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Mohamad T, Kanaan E, Ogieuhi IJ, Mannaparambil AS, Ray R, Al-Nazer LWM, Ahmed HM, Hussain M, Kumar N, Kumari K, Nadeem M, Kumari S, Varrassi G. Thrombolysis vs Anticoagulation: Unveiling the Trade-Offs in Massive Pulmonary Embolism. Cureus 2024; 16:e52675. [PMID: 38380194 PMCID: PMC10877223 DOI: 10.7759/cureus.52675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
Massive pulmonary embolism (MPE) is a severe form of venous thromboembolism (VTE) wherein enormous blood clots block the pulmonary arteries, resulting in substantial illness and death. Even with the progress made in diagnostic methods and treatments, the most effective approach for managing MPE is still a topic of considerable discussion. This study examines the delicate equilibrium between thrombolysis and anticoagulation in managing the problematic clinical situation posed by MPE, elucidating the compromises linked to each strategy. The genesis of MPE lies in the pathophysiology of VTE, when blood clots that originate from deep veins in the lower legs or pelvis move to the pulmonary vasculature, leading to an abrupt blockage. This obstruction leads to a series of hemodynamic alterations, such as elevated pulmonary vascular resistance, strain on the right ventricle, and compromised cardiac output, finally resulting in cardiovascular collapse. The seriousness of MPE is commonly categorized according to hemodynamic stability, with significant cases presenting immediate risks to patient survival. Traditionally, heparin has been the primary approach to managing MPE to prevent the spread of blood clots and their movement to other parts of the body. Nevertheless, there have been ongoing discussions regarding the effectiveness of thrombolysis, which entails the immediate delivery of fibrinolytic drugs to remove the blood clot. The use of thrombolysis in managing MPE is being reconsidered because of concerns over bleeding complications and long-term results despite its capacity to resolve the blocking clot quickly. This review rigorously analyzes the current body of evidence, exploring the intricacies of thrombolysis and anticoagulation in MPE. The focus is on evaluating the risk-benefit balance of each treatment option, considering aspects such as the patient's other medical conditions, hemodynamic stability, and potential long-term consequences. This review aims to clarify the complexities of the thrombolysis versus anticoagulation dilemma. It seeks to provide clinicians, researchers, and policymakers with a thorough understanding of the trade-offs in managing MPE. The goal is to facilitate informed decision-making and enhance patient outcomes.
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Affiliation(s)
- Tamam Mohamad
- Cardiovascular Medicine, Wayne State University, Detroit, USA
| | - Eyas Kanaan
- Internal Medicine, Corewell Health, Grand Rapids, USA
| | - Ikponmwosa J Ogieuhi
- Physiology, University of Benin, Benin City, NGA
- General Medicine, Siberian State Medical University, Tomsk, RUS
| | | | - Rubela Ray
- Internal Medicine, Bankura Sammilani Medical College and Hospital, Bankura, IND
| | | | | | | | | | - Komal Kumari
- Medicine, NMC Royal Family Medical Centre, Abu Dhabi, ARE
| | | | - Sanvi Kumari
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
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Poncz M, Zaitsev SV, Ahn H, Kowalska MA, Bdeir K, Camire RM, Cines DB, Stepanova V. Packaging of supplemented urokinase into naked alpha-granules of in vitro -grown megakaryocytes for targeted therapeutic delivery. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.05.570278. [PMID: 38106191 PMCID: PMC10723305 DOI: 10.1101/2023.12.05.570278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Our prior finding that uPA endogenously expressed and stored in the platelets of transgenic mice prevented thrombus formation without causing bleeding, prompted us to develop a potentially clinically relevant means of generating anti-thrombotic human platelets in vitro from CD34 + hematopoietic cell-derived megakaryocytes. CD34 + -megakaryocytes internalize and store in α-granules single-chain uPA (scuPA) and a uPA variant modified to be plasmin-resistant, but thrombin-activatable, (uPAT). Both uPAs co-localized with internalized factor V (FV), fibrinogen and plasminogen, low-density lipoprotein receptor-related protein 1 (LRP1), and interferon-induced transmembrane protein 3 (IFITM3), but not with endogenous von Willebrand factor (VWF). Endocytosis of uPA by CD34 + -\megakaryocytes was mediated in part via LRP1 and αIIbβ3. scuPA-containing megakaryocytes degraded endocytosed intragranular FV, but not endogenous VWF, in the presence of internalized plasminogen, whereas uPAT-megakaryocytes did not significantly degrade either protein. We used a carotid-artery injury model in NOD-scid IL2rγnull (NSG) mice homozygous for VWF R1326H (a mutation switching binding VWF specificity from mouse to human glycoprotein IbmlIX) to test whether platelets derived from scuPA-MKs or uPAT-Mks would prevent thrombus formation. NSG/VWF R1326H mice exhibited a lower thrombotic burden after carotid artery injury compared to NSG mice unless infused with human platelets or MKs, whereas intravenous injection of either uPA-containing megakaryocytes into NSG/VWF R1326H generated sufficient uPA-containing human platelets to lyse nascent thrombi. These studies suggest the potential to deliver uPA or potentially other ectopic proteins within platelet α-granules from in vitro- generated megakaryocytes. Key points Unlike platelets, in vitro-grown megakaryocytes can store exogenous uPA in its α-granules.uPA uptake involves LRP1 and αIIbβ3 receptors and is functionally available from activated platelets.
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Bigdelu L, Daloee MH, Emadzadeh M, Parsa L, Najafi M, Baradaran Rahimi V. Comparison of echocardiographic pulmonary flow Doppler markers in patients with massive or submassive acute pulmonary embolism and control group: A cross-sectional study. Health Sci Rep 2023; 6:e1249. [PMID: 37152221 PMCID: PMC10158783 DOI: 10.1002/hsr2.1249] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/09/2023] Open
Abstract
Background and Aims Computed tomography angiography (CTA) is the gold standard for the diagnosis of massive (MPE) and submassive pulmonary embolism (SMPE). Ultrasound has not been accepted as a diagnostic tool. We aim to evaluate the pattern of pulmonary Doppler echocardiography in patients with pulmonary embolism (PE). Methods From 2020 to 2022, 30 patients with acute MPE or SMPE confirmed by CTA and normal pulmonary pressures were selected. A control group was created with 30 individuals without PE. All patients had an echocardiography Doppler study of the pulmonary flow with a focus on early systolic notching (ESN), McConnell's (MC) sign, Right ventricular outflow tract velocity time integral (RVOT VTI), segmental thickness variability (STV), right ventricular end-diastolic diameter (RVEDD), tricuspid regurgitation (TR) gradient, pulmonary artery pressure (PAP), and acceleration (AT) or ejection time (ET). Results ESN was identified in 96.6% of PE patients and 0% of the control group (p < 0.001). In comparison with the control group, STV (p < 0.001), RVOT VTI (p < 0.001), ET (p = 0.04), and AT (p < 0.001) values were lower in patients with PE while RVEDD, TR gradient, PAP, ESN, MC sign, and d-shape were higher (p < 0.001). Identification of the ESN pattern and AT/ET < 0.4 showed excellent predictive ability for MPE and SMPE with a sensitivity of 97.0% and 100%, specificity of 99.0% and 97%, and an area under the ROC curve of 0.967 (95% CI 0.914-1.00) and 0.933 (95% CI 0.844-1.00), respectively. Conclusion Doppler echocardiography with particular attention to ESN, may be a suitable noninvasive method for the diagnosis of MPE and SMPE. Further studies with more sample sizes are needed to confirm its diagnostic benefit.
