnosed with ultrasonography.

RESULTS

In the acute thrombus distribution, the thrombi of central veins were significantly more frequent than the thrombi of medial veins in the unilateral SVT. The thrombi of central veins were not more significantly frequent than the thrombi of medial veins in the bilateral SVT.

CONCLUSION

The risk factors of bilateral SVT are considered to be different from that of the unilateral SVT. (English translation of J Jpn Coll Angiol 2013; 53: 159-166).

Immune function of peripheral T cells in patients with venous thromboembolism or coronary artery atherosclerosis

INTRODUCTION AND OBJECTIVES

Recent studies have shown that the major risk factors for arterial thrombotic diseases are closely associated with venous thromboembolism (VTE). This study aimed to investigate the expression of CD3, CD4 and CD8 in T lymphocytes, the CD4/CD8 ratio and high-sensitivity C-reactive protein (hs-CRP) levels in patients with VTE, coronary artery atherosclerosis (CAA) and healthy subjects.

METHODS

A total of 82 healthy subjects, 51 VTE patients and 114 CAA patients were recruited, and the expression of CD3, CD4 and CD8 in T lymphocytes and the CD4/CD8 ratio were determined. Serum hs-CRP was also measured.

RESULTS

Compared to healthy subjects, VTE patients had significantly reduced CD3 expression (p=0.019), comparable CD4 expression (p=0.868), significantly reduced CD8 expression (p<0.001) and increased CD4/CD8 ratio (p=0.044). However, VTE patients had comparable expression of CD3, CD4 and CD8 and CD4/CD8 ratio to CAA patients. In addition, among patients with VTE or CAA, the proportion of patients with reduced CD3+ and CD8+ T lymphocytes or increased CD4/CD8 ratio was significantly higher than in healthy subjects. In addition, hs-CRP in both VTE and CAA groups was significantly higher than in healthy subjects.

CONCLUSIONS

The antigen recognition and signal transduction activation of T cells is significantly reduced in patients with VTE or CAA, and the killing effect of T cells on pathogens, including viruses, is also significantly compromised. In addition, inflammatory and immune mechanisms are involved in the occurrence and development of venous and arterial thrombosis.

Lethal pulmonary thromboembolism: an autopsy-based study on a rare but legally relevant event

CONTEXT

Pulmonary thromboembolism (PTE) is the severe end stage of many different diseases producing prolonged patient immobilization or a hypercoagulative state. Lethal PTE is also one of the most frequent topics for suspected medical malpractice, especially when dealing with patients originally affected by non-critical illnesses and suddenly killed by a non-prevented embolic event. The crucial forensic question about a lethal PTE is the following one: was this lethal PTE an unpreventable complication or was it a consequence of real medical malpractice?

MATERIALS AND METHODS

The authors analyzed the 1999-2009 autopsy archive of the Institute of Forensic Medicine of Milan University and selected all the cases where PTE was the cause of death. For every selected case, the authors also collected all the available demographic and clinical data. Statistical analysis was performed using SPSS V.16.00.

RESULTS

In the period 1999-2009, 129 (1.25%) cases out of a total of 10,288 autopsies were diagnosed as having suffered lethal PTE. The male to female ratio was 1:2 (34.1% versus 65.9%). The mean age at death was 67 ± 18 years. In 41% of cases the death occurred outside of the hospital and in the absence of any medical support; in 36.5% of cases it occurred during the territorial paramedical support or during the very first evaluation in the emergency; and in the remaining 22.5% of cases it occurred during a period of hospitalization. In 33.4% of the selected cases, a typical preliminary event was positively identified: a pure major trauma (18.6%); a trauma followed by a major surgery (7%); a major non post-traumatic surgery (7%); and a non-surgical delivery. Symptoms suggesting PTE were detected in 46 cases (35.7%). Nine cases underwent a judicial autopsy in the same original hypothesis of a medical malpractice for incorrect prophylaxis in acutely bed-restricted patients.

CONCLUSIONS

Post-surgical PTE cannot be automatically labeled a consequence of medical malpractice. The combination of correct prophylaxis, careful diagnostic monitoring of the high-risk patient and the correct therapy surely reduces the occurrence of lethal PTE, but it does not completely erase such an insidious pathology. In the hypothesis of a causative medical malpractice, only careful analysis by an experienced forensic pathologist can make a reliable distinction between an unpreventable complication and real medical malpractice.

