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PubMed2003

Impending paradoxical embolus: a case report and review of the literature.

A case of a 43-year-old man with impending paradoxical embolism (IPE) is described. The patient initially presented with pulmonary embolism and was diagnosed with an IPE on transthoracic and transesophageal echocardiography. He was subsequently treated with heparin and thrombolysis. A comprehensive review of the English literature over the past 20 years identified 60 previously reported cases of IPE. This report discusses the main clinical features, the diagnostic role of echocardiography and the outcome of medical and surgical treatment strategies in patients with IPE. Based on the literature to date, we recommend that patients with impending paradoxical embolism be treated with initial systemic heparinization followed by emergent surgical embolectomy if the surgical risks are acceptable.

Adult↗

PubMed2003

Acute embolic occlusion of the superior mesenteric artery: a case report and discussion of management.

INTRODUCTION: We present a case of acute embolus to the superior mesenteric artery (SMA). CLINICAL PICTURE: A 70-year-old gentleman with atrial fibrillation complained of colicky abdominal pain with clinical signs of tenderness and mild guarding. TREATMENT AND OUTCOME: Laparotomy revealed extensive bowel ischaemia but no overt infarction. The SMA was occluded by an embolus at the root of the mesentery and balloon catheter embolectomy was carried out at once. Bowel resection was deferred in order to allow clear demarcation of gangrene to avoid sacrificing unnecessary length. At second look laparotomy, 1.2 m of bowel from mid-jejunum to mid-ileum was resected, salvaging about 1 m of previously dusky small and large bowel. CONCLUSION: This case illustrates the importance of accurate history taking, the role of early intervention and the usefulness of a second look laparotomy in cases of mesenteric ischaemia to minimise the extent of bowel resection.

Aged↗

PubMed2003

[Incidence and clinical characteristics of perioperative pulmonary thromboembolism under the use of intermittent pneumatic compression as a preventive measure].

Pulmonary thromboembolism (PTE) is a crucial complication characterized by rapid onset and a high mortality rate. There are few reports concerning perioperative incidence of PTE and deep vein thrombosis (DVT) among Japanese population. All surgical patients excluding young patients for minor surgery were equipped with calf- or thigh-length intermittent pneumatic compression (IPC) device as a DVT preventive method during the period of immobility. Incidence and clinical characteristics of perioperative PTE and DVT under the use of IPC device were analyzed at Kobe University Hospital. One patient developed DVT and four patients developed PTE among the 6500 surgical cases. All patients with DVT or PTE were 66 years or older, and all patients were diagnosed by computer tomography, venography and pulmonary angiography between 7 to 14 days after each operation. One patient was surgically treated by embolectomy and removal of intraarterial thrombus, and others were treated with thrombolysis, anticoagulants and placement of vena cava filters. For prevention of DVT and PTE, other preventive methods such as anticoagulants and prolonged application of IPC should be necessary.

Age Factors↗

PubMed2004

[Single lung ventilation in a pediatric patient using a Fogarty catheter with a hollow center].

A six-year-old boy with left pulmonary segmentation was scheduled for video-assisted thoracoscopic left lower lobectomy. Because he had had repeated pneumonia, and the operation needed good surgical visualization, we used a 4 Fr Fogarty catheter with a hollow center (Fogarty Thru-Lumen Embolectomy: Baxter) as a bronchial blocker for one-lung ventilation. The Fogarty catheter was advanced to the left mainstem bronchus through the 5.5 mmID standard tube under direct view with a fiberscope. The one lung anesthesia was successfully performed. We could easily deflate the lung and drain the blood and sputum from the blocked lung. Postoperatively, there was no evidence of atelectasis of the lungs. The post-operative course was uneventful. The Fogarty catheter with a hollow center is useful for one lung anesthesia for pediatric patients. It is easy to insert and fix. And, we can easily deflate and drain the blocked lung.

Anesthesia, General↗

PubMedDate not supplied

Primary cardiac tumors: surgical experience and follow-up.