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Affiliation(s)
- Leila Bigdelu
- Vascular and Endovascular Surgery Research CenterMashhad University of Medical SciencesMashhadIran
| | - Mahdi Hasanzadeh Daloee
- Department of Cardiovascular Diseases, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Maryam Emadzadeh
- Clinical Research Development Unit, Ghaem HospitalMashhad University of Medical SciencesMashhadIran
| | - Leila Parsa
- Edward Via College of Osteopathic MedicineBlacksburgVirginiaUSA
| | - Mahnaz Najafi
- Department of Cardiovascular Diseases, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Vafa Baradaran Rahimi
- Department of Cardiovascular Diseases, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
- Pharmacological Research Center of Medicinal PlantsMashhad University of Medical SciencesMashhadIran
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Comments on an intracardiac thrombus as a cause of cardiac arrest during a cesarean delivery: a response. Am J Obstet Gynecol 2023; 228:361-362. [PMID: 36309311 DOI: 10.1016/j.ajog.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022]
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Durack JC, Chen LL, Imran S, Halpern NA. A Tale of Two Pulmonary Artery Catheters. Crit Care Nurs Q 2022; 45:8-12. [PMID: 34818292 PMCID: PMC9911303 DOI: 10.1097/cnq.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Innovative catheter-based therapies are increasingly being used for the treatment of patients with submassive pulmonary embolism. These patients may be monitored in the intensive care unit following insertion of specialized pulmonary artery catheters. However, the infusion catheters utilized in catheter-based therapies differ greatly from traditional pulmonary artery catheters designed for hemodynamic monitoring. As such, the critical care team will have to be familiar with the monitoring and management of these novel catheters. Important distinctions between the catheters are illustrated using a clinical case report.
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Affiliation(s)
- Jeremy C Durack
- Interventional Radiology Service, Department of Radiology (Dr Durack), and Critical Care Center and Critical Care Medicine Service, Department of Anesthesiology and Critical Care Medicine (Drs Chen, Imran, and Halpern), Memorial Sloan Kettering Cancer Center, New York City, New York
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Kulka HC, Zeller A, Fornaro J, Wuillemin WA, Konstantinides S, Christ M. Acute Pulmonary Embolism–Its Diagnosis and Treatment From a Multidisciplinary Viewpoint. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:618-628. [PMID: 34382576 DOI: 10.3238/arztebl.m2021.0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 12/31/2020] [Accepted: 04/28/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Physicians from many different specialties see patients suffering from acute pulmonary embolism (PE), which has an incidence of 39-115 cases per 100 000 persons per year. Because PE can be life-threatening, a rapid, targeted response is essential. METHODS This review is based on pertinent publications retrieved by a selective literature search of international databases, with particular attention to current guidelines and expert opinions. RESULTS Whenever PE is suspected, clinical assessment tools must be applied for risk stratification and diagnostic evaluation. The PERC (Pulmonary Embolism Rule-out Criteria) and the YEARS algorithm lead to more effective diagnosis. For hemodynamically unstable patients, bedside echocardiography is of high value and enables risk stratification. New oral anticoagulants have fewer hemorrhagic complications than vitamin K antagonists and are not inferior to them with respect to the risk of recurrent PE (hazard ratio 0.84-1.09). The duration of anticoagulation is set according to the risk of recurrence. Systemic thrombolysis is recommended for patients with a high-risk PE, in whom it significantly reduces mortality (odds ratio 0.53, number needed to treat 59). Surgical or interventional techniques can be considered if thrombolysis is contraindicated or unsuccessful. CONCLUSION Newly introduced diagnostic aids and algorithms simplify the diagnosis and treatment of acute PE while continuing to assure a high degree of patient safety.
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Vetrugno L, Bignami E, Deana C, Bassi F, Vargas M, Orsaria M, Bagatto D, Intermite C, Meroi F, Saglietti F, Sartori M, Orso D, Robiony M, Bove T. Cerebral fat embolism after traumatic bone fractures: a structured literature review and analysis of published case reports. Scand J Trauma Resusc Emerg Med 2021; 29:47. [PMID: 33712051 PMCID: PMC7953582 DOI: 10.1186/s13049-021-00861-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
Background The incidence of cerebral fat embolism (CFE) ranges from 0.9–11%, with a mean mortality rate of around 10%. Although no univocal explanation has been identified for the resulting fat embolism syndrome (FES), two hypotheses are widely thought: the ‘mechanical theory’, and the ‘chemical theory’. The present article provides a systematic review of published case reports of FES following a bone fracture. Methods We searched MEDLINE, Web of Science and Scopus to find any article related to FES. Inclusion criteria were: trauma patients; age ≥ 18 years; and the clinical diagnosis of CFE or FES. Studies were excluded if the bone fracture site was not specified. Results One hundred and seventy studies were included (268 cases). The male gender was most prominent (81.6% vs. 18.4%). The average age was 33 years (±18). The mean age for males (29 ± 14) was significantly lower than for females (51 ± 26) (p < 0.001). The femur was the most common fracture site (71% of cases). PFO was found in 12% of all cases. Univariate and multivariate regression analyses showed the male gender to be a risk factor for FES: RR 1.87 and 1.41, respectively (95%CI 1.27–2.48, p < 0.001; 95%CI 0.48–2.34, p < 0.001). Conclusions FES is most frequent in young men in the third decades of life following multiple leg fractures. FES may be more frequent after a burst fracture. The presence of PFO may be responsible for the acute presentation of cerebral embolisms, whereas FES is mostly delayed by 48–72 h. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00861-x.
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Affiliation(s)
- Luigi Vetrugno
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care Clinic, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy. .,Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy.