Deep venous thrombosis among disaster shelter inhabitants following the March 2011 earthquake and tsunami in Japan: a descriptive study

Objectives

A retrospective analysis of data collected during subject screening following Japan's March 2011 earthquake and tsunami was performed. We aimed to determine the incidence of deep venous thrombosis (DVT) among screened subjects and to identify risk factors associated with the development of DVT as independent variables.

Methods

Calf ultrasonography was undertaken in 269 subjects living in 21 shelters in Miyagi prefecture during the one-month period immediately following the March 2011 disaster. Information regarding the health and risk factors of subjects was collected by questionnaire and assessment of physical signs.

Results

Of the 269 evacuees screened, 65 (24%) met the criteria for calf DVT. We found lower limb trauma, reduced frequency of urination and sleeping in a vehicle to be independent positive predictors of DVT.

Conclusions

Evacuees had an increased risk of developing DVT, associated with tsunami-related lower limb injury, immobility and dehydration.

Economic Impact of Venous Thromboembolism Following Major Orthopaedic Surgery in Japan

OBJECTIVES

Venous thromboembolism (VTE) is the most frequent complication following major orthopaedic surgery (MOS). Although studies in Western populations have demonstrated significantly higher costs for patients with VTE versus those without VTE after MOS, there is a paucity of such data in Japan. This study was conducted to understand the costs and VTE rates in Japanese patients.

METHODS

Data were extracted from a hospital claims database. MOS was defined as total hip replacement, total knee replacement, or hip fracture repair. Subjects who underwent more than one MOS during the same admission were excluded. Identified VTE cases were matched on a 1:2 matching scheme on the basis of surgery type, hospital, and date of surgery (±6 months). The primary outcome was the difference in 90-day costs. Secondary outcomes included differences in total 6-month costs postsurgery and average length and cost of initial hospital stay.

RESULTS

The 90-day cumulative VTE incidence was 0.774%, with 94% of the cases occurring within 30 days postsurgery. Total 90-day costs were significantly higher in patients with VTE (difference of 864,153 Japanese yen [US $10,538]). Average length of stay was longer for patients with VTE (66 days vs. 42 days). Costs incurred by patients with VTE were on average much higher than those incurred by patients without VTE throughout 5 months postsurgery.

CONCLUSIONS

The development of a VTE in patients undergoing MOS results in a 1.5-fold increase in the length of stay and a 1.7-fold increase in 90-day costs. Findings indicate that the avoidance of VTEs through more effective prophylaxis will help to reduce the economic burden associated with MOS.

Fatal pulmonary thromboembolism. A retrospective autopsy study: searching for genetic thrombophilias (Factor V Leiden (G1691A) and FII (G20210A) gene variants) and dating the thrombus

The accuracy of antemortem diagnosis of pulmonary embolism is within the range of just 10-30%, so representing one of the most frequent missed diagnosis in sudden, unexpected death. We describe 43 fatal cases of pulmonary embolism as confirmed by post-mortem examination. The aim of our study was to verify the systematic search for the most common genetic thrombophilias (Factor V Leiden (G1691A) and FII (G20210A) gene variants) and dating the thrombus. As a whole, 41 patients (95.3%) had at least one risk factor. Pre-existing symptoms are described just before fatal embolism in 18 (41.9%) out 43 patients. In 18 out of 43 (41.9%) it was not possible to find the thrombotic site. In 24 out of the remaining 25 cases the involvement of the deep veins of one leg was shown; in 1 case the thrombus was localised in the inferior caval vein. 10 (41.7%) were iliac vein thromboses, 7 (29.1%) femoral, 2 (8.3%) popliteal, 3 (12.6%) posterior-tibial, 1 (4.1%) anterior-tibial and 1 (4.1%) peroneal vein thromboses. In our cohort of patients, 4 (10%) out of 40 cases carried the 20210A prothrombin gene variant in heterozygosis. One (2.5%) out of 40 carried the Factor V Leiden (G1691A) gene variant in heterozygosis. Patients carrying these gene variants in homozygosis or carrying both were not present in our case-series. We strongly underline the relevance of a complete methodological approach, integrating clinical data by means of autopsy findings and histological study. On the contrary, investigating common inherited thrombophilia is not warranted.