BACKGROUND: Primary cardiac tumors are rare. There are only a few reports of such tumors from India. METHODS AND RESULTS: We report our experience with 34 patients with primary cardiac tumors operated on at our institute between December 1989 and October 2001. The study group comprised 16 males and 18 females with a mean age of 40.05 +/- 13.06 years (range 7-65 years). The predominant symptoms were breathlessness and congestive heart failure. In addition, 1 patient presented with peripheral embolism with impending limb ischemia that necessitated emergency embolectomy. Echocardiography was confirmatory in the diagnosis of all the benign tumors, whereas the malignant tumors were incidentally found during surgery. All the patients survived the operation. Complete resection of the tumor was possible only in benign tumors; however, malignant tumors were partly removed to relieve obstruction. All the excised benign tumors showed no recurrence on a mean follow-up of 54.78 +/- 31.30 months (range 3-108 months). Myxoma was found in 31 patients, left ventricular fibroma in 1, and leiomyosarcoma in 2. Both the patients with malignant tumors developed recurrence postoperatively, and succumbed to extensive distant metastases. CONCLUSIONS: The long-term outcome of surgery was excellent in patients with benign cardiac tumors. However, malignant tumors had an unchanged prognosis, although symptomatic relief was achieved.

Adolescent↗

PubMed2004

Methods of lung separation.

During video assisted thoracoscopy (VAT) the lung should be well collapsed. When the separation of the lungs is strictly indicated, use of difficult tube, such as double lumen tube (DLT) or Univent tube cannot be avoided, despite the presence of a difficult airway. If a patient has a recognized difficult airway, awake intubation with fiberoptic bronchoscopy can be attempted with Univent tube, DLT or with single lumen tube (SLT). If failure to provide a lung separation could result in a life-threatening situation, there are 2 possibilities to provide a one lung ventilation (OLV) when a SLT is in place: a tube exchanger can be used to position a DLT or a bronchial blocker (BB) can be directed through the SLT in the bronchus. The most used BB is a Fogarty embolectomy catheter. More recently a new BB has been approved by FDA: the Cohen Flexitip Endobronchial Blocker. The most important feature of the blocker is its flexible soft tip that allows to direct it in the desired bronchus. The blocker contains a lumen that allows suctioning of the lung to facilitate deflation, suctioning of secretion and insufflation of oxygen. In summary, the clinician should be able to master different methods of lung separation and make him/her self familiar with the available devices.

Anesthesia↗

PubMed1992

[Report of three cases of emergency surgical salvage for acute pulmonary embolism].

Pulmonary embolism (PE) is one of the increasing diseases in Japan, which is aggravated rapidly and early diagnosis is necessary to improve its prognosis. We experienced three cases of successful surgical salvage. It is emphasized that the Doppler ultrasonic echocardiography plays important part in diagnosing PE early and noninvasively. Namely, it shows a appearance of acute cor pulmonale, and is usually able to guess the pulmonary artery pressure by using the simplified formula of Bernoulli's equation. We believe that the surgical pulmonary embolectomy under the cardiopulmonary bypass should be immediately considered in case of unsatisfactory conservative thrombolytic therapy.

Acute Disease↗

PubMed1989

Indications for thrombolytic therapy in acute pulmonary embolism.

Pulmonary thromboembolism is commonly misdiagnosed and is associated with significant morbidity and mortality both in the early and late stages. A major cause of late morbidity is chronic pulmonary hypertension. Although the incidence of chronic thromboembolic pulmonary hypertension is unknown, there is anatomic and physiologic evidence that it is responsible for a significant degree of the late morbidity and mortality following acute pulmonary embolism. In the absence of underlying cardiopulmonary disease, pulmonary artery pressure is a useful indicator of the severity of acute pulmonary embolism and of the patient's prognosis. Thrombolytic agents accelerate the lysis of the thromboemboli, offer an excellent alternative to emergency embolectomy, and are likely to decrease the incidence of chronic pulmonary hypertension. All currently available agents have been shown to be effective and have similar bleeding-complication profiles. In this review, we discuss the natural history and pathophysiology of pulmonary thromboembolic disease, as well as applications of thrombolytic therapy in the treatment of acute pulmonary embolism.