| | - Elena Bignami
- Department of Medicine and Surgery, Unit of Anesthesiology, Parma University Hospital, Parma, Italy
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care Unit 1, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care Unit 2, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Naples, Italy
| | - Maria Orsaria
- Department of Medicine, Surgical Pathology Section, University of Udine, Udine, Italy
| | - Daniele Bagatto
- Department of Diagnostic Imaging, Neuroradiology Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Cristina Intermite
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
| | - Francesco Meroi
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
| | | | - Marco Sartori
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
| | - Daniele Orso
- Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
| | - Massimo Robiony
- Department of Medicine, Maxillofacial Surgery, University of Udine, Udine, Italy.,Azienda Sanitaria Universitaria Friuli Centrale, Maxillofacial Surgery, Udine, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, Anesthesia and Intensive Care Clinic, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy.,Department of Medicine, Anesthesia and Intensive Care Clinic, University of Udine, Udine, Italy
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Nakamura K, Orii K, Hanai M, Abe T, Haida H. Management of acute pulmonary embolism after acute aortic dissection surgery. J Cardiol Cases 2020; 22:195-197. [PMID: 33014204 PMCID: PMC7520534 DOI: 10.1016/j.jccase.2020.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 11/24/2022] Open
Abstract
Acute aortic dissection (AAD) continues to be associated with high mortality and morbidity. Pulmonary embolism is also a life-threatening disease. The treatment of these life-threatening diseases remains controversial in case complications arise. Thrombolytic therapy and intensive treatment would be needed to manage these fatal diseases. A 49-year-old man with progressive back pain was admitted to our hospital. Computed tomography (CT) scan revealed type A AAD. Emergency operation for hemiarch replacement was performed. Two weeks postoperatively, the patient’s oxygenation worsened and his d-dimer levels elevated. CT scan revealed a massive thrombus in the bilateral pulmonary arteries. Intensive anticoagulation therapy was started immediately. On postoperative day 27, the patient was weaned from mechanical ventilation, but the false lumen with thrombus was recanalized again. The patient was discharged on postoperative day 75 without resulting in major complications for aortic dissection. The diagnosis of pulmonary embolism concomitant with AAD is difficult. The treatment of pulmonary embolism after AAD is controversial. Our strategy seems to be suitable for acute pulmonary embolism that occurs during the treatment of AAD. ˂Learning objective: The diagnosis of pulmonary embolism concomitant with acute aortic dissection (AAD) is difficult. The treatment of pulmonary embolism after AAD is controversial. Investigating factor XIII levels might help in the early detection of pulmonary embolism.>
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Affiliation(s)
- Ken Nakamura
- Department of Cardiac Surgery, Saitama Cardiovascular and Respiratory Center, Kumagaya-shi, Saitama, Japan
| | - Kouan Orii
- Department of Cardiac Surgery, Saitama Cardiovascular and Respiratory Center, Kumagaya-shi, Saitama, Japan
| | - Makoto Hanai
- Department of Cardiac Surgery, Saitama Cardiovascular and Respiratory Center, Kumagaya-shi, Saitama, Japan
| | - Takayuki Abe
- Department of Cardiac Surgery, Saitama Cardiovascular and Respiratory Center, Kumagaya-shi, Saitama, Japan
| | - Hirofumi Haida
- Department of Cardiac Surgery, Saitama Cardiovascular and Respiratory Center, Kumagaya-shi, Saitama, Japan
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Salisbury JB, Shields JR, Steenburg SD. Clinical Impact of a Radiologic Quality Initiative Promoting More Timely Communication of Critical Pulmonary Embolus Results. Acad Radiol 2020; 27:922-928. [PMID: 32430226 DOI: 10.1016/j.acra.2019.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 10/23/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND A section quality initiative was implemented beginning 2013 requiring positive pulmonary embolism (PE) results to be documented and communicated within 90 minutes of exam completion. The objective of this study is to evaluate the effect of this quality initiative on different intervals comprising the total patient processing time, namely the time from when the imaging exam was ordered to study completion interval, the time from study completion to positive PE result communication (TAT interval) or treatment initiation (TTT interval), the time from result communication to treatment initiation (TRCTI interval), and the total patient processing time (TPT interval). METHODS This was a retrospective, single-institution, IRB-approved cohort study that included 830 patients with the diagnosis of acute PE confirmed by CT pulmonary angiography. A maximum of 10 positive exams per month were identified and analyzed over an 84-month period from January 2010 to December 2016. The following data were obtained: time when exam ordered, time of imaging study completion, time of report completion, time of result communication, time of treatment, type of treatment, and reasons for any treatment delay. Analysis was done by determining the mean time spent in various intervals, the cumulative relative frequency of interval completion, and the fraction of the entire patient processing time spent in each interval. RESULTS Mean analysis demonstrated a decrease in all time intervals in the postpolicy period (ordered to study completion: Δ24.50%, p = 0.004; TAT: Δ23.91%, p < 0.001; TRCTI: Δ16.86%, p = 0.031; TTT: Δ17.40%, p = 0.005; TPT: Δ15.94%, p = 0.002). Cumulative relative frequency analysis demonstrated a higher rate of interval completion in the postpolicy period (TAT: p < 0.001; TRCTI: p = 0.007; TPT: p = 0.025). Interval fraction analysis demonstrated changes in the fraction of processing time spent in varying intervals (TAT: -Δ14.42%, p = 0.002; TRCTI: +Δ17.65%, p = 0.001). CONCLUSION Total patient processing time decreased after the policy implementation with a more significant decrease in TAT compared to other intervals. Radiologic processing time does not appear to be the rate-limiting step in total patient processing time.
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Affiliation(s)
- Jared B Salisbury
- Indiana University School of Medicine, Department of Radiology and Imaging Sciences, 550 N. University Blvd., Room 0663; Indianapolis, IN 46202.
| | - Jared R Shields
- Indiana University School of Medicine, Department of Radiology and Imaging Sciences, 550 N. University Blvd., Room 0663; Indianapolis, IN 46202
| | - Scott D Steenburg
- Indiana University School of Medicine, Department of Radiology and Imaging Sciences, 550 N. University Blvd., Room 0663; Indianapolis, IN 46202
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A successful surgical treatment of pulmonary thromboembolism after endovenous radiofrequency ablation with extracorporeal membrane oxygenation bridging. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:369-371. [PMID: 32551169 DOI: 10.5606/tgkdc.dergisi.2020.17565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 12/23/2019] [Indexed: 11/21/2022]
Abstract
Pulmonary embolism after endovenous radiofrequency ablation is very rare, but a clinically severe complication. Herein, we report a case of pulmonary embolism after endovenous radiofrequency ablation. Early after radiofrequency ablation pulmonary embolism developed and extracorporeal membrane oxygenation implantation was performed. Under extracorporeal membrane oxygenation support, surgical pulmonary embolectomy was performed successfully using the same cannulas and the patient was discharged without any neurological sequelae. In conclusion, although rare after radiofrequency ablation, early recognition of pulmonary embolism and prompt treatment can be life-saving.
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Abstract
Management of pulmonary embolism (PE) has become more complex due to the expanded role of catheter-based therapies, surgical thrombectomies, and cardiac assist technologies, such as right ventricular assist devices and extracorporeal support. Due to the heterogeneity of PE, a multidisciplinary team approach is necessary. The manifestation of PE response teams are in response to this complex need and similar to the proliferation of stroke, trauma, and rapid response teams. Intensive care units are an ideal location for formulating a comprehensive treatment plan that necessitates an interaction between multiple specialties. This article addresses the unique needs of critically ill patients with PE.
