Pulmonary embolectomy for acute massive pulmonary thromboembolism

Acute pulmonary thromboembolism is a frequently lethal and acute-onset in-hospital complication after surgery. Absolute indications for surgical embolectomy are acute massive pulmonary embolism with deep shock, refractory circulatory collapse, and continuous hypoxemia. Although thrombolytic therapy is indicated for patients with pulmonary thromboembolism with right ventricular overload, it is contraindicated for patients after major surgery or with stroke due to the high risk of rebleeding. Therefore surgical embolectomy should be considered in those patients. Pulmonary embolectomy relieves the right ventricular overload, and immediate restoration of right ventricular function contributes to the recovery of hemodynamics. A recent study revealed improved outcome for massive pulmonary embolism with early diagnosis with multidetector-row computed tomography, risk stratification using echocardiography, and surgical embolectomy. Surgical pulmonary thromboembolectomy should be considered for critically ill patients with massive pulmonary thromboembolism.     

Symptomatic pulmonary embolism after outpatient arthroscopic procedures of the knee: the incidence and risk factors in 418,323 arthroscopies

Pulmonary embolism is a serious complication after arthroscopy of the knee, about which there is limited information. We have identified the incidence and risk factors for symptomatic pulmonary embolism after arthroscopic procedures on outpatients. The New York State Department of Health Statewide Planning and Research Cooperative System database was used to review arthroscopic procedures of the knee performed on outpatients between 1997 and 2006, and identify those admitted within 90 days of surgery with an associated diagnosis of pulmonary embolism. Potential risk factors included age, gender, complexity of surgery, operating time defined as the total time that the patient was actually in the operating room, history of cancer, comorbidities, and the type of anaesthesia. We identified 374,033 patients who underwent 418,323 outpatient arthroscopies of the knee. There were 117 events of pulmonary embolism (2.8 cases for every 10 000 arthroscopies). Logistic regression analysis showed that age and operating time had significant dose-response increases in risk (p < 0.001) for a subsequent admission with a pulmonary embolism. Female gender was associated with a 1.5-fold increase in risk (p = 0.03), and a history of cancer with a threefold increase (p = 0.05). These risk factors can be used when obtaining informed consent before surgery, to elevate the level of clinical suspicion of pulmonary embolism in patients at risk, and to establish a rationale for prospective studies to test the clinical benefit of thromboprophylaxis in high-risk patients.     

Pulmonary emboli: the differential diagnosis dilemma

Pulmonary embolism is a rare but serious medical condition, with an estimated mortality of 5% to 20%. Many patients receiving physical therapy may be at risk for developing pulmonary embolism, especially after periods of immobilization or surgery. Patients presenting with dyspnea, chest pain, or tachypnea, particularly after trauma or surgery, have an increased likelihood of pulmonary embolism. Clinical prediction rules have been developed, which can aid the practitioners in assessing the risk a patient has for developing pulmonary embolism. The present clinical commentary discusses the existing evidence for screening patients for pulmonary embolism. To illustrate the importance of the screening examination, a patient is presented who was referred to physical therapy 5 days after cervical discectomy and fusion. This patient was subsequently referred for medical evaluation and a confirmatory diagnosis of pulmonary embolism.     

Pulmonary Embolism Following Outpatient Vasectomy

Venous thromboembolic events have several known major risk factors such as prolonged immobilization or major surgery. Pulmonary embolism has rarely been reported after an outpatient vasectomy was completed. We present the rare case of a healthy 32-year-old Caucasian male with no known risk factors who presented with pleuritic chest pain 26 days after his outpatient vasectomy was performed. Subsequently, he was found to have a pulmonary embolism as per radiological imaging. We explore the association between outpatient vasectomies and venous thromboembolic events. A review of the literature is also included.Key Words: Vasectomy, Pulmonary embolism, Thrombophlebitis, Thromboembolism risk factors     

普通外科医师如何识别和紧急救治肺动脉栓塞

肺动脉栓塞(PE)在普通外科病人中并不少见。普通外科医师有必要掌握诊断和治疗的基本知识,提高及时识别PE能力。在紧急抢救时,早期处理和快速启动会诊系统非常重要。发现病人存在PE的可疑临床表现和体征时,监测血D-二聚体,如果阳性启动Wells评分,当评分≥2分时,进行相关确诊检查。高度疑诊和确诊的高危PE的紧急救治需要区别对待,前者难度和风险更大,需要多学科团队的快速联合干预。     