Journal Article↗

PubMed1992

Peripartum cardiomyopathy and arterial embolism.

A severely pre-eclampic patient developed peripartum cardiomyopathy and bilateral femoral emboli. Medical therapy for cardiac failure was commenced prior to delivery by Caesarean Section. Bilateral femoral embolectomy was performed on the sixth postpartum day.

Adult↗

PubMedDate not supplied

Intraoperative massive pulmonary tumor embolism from clear cell sarcoma in the retroperitoneum: successful treatment using cardiopulmonary bypass.

Malignant neoplasms rarely extend into the inferior vena cava and up to the right side of the heart. Although massive pulmonary tumor embolism occurs relatively rarely, it can be a catastrophic problem. Intraoperative pulmonary tumor embolism and cardiac arrest occurred in a 68-year-old woman while dissecting the inferior vena cava to resect a pararenal tumor extending into the retrohepatic inferior vena cava. Abrupt arterial hypotension, tachycardia, and increased central venous pressure lead to the diagnosis of massive pulmonary tumor embolism. Emergency cardiopulmonary bypass was commenced under profound hypothermia and cardiac arrest. The tumors in the main pulmonary artery were extracted, and fragments of remnant tumor were retrieved by a vascular endoscope, a Fogarty catheter, and milking of the lung. Following embolectomy, the tumor in the retrohepatic to infrarenal inferior vena cava was removed and the primary tumor together with the infrarenal inferior vena cava was resected under hepatic vascular exclusion and partial cardiopulmonary bypass. The inferior vena cava below the renal veins was not reconstructed. The patient recovered with slight retrograde amnesia. A postoperative pulmonary perfusion scintigram showed no defect in the pulmonary circulation. She is well now 8 months after surgery. Safe prevention measures should be accomplished as a part of the perioperative management of patients with inferior vena cava tumor thrombus that may be fragile, and cardiopulmonary bypass should always be stand-by on surgery.

Aged↗

PubMed2004

[Experiences in surgical management of acute arterial occlusions of the lower limb in the course of 20 years].

INTRODUCTION: In Hungary surgeons perform every year more then 2000 operations for treatment of acute arterial occlusion. Because of the advanced age and poor general condition of these patients, the postoperative mortality and complication rate is considerable. AIM: Authors analyzed changes in the etiology and therapy of acute arterial occlusions of lower limb in the last 20 years in a retrospective study. PATIENTS AND METHODS: 563 patients were operated on with acute arterial occlusion of lower extremities from 1983 to 2002 by the authors. Patients with vascular surgery in their history were excluded from this study. Student's two-samples "t"-test, chi2- and Fisher's exact test were used in Statistica 6.0 for statistics. RESULTS: Period of 1983-1992 compared to period of 1993-2002 they found increased rate of occlusions caused by thrombosis (35 vs. 46%, p < 0.01) and increased number of acute vascular reconstructions performed with indication of acute thrombosis (17.6 vs. 47.0%, p < 0.001). Mortality was higher in patients operated with embolism than in patients with thrombosis (17.7 vs. 11.6%, p < 0.01), but the ratio of postoperative amputation following embolectomy was lower than following thrombectomy (5.0 vs. 16.0%, p < 0.01). Thrombectomy itself could solve the occlusion caused by thrombosis only in 50% of cases. Results of reoperations following unsuccessful thrombectomies are very poor. Amputation was necessary in 6.8% (in 5 cases of 74 patients) after primary reconstructions, but in 28.6% (in 14 cases of 49 patients) after reoperations. There was no significant difference in postoperative mortality among primary reconstructed, reoperated and conservatively treated groups. CONCLUSIONS: By author's experience, in cases of acute occlusion caused by thrombosis as a complication of chronic obliterative arterial disease, basic cause of occlusion should be searched for and--if conditions are suitable--procedure should be extend to vascular reconstruction.

Acute Disease↗

PubMed1992

[Trash foot following abdominal aortic surgery].