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Affiliation(s)
- Michael Baram
- Department of Medicine, Division of Pulmonary and Critical Care, Jefferson University Hospital, Korman Lung Institute, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA.
| | - Bharat Awsare
- Department of Medicine, Division of Pulmonary and Critical Care, Jefferson University Hospital, Korman Lung Institute, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA
| | - Geno Merli
- Department of Medicine and Surgery, Division of Vascular Medicine, Jefferson University Hospital, 111 South 11th Street Suite 6210, Philadelphia, PA 19107, USA
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Lio KU, Jiménez D, Moores L, Rali P. Clinical conundrum: concomitant high-risk pulmonary embolism and acute ischemic stroke. Emerg Radiol 2020; 27:433-439. [PMID: 32211984 DOI: 10.1007/s10140-020-01772-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 01/01/2023]
Abstract
High-risk PE can be complicated by the presence of a patent foramen ovale (PFO), which can lead to paradoxical systemic embolization, including cerebral embolism ultimately leading to acute ischemic stroke (AIS). Acute management is challenging given the competing benefits and risks of systemic thrombolysis. Herein, we aim to provide a review of clinical presentations, diagnostic findings, and treatment and outcome from the available literature, with the hopes of providing insight into treatment options. We followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic literature search using PubMed/MEDLINE database, Cochrane Library, and Google Scholar for all reported cases/case series of concomitant high-risk PE and paradoxical ischemic stroke was conducted from inception to July 2019. Twenty-nine cases from 27 articles (26 single case reports, 1 case series of 3 patients) were included. There were 10 men and 19 women, ranging in age from 29 to 81 years (mean 56.1 ± 13.5 years). PFO was diagnosed in 89.7% of patients, mostly by transesophageal echocardiography. Treatment modalities included systemic thrombolysis (40%), anticoagulation alone (36%), surgical thrombectomy (16%), and percutaneous thrombectomy (8%). Overall mortality rate was 31%. Patients receiving thrombolysis and surgical thrombectomy had the most favorable outcome. Survival to discharge was 90% (9 out of 10), 100% (5 out of 5), and 50% (4 out of 8) in the systemic thrombolysis, surgical thrombectomy, and anticoagulation alone groups respectively. In the setting of combined high-risk PE and ischemic stroke, PFO can be detected in 90% of published cases. Thrombolysis and surgical thrombectomy seem to be effective management, but further studies are needed for validation.
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Affiliation(s)
- Ka U Lio
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcala, Madrid, Spain
| | - Lisa Moores
- Department of Medicine, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School Of Medicine, Temple University Hospital, Philadelphia, PA, USA.
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13
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Aslam HM, Naeem HS, Prabhakar S, Awwal T, Khalid M, Kaji A. Effect of Beta-blockers on Tachycardia in Patients with Pulmonary Embolism. Cureus 2019; 11:e6512. [PMID: 32025431 PMCID: PMC6988733 DOI: 10.7759/cureus.6512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hypothesis Beta-blockers (BBs) lower the heart rate, which may mask the diagnosis of pulmonary embolism (PE) since one of the main clinical diagnoses of PE is tachycardia. The endpoint of our retrospective study is to determine if the pre-existing use of (BB) significantly affects the utility of these scoring criteria in diagnosing PE. Introduction Diagnosing PE is a challenge because of the non-specificity of its symptoms and signs. The initial step is to assess the patient's likelihood of having a PE. This involves using a scoring system to stratify patients into different levels of risk of having PE (for example, as 'low,' 'moderate,' or 'high' risk). Some of the commonly used criteria are Wells' Score, Geneva Score, and Pulmonary Embolism Rule-out Criteria (PERC) Rule (Charlotte Rule). Methodology This retrospective study was conducted at St. Francis Medical Center. Subjects were taken from a patient population with a new diagnosis of PE (between 2010 and 2017) on the basis of computed tomography angiography (CTA) of the chest. Patients with sepsis or septic shock, heart block, atrioventricular (AV) nodal ablation, pacemaker placement, or taking more than one AV nodal blocker were excluded from the study. Subjects were categorized on the basis of beta-blocker consumption. Result Out of a total of 170 cases, 71 patients were taking beta-blockers and 99 patients were not taking beta-blockers. Among the participants taking BBs, 30.4% had a heart rate <60 and 55.8% had a heart rate between 60 and 100. Conclusion BBs significantly obviate tachycardia in patients with PE. It falsely decreases the Wells' Score and the Geneva Score and results in the inappropriate fulfilling of PERC criteria.
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Affiliation(s)
- Hafiz M Aslam
- Internal Medicine, Seton Hall University / Hackensack Meridian School of Medicine, Trenton, USA
| | - Hafiz S Naeem
- Internal Medicine, St. Francis Medical Center, Trenton, USA
| | | | - Talha Awwal
- Internal Medicine, St. Francis Medical Center, Trenton, USA
| | | | - Anand Kaji
- Internal Medicine, St. Francis Medical Center, Trenton, USA
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Wible BC, Buckley JR, Cho KH, Bunte MC, Saucier NA, Borsa JJ. Safety and Efficacy of Acute Pulmonary Embolism Treated via Large-Bore Aspiration Mechanical Thrombectomy Using the Inari FlowTriever Device. J Vasc Interv Radiol 2019; 30:1370-1375. [PMID: 31375449 DOI: 10.1016/j.jvir.2019.05.024] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/19/2019] [Accepted: 05/19/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To report initial experience with safety and efficacy in the treatment of pulmonary embolism (PE) using the FlowTriever device. MATERIALS AND METHODS A single-center retrospective study was performed in all patients with acute central PE treated using the FlowTriever device between March 2018 and March 2019. A total of 46 patients were identified (massive = 8; submassive = 38), all with right ventricular (RV) strain and 26% with thrombolytic contraindications. Technical success (according to SIR reporting guidelines) and clinical success (defined as mean pulmonary artery pressure intraprocedural improvement) are reported, as are major device and procedure-related complications within 30 days after discharge. RESULTS Technical success was achieved in 100% of cases (n = 46). Average mean pulmonary artery pressure improved significantly from before to after the procedure for the total population (33.9 ± 8.9 mm Hg before, 27.0 ± 9.0 mm Hg after; P < .0001; 95% confidence interval [CI], 5.0-8.8), submassive cohort (34.7 ± 9.1 mm Hg before, 27.4 ± 9.2 mm Hg after; P < .0001; 95% CI, 5.2-9.5) and massive cohort (30.4 ± 6.9 mm Hg before, 25.4 ± 8.2 mm Hg after; P < .05; 95% CI:0.4-9.6). Intraprocedural reduction in mean pulmonary artery pressure was achieved in 88% (n = 37 of 42). A total of 100% of patients (n = 46 of 46) survived to hospital discharge. In total, 71% of patients (n = 27 of 38) experienced intraprocedural reduction in supplemental oxygen requirements. Two major adverse events (4.6%) included hemoptysis requiring intubation, and procedure-related blood loss requiring transfusion. No delayed procedure-related complications or deaths occurred within 30 days of hospital discharge. CONCLUSIONS Initial clinical experience using the FlowTriever to perform mechanical thrombectomy showed encouraging trends with respect to safety and efficacy for the treatment of acute central, massive, and submassive pulmonary embolism.