脊柱手术后并发肺栓塞11例临床分析

目的分析脊柱手术后并发肺栓塞的临床特点,探讨早期诊断、治疗方法。方法1995年1月至2006年5月,在我院接受脊柱手术患者10993例,其中术后出现肺栓塞患者11例。回顾性分析该11例患者的临床特点及诊断、治疗方式。结果脊柱术后肺栓塞占同期我院脊柱手术总数的0．1％;出现肺栓塞的时间为术后5～14d（平均9．8d）,患者可见呼吸困难、心悸、胸痛、咯血等特征性肺栓塞症状;本组死亡5例,死亡率45．5％。早期使用肺动脉造影明确诊断、早期经肺动脉导管介入治疗可以显著降低死亡率。结论肺栓塞是脊柱手术后的严重并发症,术后1～2周是致死性肺栓塞的高危时段,死亡率高;肺动脉造影与介入治疗在早期诊断、治疗中占有重要地位。     

骨科手术后肺栓塞的诊断与治疗

目的：探讨骨科手术后肺栓塞的诊断与治疗。方法：从1998年6月－2002年4月共治疗骨科手术后肺栓塞（PE）5例，男1例，女4例。年龄40－78岁，平均63岁。手术类别：人工股骨头置我术、人工全髋置换术、右肱骨外科颈骨折内固定术、右肱骨肿瘤切除术以及多发骨折内固定术各1例。肺栓塞发生时间3－14d，平均10d。诊断依据：呼吸困难和气短、动脉血敢PO2下降和低碳酸血症、ECT－肺通气灌注静态显像异常等。治疗：5例均行抗凝治疗，其中3例行栓体舒（t-PA)溶栓治疗。结果：本组5例中3例诊断及时，行溶栓治疗后痊愈出院，2例抢救无效死亡。结论：必须提高对肺栓塞的认识，才能早期发现、早期治疗、减少和避免严重后果。急性肺栓塞的治疗包括溶栓治疗、抗凝治疗、介入治疗和外科手术等。肺栓塞最好的治疗还是预防。特别是预防下肢深静脉血栓的发生至关重要。     

Perioperative pulmonary embolism: a nationwide survey in Japan]

Pulmonary embolism is a leading cause of death and morbidity in the perioperative period. To obtain a contemporary overview of the epidemiology of acute pulmonary embolism, a questionnaire was mailed to anesthesia department chair-persons at 179 hospitals in Japan. The 158 cases were reported from the 88 hospitals. The cause of embolism was thromboembolism 127, gas 13, fat 9, amniotic fluid 4 and tumor 3. The mortality rate for patients with thromboembolism was high (29%). Dyspnea was the most frequent symptom (60%) and hypotension was the most frequent clinical sign (54%). The signs which suggested massive pulmonary embolism, such as hypotension, cyanosis (53%), syncope (39%) and cardiac arrest (29%) were frequently seen. Most of the pulmonary embolisms occurred during the operation and within 7 days after the operation. The high risk factors associated with thromboembolism were age, malignancy, obesity and the type of surgery performed. Treatment performed included anticoagulation 81%, catecholamine infusion 66%, thrombolysis 14%, surgical embolectomy 8% and extra-corporeal circulation 4%. This study indicates that the perioperative pulmonary embolism is still associated with high mortality and requires an immediate diagnosis and intensive therapy.     

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??Diagnosis and treatment of pulmonary embolism after surgical operation: an analysis of 13 cases YANG Ren*??WANG Qiang??FENG-Yong??et al. *Department of General Surgery, Shengjing Hospital Affiliated to China Medical University??Shenyang 110004??China
Corresponding author ??FENG Yong??E-mail:Feny@sj-hospital.org
Abstract Objective To study the diagnosis, treatment and prevention of postoperative pulmonary embolism and reduce the incidence. Methods The diagnosis and treatment procedures of 13 patients with postoperative pulmonary embolism admitted between October 2006 and September 2010 in the Department of General Surgery of Shengjing Hospital Affiliated to China Medical University were analyzed. Some experiences of preventing pulmonary embolism by using low molecular heparin were explored. Results Ten of 13 pulmonary embolism patients were diagnosed and 3 patients were misdiagnosed. Ten patients survived and 3 patients died. There was no pulmonary embolism happened in patients who were evaluated middle or more risk because of using low molecular heparin after August 2009. Conclusion Pulmonary embolism after operation should be valued. Early diagnosis and treatment are the keys for suspicious patients. Evaluating risk before operation and using low molecular heparin after operation are necessary to prevent pulmonary embolism.     