Peripheral embolism from dislodgement of intraarterial debris can convert successful surgery of the abdominal aorta into tragedy. An embolic shower from such surgery, often containing cholesterol, can result in forefoot or toe ischemia referred to as "trash foot." The incidence of this early complication is reported as 7-29%, but is believed to be even higher. Prevention and treatment includes heparin, embolectomy, lumbar sympathectomy, aspirin, rheomacrodex and prostaglandins. 3 such patients, 2 men aged 62 and 69, respectively, and a woman of 72, are reported. In 2 of the cases below-knee amputation was required, while the third patient died.

Aged↗

PubMed1992

Chronic thromboembolic pulmonary hypertension: clinical picture and surgical treatment.

Chronic, major vessel thromboembolic pulmonary hypertension (CTEPH), is an uncommon condition which, in the past, was an autopsy curiosity. Advances in diagnostic approaches, surgical techniques and postoperative management have transformed this disorder into a potentially curable form of pulmonary hypertension. The predominant symptom is unexplained dyspnoea on exertion. In patients with this complaint, CTEPH should be considered. Numerous pitfalls exist along the diagnostic path. Perfusion lung scans point toward the diagnosis, but often underestimate the extent of central arterial obstruction. Pulmonary angiography is the key diagnostic procedure, but the many patterns of thrombus organization-recanalization require a base of experience for proper interpretation. Criteria for selection of patients for surgery are evolving, but assurance of thrombus accessibility to surgery is critical. Surgical thromboendarterectomy bears no resemblance to acute pulmonary embolectomy. Recognition of thrombus (versus normal intima), meticulous dissection and a bloodless surgical field are essential for adequate restoration of pulmonary vascular patency. Multiple complications may arise postoperatively, and detailed attention to these is required for patient survival. With a co-ordinated, multi-specialty team effort, however, haemodynamic and clinical outcomes have been rewarding and persist long-term. Surgical mortality should steadily decline with such a co-ordinated effort, as well as earlier diagnosis and advances in surgical and postoperative management techniques.

Angiography↗

PubMed2005

[Assessment of early complications in patients with abdominal aortic aneurysm after endovascular operations].

UNLABELLED: During past few years endovascular procedures at patients with abdominal aorta aneurysm (AAA) have widely replaced surgical treatment. The number of patients being operated by the use of this method has been growing. AIM OF THE STUDY: The aim of this study is to estimate early complications in patients with AAA treated by the use of bifurcated aortic stent-grafts. MATERIAL AND METHODS: Between the May 2002 and April 2003, 42 patients were qualified to endovascular operations (of the average age of 65). All of them represented a group of high operative risk patients. Patients were operated in epidural anesthesia (n=36) and in general intravenous anesthesia (n=6). In all the patients angiography was performed right after the operation to estimate the efficacy of treatment. The follow-up examinations proceeded after 1, 3, and 6 months. RESULTS: During the hospitalization, which lasted 7 days on average, clotting in one of the crura of the stent-graft in common iliac artery with the necessity of embolectomy, the some patient had to have an additional crossover by-pass implanted. There were also observed certain post-hospitalization complications which contained: a) clotting of stent-graft leg in one case, b) leak type I which demanded implantation of additional element of stent-graft in one case c) small leaks type I in 2 cases and type II in 2 cases which did not demand any further intervention, the type II leaks were observed in 3 cases 6 months after the operation, d) the increase of parietal circular thrombus inside the main part of the stent-graft in one case, e) complaints connected with the internal iliac artery occlusion were declared by one patient. CONCLUSIONS: The early results of AAA treatment by the use of bifurcated stent-grafts are satisfactory and connected with low rate of complications. Most of the early complications is connected with wrong qualification of patients, improper stent-graft choice and technical errors during the operation. Constant, periodical follow-up examinations (USG, angio CT) are necessary to estimate the late results.

Aged↗

PubMed2005

[Treatment of rupture of the infrarenal aneurysm of the abdominal aorta].