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Affiliation(s)
- Brandt C Wible
- Saint Luke's Health System, Department of Radiology, Saint Luke's Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
| | - Jennifer R Buckley
- Saint Luke's Health System, Department of Radiology, Saint Luke's Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Kenneth H Cho
- Saint Luke's Health System, Department of Radiology, Saint Luke's Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Matt C Bunte
- Saint Luke's Mid America Heart Institute, Saint Luke's Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Nathan A Saucier
- Saint Luke's Health System, Department of Radiology, Saint Luke's Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - John J Borsa
- Saint Luke's Health System, Department of Radiology, Saint Luke's Hospital and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Tak T, Karturi S, Sharma U, Eckstein L, Poterucha JT, Sandoval Y. Acute Pulmonary Embolism: Contemporary Approach to Diagnosis, Risk-Stratification, and Management. Int J Angiol 2019; 28:100-111. [PMID: 31384107 DOI: 10.1055/s-0039-1692636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Pulmonary embolism (PE) affects over 300,000 individuals each year in the United States and is associated with substantial morbidity and mortality. Improvements in the diagnostic performance and availability of computed tomographic pulmonary angiography and D-dimer testing have facilitated the evaluation of patients with suspected PE. High clinical suspicion is required in those with risk factors and/or those that manifest signs or symptoms of venous thromboembolic disease, with validated clinical risk scores such as the Wells and modified Wells score or the PE rule-out criteria helpful in estimating the likelihood for PE. For those with confirmed PE, patients should be categorized and triaged according to the presence or absence of shock or hypotension. Normotensive patients can be further risk-stratified using validated prognostic risk scores, as well as by using imaging and cardiac biomarkers, with those having either signs of right ventricular dysfunction on imaging studies and/or abnormal cardiac biomarkers categorized as being at intermediate-risk and requiring close monitoring and hospital admission. Early discharge and/or home therapy are possible in those that do not manifest any high-risk features. The initial treatment for most patients that are stable consists of anticoagulation, with advanced therapies such as thrombolysis, catheter-based therapies, or surgical embolectomy deferred for those at high risk. Given the heterogeneous presentations of PE and various management strategies available, the development of multidisciplinary PE response teams has emerged to help facilitate decision-making in these patients.
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Affiliation(s)
- Tahir Tak
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Swetha Karturi
- Department of Hospital Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Umesh Sharma
- Department of Hospital Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Lee Eckstein
- Department of Imaging Services, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Joseph T Poterucha
- Division of Critical Care Medicine, Mayo Clinic Health System, La Crosse, Wisconsin
| | - Yader Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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The Association between the Pulmonary Arterial Obstruction Index and Atrial Size in Patients with Acute Pulmonary Embolism. Radiol Res Pract 2019; 2019:6025931. [PMID: 31275649 PMCID: PMC6582783 DOI: 10.1155/2019/6025931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 04/21/2019] [Indexed: 11/29/2022] Open
Abstract
Purpose Pulmonary embolism (PE) is a common and potentially fatal form of venous thromboembolism. The aim of this study is to investigate the association between the pulmonary arterial obstruction index and atrial size in patients with acute pulmonary embolism. Basic Procedure The study consisted of 86 patients with clinical symptoms of PE. Out of 86 individuals, 50 patients were diagnosed with PE and considered as the patient group. The others were considered as the control group. All patients were scanned by a multidetector CT scanner. Using the radiology workstation, an expert radiologist calculated the left atrium (LA) and right atrium (RA) areas from planimetric measurements obtained from free-hand delineation of the atrial boarders using an electronic pen. Quantitative volumetric measurements of LA and RA were obtained from original axial images. Main Findings There were 25 males and 25 females with PE, who had a mean age of 58 years. There was not a significant difference in the positive history of diabetes mellitus, hypertension, asthma, chronic obstructive pulmonary diseases, ischemic heart disease, and smoking between patients and control group. There was a significant negative correlation between almost all LA measurements and the PAOI. RA area and volume had the highest area under the curves for recognizing larger clot burden. Principal Conclusions A higher clot load is associated with a smaller LA size and increased RA/LA ratios, measured with CTPA. Atrial measurements are correlated with POAI, and they could be used as sensitive parameters in predicting heart failure in patients with PE.
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Prentice D, Wipke-Tevis DD. Diagnosis of pulmonary embolism: Following the evidence from suspicion to certainty. JOURNAL OF VASCULAR NURSING 2019; 37:28-42. [PMID: 30954195 DOI: 10.1016/j.jvn.2018.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/23/2018] [Accepted: 10/02/2018] [Indexed: 12/16/2022]
Abstract
Accurate, timely and cost-effective identification of pulmonary embolism remains a diagnostic challenge. This article reviews the pulmonary embolism diagnostic process with a focus on the best practice advice from the American College of Physicians. Benefits and risks of each diagnostic step are discussed. Emerging diagnostic tools, not included in the algorithm, are briefly reviewed.
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Affiliation(s)
- Donna Prentice
- Clinical Nurse Specialist, Barnes-Jewish Hospital, St. Louis, MO; PhD Candidate, Sinclair School of Nursing, University of Missouri, Columbia, MO.
| | - Deidre D Wipke-Tevis
- Associate Professor and PhD Program Director, Sinclair School of Nursing, University of Missouri, Columbia, MO
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18
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Smeltz AM, Kolarczyk LM, Isaak RS. Update on Perioperative Pulmonary Embolism Management: A Decision Support Tool to Aid in Diagnosis and Treatment. Adv Anesth 2018; 35:213-228. [PMID: 29103574 DOI: 10.1016/j.aan.2017.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pulmonary embolism (PE) affects up to 1 in every 1000 people per year, one-third of whom do not survive. Moreover, perioperative presentation of PE is 5 times more likely than at other times and poses a unique set of challenges for both diagnosis and treatment. This article discusses several important aspects regarding the prevention, diagnosis, and management of perioperative PE, incorporating information from the most recent practice guidelines, emerging literature on medical therapy, and interventional therapies. It proposes a clinical decision support tool that organizes the salient aspects of perioperative PE management to serve as an aid in practice.
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Affiliation(s)
- Alan M Smeltz
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA
| | - Lavinia M Kolarczyk
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA
| | - Robert S Isaak
- Department of Anesthesiology, University of North Carolina at Chapel Hill School of Medicine, N2198 UNC Hospitals, CB 7010, Chapel Hill, NC 27599, USA.
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19
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Morrone D, Morrone V. Acute Pulmonary Embolism: Focus on the Clinical Picture. Korean Circ J 2018; 48:365-381. [PMID: 29737640 PMCID: PMC5940642 DOI: 10.4070/kcj.2017.0314] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/27/2018] [Accepted: 04/11/2018] [Indexed: 12/29/2022] Open
Abstract
Acute pulmonary embolism (APE) is characterized by numerous clinical manifestations which are the result of a complex interplay between different organs; the symptoms are therefore various and part of a complex clinical picture. For this reason, it may not be easy to make an immediate diagnosis. This is a comprehensive review of the literature on all the various clinical pictures in order to help physicians to promptly recognize this clinical condition, remembering that our leading role as cardiologists depends on and is influenced by our knowledge and working methods.
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Affiliation(s)
- Doralisa Morrone
- Department of Surgery, Medical, Molecular and Critical Area Pathology, University of Pisa, Italy.
| | - Vincenzo Morrone
- Department of Cardiology, SS. Annunziata Hospital, Taranto, Italy
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20
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Healthcare Strategies for Reducing Pregnancy-Related Morbidity and Mortality in the Postpartum Period. J Perinat Neonatal Nurs 2018; 32:241-249. [PMID: 30036306 DOI: 10.1097/jpn.0000000000000344] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The majority of pregnancy-related deaths in the United States occur in the postpartum period, after a woman gives birth. Many of these deaths are preventable. Researchers and health care providers have been focusing on designing and implementing strategies to eliminate preventable deaths and ethnic and racial disparities. Six healthcare strategies for reducing postpartum maternal morbidity and mortality will be described. These strategies, if provided in an equitable manner by all providers to all women, will assist in closing the disparity in outcomes between black women and women of all other races and ethnicities who give birth throughout the United States.