Pulmonary complications associated with head and neck cancer surgery

Objective: To evaluate the frequency of short-term pulmonary complications in the patients undergoing various head and neck cancer surgeries in our setup and to assess possible risk factors responsible for these complications. Study Design: Quasi experimental study. Place and Duration of Study: Department of ENT, Head and Neck Surgery, Combined Military Hospital, Rawalpindi from July 2005 till August 2006. Patients and Methods: Seventy patients of age group 20 to 80 years, regardless of gender, treated surgically for head and neck cancers were enrolled. Main outcome measures included development of pulmonary complications following 15 days of oncological surgery. The complications studied were pneumothorax, bronchopneumonia, atelectasis, pulmonary embolism and cardiopulmonary arrest. Results: A total of 24.28% patients suffered from postoperative pulmonary complications; 17.14% developed bronchopneumonia, 5.71% pulmonary embolism, and 1.42% went into cardiopulmonary arrest, none developed pneumothorax or pulmonary atelectasis. A significant correlation of postoperative bronchopneumonia was seen with heavy smoking and assisted ventilation. Pulmonary embolism was associated with extended assisted ventilation and prolonged surgery. Cardiopulmonary arrest was associated with comorbidity and assisted ventilation after surgery. Conclusion: The frequency of bronchopneumonia supersedes all of the postoperative pulmonary complications in head and neck oncological surgery. Patients at risk of developing postoperative complications are heavy smokers, diabetics, those undergoing prolonged surgery, tracheostomy, and extended assisted ventilation.     

Failure of low dose heparin to prevent pulmonary embolism after hip surgery or above the knee amputation.

In a randomized, double-blind trial, 5,000 USP units of sodium heparin or saline were give subcutaneously at least two hours before surgery and at 12 hour intervals thereafter to patients requiring total hip replacement, surgical correction of hip fracture, or major lower extremity amputation for vascular insufficiency. Lung perfusion scans were performed before surgery and at weekly intervals during the postoperative period. Pulmonary arteriograms were requested in patients developing new perfusion defects on serial scans. Two hundred twelve patient hospitalizations were analyzed. We diagnosed acute pulmonary embolism by serial lung perfusion scans or at autopsy in 37 patients. The incidence of pulmonary embolism in 40 patients with below the knee amputation was too low to warrant conclusions. The incidence of acute pulmonary embolism in 94 patients undergoing above the knee amputation was 25% in patients receiving heparin and 27% in patients receiving saline. The incidence of acute pulmonary embolism in 78 patients undergoing hip surgery was 13% in patients receiving heparin and 12% in patients receiving saline. We conclude that the regimen used had no significant effect on the incidence of acute pulmonary embolism in patients undergoing hip surgery or above the knee amputation.     

Surgical treatment of massive pulmonary embolism. A case report

Pulmonary embolism is a serious complication following trauma and bed rest and it represents a challenge in the prompt diagnosis and medical or surgical therapy. We present a surgically treated patient with a massive pulmonary embolism (more than 50% of the vascular pulmonary bed) which occurred after an inferior leg trauma which required a prolonged bed immobilization. We believe surgical intervention is the treatment of choice in patients with massive pulmonary embolism who do not respond to fibrinolytic therapy. Moreover prompt surgical embolectomy is mandatory to have more chances to save the patient's life.     

ICU management of pulmonary embolism

Pulmonary embolism (PE), a consequence of venous thromboembolic disease, is a common medical problem with an incidence of 60–70 cases/100,000 UK population. A spectrum of disease severity exists, ranging from subclinical to massive pulmonary embolism, which is life-threatening. Many clinical risk factors predispose to the development of pulmonary embolism, the most frequent of which are recent immobility, including surgery, and the presence of malignant disease. Investigations designed to confirm the diagnosis and establish the degree of severity in massive PE include CT pulmonary angiography, cardiac troponins and echocardiography. Treatment consists of general supportive measures, with oxygen and intravenous fluids, together with specific measures of thrombolysis and anticoagulation. The thrombolytic agent of choice is recombinant tissue plasminogen activator; anticoagulation is undertaken initially with heparin and subsequently with warfarin. The major risk of both thrombolytic and anticoagulation treatment is haemorrhage. Certain clinical settings preclude the use of these treatments because of the unacceptably high risk of haemorrhage. In these cases surgical intervention may be considered.     