One of the 15 most common cause of death in USA is rupture of the aneurism of the abdominal aorta. In 8-10% cases patients have no previous symptoms of aneurysm of the abdominal aorta, and they are coming to thr hospital with clinical picture of rupture This paperwork presents one such case. After assuming the data of basic lab. findings, clinical finding, and diagnostic procedures, an urgent operation was indicated. A resection of aneurismaticly changed infrarenal portion of abdominal aorta and its reconstruction with synthetic graft was done. In postoperative course we noticed cardiac decompensation followed by acute ischaemic attac of the left lower limb. It was solved by urgent disobliterative procedure--embolectomy in local anestesion. Patient was discharged after 21 day in good general condition.

Aged↗

PubMed2005

[Diagnosis and treatment of pulmonary hypertension: current concepts].

Pulmonary hypertension is diagnosed when pulmonary artery pressure is above 25 mm Hg at rest and 30 mm Hg during exercise; it can be primary or secondary if complicates some basic disease. Untreated pulmonary hypertension leads to progressive right ventricular failure and is associated with high risk of sudden death. Necessary components of management of any variant of pulmonary hypertension are limitation or avoidance of isometric exercise, yearly influenza and pneumococcal vaccination, and active treatment of pulmonary infections. Drug therapy is aimed at three main pathophysiological mechanisms: thrombosis, vasoconstriction and proliferation. Anticoagulants and vasodilators (calcium antagonists, nitric oxide, and prostacyclin or its derivatives) constitute basis of treatment of pulmonary hypertension. However principally novel drugs such as endothelin receptor antagonists has been also suggested. Diuretics, digitalis and oxygen are added when necessary. Gene therapy has been considered as potential future intervention. Surgical approaches comprise mitral valvuloplasty or mitral valve replacement and embolectomy in case of major pulmonary artery branch thromboembolism. In cases of other treatment failure lung or heart-lung transplantation is appropriate but can not widely used.

Anticoagulants↗

PubMed1992

[A case report of a massive pulmonary tumor embolism occurring during surgery for renal cell carcinoma].

A 59-year-old man, who suffered a massive pulmonary tumor embolism during surgery for renal cell carcinoma with vena caval invasion, was treated by emergency pulmonary embolectomy using cardiopulmonary bypass. Renal cell carcinoma occasionally extends into the inferior vena cava (IVC) as a tumor thrombus. In such patients, removal of the tumor thrombus from the IVC has to be performed in addition to radical nephrectomy. However, the massive pulmonary tumor embolism is a major potential hazard during radical surgical resection. To prevent intraoperative pulmonary embolisms from occurring, scheduled use of cardiopulmonary bypass with the cooperation of cardiovascular surgeons is recommended.

Carcinoma, Renal Cell↗

PubMed2005

Real-time detection of migratory thrombi by transesophageal echocardiography in a patient undergoing thrombectomy.

We report a 44-year-old male patient who sustained a right atrial (RA) thrombosis with evolvement into right pulmonary artery embolism in consequence of placement of a temporary pacing lead and was successfully treated with surgical thrombectomy under the guidance of perioperative transesophageal echocardiography (TEE). Because of intermittent complete atrioventricular block he therefore underwent implantation of a transvenous temporary pacing. On the ensuing day a large mass was incidentally found echographically in the RA suggestive of a large thrombus. Immediate surgical removal of the mass was indicated. During the emergent open-heart surgery the mass in RA dehiscenced with fragments migrating to the right main pulmonary artery, and exploration of both the RA and right pulmonary artery was done. This migratory mass, which proved to be a fresh thrombus, was surgically removed. The cardiopulmonary bypass was then terminated and the spontaneous contraction of heart was resumed. However, another mass lesion was found in RA on the TEE screen just following the removal of the problematic transvenous pacing wire. The right atrium was thus re-opened immediately and the second thrombus was cleared. Over the on-going surgical course no further abnormal echogenic objects were visible in the cardiac chambers. It is perceivable that transvenous pacing might cause thrombois or dislodgement and dehiscence of thrombi already in existence in the cardiac chamber. Careful and continuous intraoperative surveillance with echocardiography over a patient who is undergoing cardiac embolectomy is quite important in detecting thrombus escape and residual thrombi during surgery.

Adult↗