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21
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Grapatsas K, Leivaditis V, Zarogoulidis P, Tsilogianni Z, Kotoulas S, Kotoulas C, Koletsis E, Iliadis IS, Spiliotopoulos K, Trakada G, Veletza L, Kallianos A, Tsiouda T, Kosmidis C, Hohenforst-Schmidt W, Huang H, Haussmann R, Haussmann E, Dahm M. Successful treatment of postoperative massive pulmonary embolism with paradoxal arterial embolism through extracorporeal life support and thrombolysis. Respir Med Case Rep 2017; 23:1-3. [PMID: 29159030 PMCID: PMC5683805 DOI: 10.1016/j.rmcr.2017.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 10/29/2017] [Accepted: 10/30/2017] [Indexed: 12/31/2022] Open
Abstract
Pulmonary embolism is a common clinical entity related to high mortality. About 200,000 to 300,000 patients die every year due to pulmonary embolism. The purpose of this article is to describe a case of a patient who on the second postoperative day after undergoing thromboembolectomy of the left femoral artery, manifested a massive pulmonary embolism. Due to cardiorespiratory collapse a combined treatment via extracorporeal life support (ECLS) and parallel catheter thrombolysis was decided and performed. By cardiorespiratory improvement and final stabilization the patient was successfully weaned from ECLS and the system was successfully removed. After a reasonable postoperative time the patient was dismissed in good overall condition.
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Affiliation(s)
- Konstantinos Grapatsas
- Department of Cardiothoracic and Vascular Surgery, Westpfalz Klinikum, Academic Educational Hospital of Mainz University, Kaiserslautern, Germany.,Department of Cardiothoracic Surgery, Iaso General, Athens, Greece
| | - Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, Westpfalz Klinikum, Academic Educational Hospital of Mainz University, Kaiserslautern, Germany
| | - Paul Zarogoulidis
- Pulmonary-Oncology Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece
| | - Zoi Tsilogianni
- Department of Pulmonology, 401 General Military Hospital, Athens, Greece
| | | | | | - Efstratios Koletsis
- Department of Cardiothoracic Surgery, Medical School, University Hospital of Patras, Patras, Greece
| | | | | | - Georgia Trakada
- Pulmonary-Oncology Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece
| | - Lemonia Veletza
- Pulmonary-Oncology Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece
| | - Anastasios Kallianos
- Pulmonary-Oncology Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece
| | - Theodora Tsiouda
- Pulmonary-Oncology Department, "Theageneio" Cancer Hospital, Thessaloniki, Greece
| | | | - Wolfgang Hohenforst-Schmidt
- Sana Clinic Group Franken, Department of Cardiology/Pulmonology/Intensive Care/Nephrology, "Hof'' Clinics, University of Erlangen, Hof, Germany
| | - Haidong Huang
- Department of Respiratory and Critical Care Medicine, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Rainer Haussmann
- Department of Anesthesiology, Emergency Care Medicine and Intensive Care Medicine, Westpfalz Klinikum, Academic Educational Hospital of Mainz University, Kaiserslautern, Germany
| | - Erich Haussmann
- Department of Anesthesiology, Emergency Care Medicine and Intensive Care Medicine, Westpfalz Klinikum, Academic Educational Hospital of Mainz University, Kaiserslautern, Germany
| | - Manfred Dahm
- Department of Anesthesiology, Emergency Care Medicine and Intensive Care Medicine, Westpfalz Klinikum, Academic Educational Hospital of Mainz University, Kaiserslautern, Germany
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22
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Ceresetto JM, Marques MA. Terapia fibrinolítica sistêmica no tromboembolismo pulmonar. J Vasc Bras 2017; 16:119-127. [PMID: 29930636 PMCID: PMC5915860 DOI: 10.1590/1677-5449.007316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
O tromboembolismo pulmonar permanece como um grande desafio terapêutico para os médicos especialistas, pois, apesar de todo investimento e desenvolvimento em seu diagnóstico, profilaxia e tratamento, essa condição continua sendo a principal causa de morte evitável em ambiente hospitalar. Ainda restam muitas dúvidas em relação a qual perfil de paciente vai se beneficiar de fato da terapia fibrinolítica sistêmica, sem ficar exposto a um grande risco de sangramento. A estratificação de risco e a avaliação do prognóstico do evento, através de escores clínicos de insuficiência ventricular direita, marcadores de dilatação e disfunção do ventrículo direito e avaliação da massa trombótica, associados ou de forma isolada, são ferramentas que podem auxiliar na identificação do paciente que irá se beneficiar dessa terapia. Os únicos consensos em relação à terapia fibrinolítica no tratamento do tromboembolismo pulmonar são: não deve ser indicada de forma rotineira; nenhum dos escores ou marcadores, isoladamente, devem justificar seu uso; e os pacientes com instabilidade hemodinâmica são os mais beneficiados. Além disto, deve-se avaliar cada caso em relação ao risco de sangramento, especialmente no sistema nervoso central.
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Klevanets J, Starodubtsev V, Ignatenko P, Voroshilina O, Ruzankin P, Karpenko A. Systemic Thrombolytic Therapy and Catheter-Directed Fragmentation with Local Thrombolytic Therapy in Patients with Pulmonary Embolism. Ann Vasc Surg 2017; 45:98-105. [PMID: 28501664 DOI: 10.1016/j.avsg.2017.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The objective was to compare immediate and long-term results of systemic thrombolytic therapy (STT) and catheter-directed fragmentation (CDF) with local thrombolytic therapy (LTT) in patients with massive pulmonary embolism (PE). METHODS About 209 patients with massive PE (the high risk of early death) were included in our study. From 2008 till 2010 in the first group (n = 102), STT was performed. From 2011 till 2013 in the second group (n = 107), CDF with LTT was carried out. Echocardiography and pulmonary arteriography were performed in all patients on admission to hospital and in 5 days after treatment. The patients of both groups were re-examined in 6 months, 1, 2, and 3 years after the operation. RESULTS In the first group, there were 5 (4.9%) cases of in-hospital 30-day mortality. In the second group, there was 1 (0.9%) case of in-hospital 30-day mortality (P = 0.08). In the first group, a clinically significant bleeding was noted in 4 (3.9%) cases, but it caused mortality only in 1 case. In the second group, the clinically significant bleeding was not found (P = 0.038). Persistent postembolic pulmonary hypertension (PPPH) in 9.8% cases of patients in the first group and 2.9% cases of patients in the second group was determined (P = 0.048). CONCLUSIONS CDF combined with LTT is an effective minimal invasive treatment (helped us to reduce significantly the number of bleeding and PPPH cases), at least in the midterm, in patients with massive PE.