Autopsy-proven untreated previous pulmonary thromboembolism: frequency and distribution in the pulmonary artery and correlation with patients' clinical characteristics

BACKGROUND

This study aimed to evaluate untreated, previous pulmonary thromboembolism (PE) in patients with acute fatal PE.

PATIENTS AND METHODS

We studied 64 patients diagnosed as having died from acute PE by medico-legal autopsy. Previous PE was histologically confirmed on the basis of organized thrombi (OT). The distributions of OT were analyzed in five different sizes of pulmonary artery branches in each of 18 pulmonary segmental arteries (90 in total). The frequency of OT in each patient was evaluated by determining the percentage of examined sections containing OT.

RESULTS

OT were confirmed in 59 of 64 (92%) patients. The mean frequency of OT per patient was 27% of the 90 branches. Among the segmental arteries, the right posterior basal lobe showed the highest frequency of OT; among the five artery branches examined, the subsegmental branch showed the highest frequency of OT. OT were not detected in arterioles. Patients with recent trauma or surgery and inpatients showed significantly lower frequencies of OT than those without these risk factors. The 26 patients with prolonged pre-existing symptoms lasting more than a day showed a higher frequency of OT than the 12 patients who suffered for less than a day and the 26 without pre-existing symptoms.

CONCLUSIONS

Most patients with acute fatal PE have a subclinical history of recurrent PE. The frequency of their untreated PE is suspected to correlate with specific risk factors for venous thromboembolism and their clinical course.

Doppler ultrasonography-aided early diagnosis of venous thromboembolism after total knee arthroplasty

OBJECTIVES

Postoperative deep venous thrombosis (DVT) is usually asymptomatic but can result in a fatal pulmonary embolism (PE). To assess the ability of transcranial Doppler (TCD) ultrasound apparatus to detect venous emboli in patients who had undergone total knee arthroplasty (TKA).

METHODS

Forty-eight patients undergoing TKA were examined postoperatively by using compression ultrasonography, computed tomographic angiography, and TCD ultrasonography that detected high-intensity transient signals (HITS) in femoral veins. An original scoring system based on both the number of HITS and the locations of DVT was tested for its accuracy in predicting PE development.

RESULTS

Twenty-three of the 48 patients had DVT postoperatively, and 8 had an asymptomatic PE. The sensitivity and specificity of the HITS assessment alone in identifying PE development were 75% and 92.5%, respectively. The scoring system, however, had a sensitivity of 100% and a specificity of 85% and the area under the receiver operating characteristic (ROC) curve (AUC) was 0.96.

CONCLUSIONS

Application of a scoring system based on the detection of both DVT and HITS may be an effective and efficient method of screening for PE after knee arthroplasty.

Morphological identification of right ventricular failure in cases of fatal pulmonary thromboembolism

Pulmonary thromboembolism is a life-threatening event potentially determining right ventricular failure. Even if the pathophysiology of this phenomenon has been widely investigated, no morphological demonstration of right ventricular ischemic damage determining right ventricular failure in cases of fatal pulmonary embolism has been reported till now. We performed an immunohistochemical investigation with the markers fibronectin and C5b-9 in 26 cases of fatal pulmonary thromboembolism (16 ♀, 10 ♂, mean age 56.4 years), as well as in 25 cases of myocardial infarction (16♀, 9♂, mean age 60.8 years) and 20 cases of hanging (3♀, 17♂, mean age 40.8 years). In each case, at least one tissue slide from both cardiac ventricles (free wall of the right ventricle, anterior and/or posterior wall of the left ventricle) was prepared. The reactions were semiquantitatively classified and the groups compared. In the study group, the occurrence of ischemic changes at the right ventricle was significantly higher than in cases of myocardial infarction and global hypoxia due to hanging. The determining aspect of the immunohistochemical examination is the identification of the prevalent ischemic lesion at the right ventricle compared to the left one. This may indicate the primary involvement of the right ventricle thus demonstrating a right ventricular failure.