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Affiliation(s)
- Julia Klevanets
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation
| | - Vladimir Starodubtsev
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation.
| | - Pavel Ignatenko
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation
| | - Olga Voroshilina
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation
| | - Pavel Ruzankin
- The Sobolev Institute of Mathematics SB RAS, Novosibirsk State University, Novosibirsk, Russian Federation
| | - Andrey Karpenko
- Academician E.N. Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Ministry for Public Health Care Russian Federation, Novosibirsk, Russian Federation
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Mortality Related Risk Factors in High-Risk Pulmonary Embolism in the ICU. Can Respir J 2016; 2016:2432808. [PMID: 28025592 PMCID: PMC5153485 DOI: 10.1155/2016/2432808] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/12/2016] [Accepted: 10/26/2016] [Indexed: 12/24/2022] Open
Abstract
Introduction. We sought to identify possible risk factors associated with mortality in patients with high-risk pulmonary embolism (PE) after intensive care unit (ICU) admission. Patients and Methods. PE patients, diagnosed with computer tomography pulmonary angiography, were included from two ICUs and were categorized into groups: group 1 high-risk patients and group 2 intermediate/low-risk patients. Results. Fifty-six patients were included. Of them, 41 (73.2%) were group 1 and 15 (26.7%) were group 2. When compared to group 2, need for vasopressor therapy (0 vs 68.3%; p < 0.001) and need for invasive mechanical ventilation (6.7 vs 36.6%; p = 0.043) were more frequent in group 1. The treatment of choice for group 1 was thrombolytic therapy in 29 (70.7%) and anticoagulation in 12 (29.3%) patients. ICU mortality for group 1 was 31.7% (n = 13). In multivariate logistic regression analysis, APACHE II score >18 (OR 42.47 95% CI 1.50–1201.1), invasive mechanical ventilation (OR 30.10 95% CI 1.96–463.31), and thrombolytic therapy (OR 0.03 95% CI 0.01–0.98) were found as independent predictors of mortality. Conclusion. In high-risk PE, admission APACHE II score and need for invasive mechanical ventilation may predict death in ICU. Thrombolytic therapy seems to be beneficial in these patients.
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Ghanem MK, Makhlouf HA, Hasan AAA, Alkarn AA. Acute pulmonary thromboembolism in emergency room: gray-scale versus color doppler ultrasound evaluation. CLINICAL RESPIRATORY JOURNAL 2016; 12:474-482. [PMID: 27608416 DOI: 10.1111/crj.12547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 07/26/2016] [Accepted: 08/12/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary thromboembolism (PTE) remains under-diagnosed fatal disease at emergency units suggesting the need for alternative, easy, and noninvasive bedside diagnostic approaches. OBJECTIVES To determine the diagnostic role of gray-scale and color Doppler transthoracic ultrasonography (TUS) in patients with PTE. PATIENTS AND METHODS Blinded to 64 multi-detectors CT pulmonary angiography (MDCTPA) examination as a gold standard, 60 patients with clinically suspected PTE underwent gray-scale and then color Doppler TUS examination. Results were compared and diagnostic accuracy of TUS was assessed. RESULTS Forty patients proved to have PTE by MDCTPA. TUS showed typical lesions in 33 patients with the mean of 2 lesions per patient. Most lesions were hypoechoic, wedge- shaped, and pleural- based and the majority (80%) was located in the lower lobes. Consolidation with little perfusion was detected by Color Doppler ultrasound in 97% of lesions. Isolated central PTE was significantly higher in TUS negative patients. For gray -scale TUS, sensitivity, specificity, positive and negative predictive values and accuracy were 82%, 90%, 94%, 72%, and 85%. Meanwhile the sensitivity, specificity, positive and negative predictive values and accuracy of color Doppler TUS were 80%, 95%, 97%, 70% and 87%, respectively. CONCLUSION TUS is a reliable diagnostic bedside test for PTE in critically ill and immobile patients. Adding color Doppler to gray-scale TUS increases the specificity and accuracy and consequently the confidence in the diagnosis of peripheral pulmonary infarctions and differentiates them from other pulmonary lesions that allow initiation of anticoagulants.
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26
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Which out-of-hospital cardiac arrest patients should be thrombolysed? Am J Emerg Med 2016; 34:916-7. [DOI: 10.1016/j.ajem.2016.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 11/20/2022] Open
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Baha A, Mehmet Baha R, Eroglu V, Logoglu A, Kemal Icen Y. Massive Pulmonary Embolism Following Varicose Vein Surgery That Was Successfully Treated with Thrombolytic Therapy. Intern Med 2016; 55:1907-10. [PMID: 27432101 DOI: 10.2169/internalmedicine.55.5068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The risk of massive pulmonary thromboembolism (PTE) secondary to varicose vein surgery is very low. There are only two cases which have been reported regarding massive PTE occurring after varicose vein surgery. We herein present the case of a woman who had suffered from chest pain. A short period following her admission to the emergency department, she had cardiac arrest and was subsequently diagnosed with massive PTE. Thrombolytic therapy was administered and her clinical status dramatically improved thereafter. Massive PTE may occur after minor surgical procedures, and thrombolytic therapy can safely be administered after cardiopulmonary resuscitation.
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Affiliation(s)
- Ayse Baha
- Department of Pulmonary Medicine, Osmaniye National Hospital, Turkey
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28
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Abstract
Pulmonary embolism (PE) is a common diagnosis in critical care. Depending on the severity of clot burden, the clinical picture ranges from nearly asymptomatic to cardiovascular collapse. The signs and symptoms of PE are nonspecific. The clinician must have a high index of suspicion to make the diagnosis. PE is risk stratified into 3 categories: low-risk, submassive, and massive. Submassive PE remains the most challenging with regard to initial and long-term management. Little consensus exists as to the appropriate tests for risk stratification and therapy. This article reviews the current literature and a suggested approach to these patients.
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Affiliation(s)
- Laurence W Busse
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Jason S Vourlekis
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
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Comparison of LMWH versus UFH for hemorrhage and hospital mortality in the treatment of acute massive pulmonary thromboembolism after thrombolytic treatment : randomized controlled parallel group study. Lung 2014; 193:121-7. [PMID: 25351610 DOI: 10.1007/s00408-014-9660-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 10/11/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Current guidelines recommend the use of low molecular weight heparin (LMWH) for most haemodynamically stable patients with pulmonary thromboembolism (PTE), however, it is not clear whether LMWH is preferable to unfractionated heparin (UFH) for the treatment of massive PTE. We aimed to compare the use of LMWH versus UFH after thrombolytic treatment in the management of acute massive PTE for hemorrhage and hospital mortality. METHODS The study, a randomized, single center, parallel design trial, included the patients who had confirmed the diagnosis of massive PTE according to clinical findings and computerized thorax angiography and no contraindication to the treatment between January 2011 and October 2013. After thrombolytic treatment, the patients assigned to therapy with LMWH or UFH. Any hemorrhage, major hemorrhage, and hospital mortality were assessed. RESULTS A total of 121 patients, 71 female (58.7 %) and 50 male (41.3 %), who had massive PTE with an average age 62.6 ± 15.7 (ranges 22-87) were included for analyses in the study. They were allocated to either LMWH (n = 60) or UFH (n = 61) group. Although the occurrence of any adverse event (21.7 vs 27.9 %) and each individual type of adverse event were all lower in the LMWH group compared to UFH group (6.7 vs 11.5 %, 3.3 vs 9.8 %, and 15.0 vs 19.7 % for death, major hemorrhage, and any hemorrhage, respectively), the differences were not statistically significant. CONCLUSIONS Our findings suggest that LMWH might be a better option in the management of the patients with massive PTE. Multi-center larger randomized controlled trials are required to confirm our results.
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Swaminathan A. Massive and submassive pulmonary embolism: diagnostic challenges and thrombolytic therapy. Acad Emerg Med 2014; 21:208-10. [PMID: 24438552 DOI: 10.1111/acem.12301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Successful treatment of fulminant pulmonary embolism with extracorporeal life support and simultaneous systemic thrombolytic therapy after 1 h of cardiopulmonary resuscitation. Gen Thorac Cardiovasc Surg 2013; 63:664-6. [DOI: 10.1007/s11748-013-0338-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 10/18/2013] [Indexed: 10/26/2022]
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Comert SS, Caglayan B, Akturk U, Fidan A, Kıral N, Parmaksız E, Salepci B, Kurtulus BAO. The role of thoracic ultrasonography in the diagnosis of pulmonary embolism. Ann Thorac Med 2013; 8:99-104. [PMID: 23741272 PMCID: PMC3667453 DOI: 10.4103/1817-1737.109822] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 12/23/2012] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES: The diagnosis of pulmonary embolism (PE) is still a problem especially at emergency units. The purpose of study was to determine the diagnostic accuracy of thoracic ultrasonography (TUS) in patients with PE. METHODS: In this prospective study, 50 patients with suspected PE were evaluated in Department of Pulmonary Diseases of a Training and Reasearch Hospital between January 2010 and July 2011. At the begining, TUS was performed by a chest physician, subsequently for definitive diagnosis computed tomography pulmonary angiography were performed in all cases as a reference method. Other diagnostic procedures were examination of serum d-dimer levels, echocardiography, and venous doppler ultrasonography of the legs. Both chest physician and radiologist were blinded to the results of other diagnostic method. Diagnosis of PE was suggested if at least one typical pleural-based/subpleural wedge-shaped or round hypoechoic lesion with or without pleural effusion was reported by TUS. Presence of pure pleural effusion or normal sonographic findings were accepted as negative TUS for PE. RESULTS: PE was diagnosed in 30 patients. It was shown that TUS was true positive in 27 patients and false positive in eight and true negative in 12 and false negative in three. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of TUS in diagnosis of PE for clinically suspected patients were 90%, 60%, 77.1%, 80%, and 78%, respectively. CONCLUSIONS: TUS with a high sensitivity and diagnostic accuracy, is a noninvasive, widely available, cost-effective method which can be rapidly performed. A negative TUS study cannot rule out PE with certainty, but positive TUS findings with moderate/high suspicion for PE may prove a valuable tool in diagnosis of PE at bedside especially at emergency setting, for critically ill and immobile patients, facilitating immediate treatment decision.
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Affiliation(s)
- Sevda Sener Comert
- Department of Pulmonary Diseases, Dr. Lütfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey
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Zochios VA, Keeshan A. Pulmonary Embolism in the Mechanically-Ventilated Critically Ill Patient: Is it Different? J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pulmonary embolism (PE) confers significant in-hospital morbidity and mortality, and critically ill patients remain at risk for venous thromboembolism despite thromboprophylaxis. Recognition of the clinical manifestations and immediate management of PE are of paramount importance. Despite diagnostic advances, PE is often undiagnosed and untreated in patients receiving mechanical ventilation, as these patients do not exhibit the common clinical features of the condition, making the diagnosis very challenging. Computed tomographic pulmonary angiography is probably the reference standard for the diagnosis of acute PE in the haemodynamically stable, ventilated patient. In the setting of circulatory collapse, bedside echocardiography may be used to risk stratify these patients, based on the presence or absence of right ventricular dysfunction, and guide further management. Treatment options include anticoagulation alone, anticoagulation plus thrombolysis, surgical or catheter embolectomy. Inotropes, vasopressors and pulmonary artery vasodilators may be considered after initial resuscitation of the right ventricle. Few studies have focused on estimating the prevalence of PE among mechanically-ventilated intensive care unit (ICU) patients and there is notable lack of data assessing predictive factors, prevention, diagnostic strategy and management of PE in the ICU setting.
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Affiliation(s)
- Vasileios A Zochios
- ACCS Anaesthesia Core Trainee, East Midlands (South) School of Anaesthesia, University Hospitals of Leicester NHS Trust
| | - Alex Keeshan
- Consultant Intensivist, University Hospitals of Leicester NHS Trust, Leicester General Hospital
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Diagnosis in a Heart Beat, or Focused Echocardiography: How Should it be Used in the Emergency Room? CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9161-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Mitchell AM, Jones AE, Tumlin JA, Kline JA. Prospective study of the incidence of contrast-induced nephropathy among patients evaluated for pulmonary embolism by contrast-enhanced computed tomography. Acad Emerg Med 2012; 19:618-25. [PMID: 22687176 DOI: 10.1111/j.1553-2712.2012.01374.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Contrast-enhanced computed tomography (CECT) of the pulmonary arteries (CTPA) has become the mainstay to evaluate patients with suspected pulmonary embolism (PE) and is one of the most common CECT imaging studies performed in the emergency department (ED). While contrast-induced nephropathy (CIN) is a known complication, this risk is not well defined in the ED or other ambulatory setting. The aim of this study was to define the risk of CIN following CTPA. METHODS The authors enrolled and followed a prospective, consecutive cohort (June 2007 through January 2009) of patients who received intravenous (IV) contrast for CTPA in the ED of a large, academic tertiary care center. Study outcomes included 1) CIN defined as an increase in serum creatinine (sCr) of ≥ 0.5 mg/dL or ≥ 25%, 2 to 7 days following contrast administration; and 2) severe renal failure defined as an increase in sCr to ≥ 3.0 mg/dL or the need for dialysis within 45 days and/or renal failure as a contributing cause of death at 45 days, determined by the consensus of three independent physicians. RESULTS A total of 174 patients underwent CTPA, which demonstrated acute PE in 12 (7%, 95% confidence interval [CI] = 3% to 12%). Twenty-five patients developed CIN (14%, 95% CI = 10% to 20%) including one with acute PE. The development of CIN after CTPA significantly increased the risk of the composite outcome of severe renal failure or death from renal failure within 45 days (relative risk = 36, 95% CI = 3 to 384). No severe adverse outcomes were directly attributable to complications of venous thromboembolism (VTE) or its treatment. CONCLUSIONS In this population, CIN was at least as common as the diagnosis of PE after CTPA; the development of CIN was associated with an increased risk of severe renal failure and death within the subsequent 45 days. Clinicians should consider the risk of CIN associated with CTPA and discuss this risk with patients.
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Affiliation(s)
- Alice M Mitchell
- Department of Emergency Medicine, Carolinas HealthCare System, Charlotte, NC, USA
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