Twenty-year results of surgical pulmonary thromboembolectomy in acute pulmonary embolism

Background. Acute massive pulmonary embolism is often a life-threatening condition and should be treated immediately. The aim of this study was to investigate risk factors and clinical outcomes of patients undergoing emergency pulmonary embolectomy for acute massive pulmonary embolism. Methods. We evaluated 49 patients undergoing emergency pulmonary embolectomy in our institution between 1995 and 2015, retrospectively. We reviewed preoperative conditions and risk factors, surgical complications, postoperative courses, predictors of mortality and long-term survival. Results. At the time of presentation, the median patients’ age was 58 years. Preoperatively, seven (14%) individuals had cardiac arrest and required cardiopulmonary resuscitation. At the time of surgery, other 23 (47%) patients presented with cardiogenic shock. The most common risk factor for development of pulmonary embolism was major surgery in the last 30 days (29%, n?=?14). Five (10%) patients received systemic thrombolysis preoperatively. The median cardiopulmonary bypass (CPB) time was 82?minutes. The median length of stay in the intensive care unit and in hospital were 1 and 14 days, respectively. Postoperative complications included revision as a consequence of mediastinal bleeding (6%, n?=?3), stroke (2%, n?=?1), and acute renal failure requiring temporary dialysis (4%, n?=?2). The 30-day mortality was 29% (n?=?14) with four (8%) cases of death during the surgery. The one-, five- and 15-year survival rates were 65%, 63%, and 57%, respectively. Conclusion. Pulmonary embolectomy can be performed in high-risk patients with massive pulmonary embolism with acceptable clinical outcome and good long-term survival.     

Pulmonary embolism. Modern concepts

Pulmonary embolism is a common disorder and an important cause of morbidity and mortality. Since genetic predisposition appears to explain only about one fifth of cases, identification of other risk factors is critical. Pulmonary embolism ranges from incidental, clinically unimportant thromboembolism to massive embolism with sudden death. The initial diagnostic approach in patients with suspected pulmonary embolism commonly involves transesophageal echocardiography and ventilation-perfusion scanning. In patients with indeterminate findings on these exams, thoracic spiral computed tomography, magnetic resonance imaging and magnetic resonance angiography have shown promise. Pulmonary angiography is becoming less used because it is invasive and expensive. Unfractioned heparin is considered the treatment of choice for most patients with pulmonary embolism, except those with hemodynamic instability, who may need thrombolytic therapy. There is limited information on the efficacy and safety of low-molecular-weight heparin for the initial treatment of symptomatic pulmonary embolism. An up to date review of the international literature focused in the epidemiology, pathophysiology, diagnosis, potential treatment and prognosis is presented.     

Prophylaxis of fatal pulmonary embolism in general surgery using low-molecular weight heparin Cy 216: a multicentre, double-blind, randomized, controlled, clinical trial versus placebo (STEP). STEP-Study Group

The effectiveness of low-molecular weight heparin CY 216 in the prophylaxis of fatal pulmonary embolism in patients undergoing general surgery was assessed in a multicentre, double-blind, randomized, clinical trial against placebo. A total of 4,498 patients aged over 40 undergoing general surgery were enrolled in the 18 centres which took part in the trial. Patients received a single daily subcutaneous injection of 7,500 anti-Xa units I.C. of CY 216 or placebo two hours before surgery, 12 hours after the initial injection and then daily for at least seven days. A post-mortem examination had to be carried out in every patient who died. The two groups of patients were well-matched for age, sex, type of disease, site and duration of operation as well as for incidence of risk factors which could predispose to the development of thromboembolism. Twenty-six deaths were recorded and validated: eight (0.36%) in the CY 216 group and 18 (0.80%) in the placebo group (p less than 0.05). At the post-mortem examination, carried out in 23 patients (88.5%), two deaths were found to be directly due to pulmonary embolism (0.09%) in the CY 216 group and four (0.18%) in the placebo group. Pulmonary embolism contributed to death in four other placebo-treated patients. Pulmonary or extrapulmonary thromboembolism was a significantly less frequent direct cause of death (p less than 0.05) in the CY 216 group (two pulmonary embolisms) than in the placebo group (four pulmonary embolisms, one acute myocardial infarction, one disseminated intravascular coagulation, two ischemic cerebral strokes).(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute pulmonary embolectomy three days following a coronary artery bypass graft procedure

Pulmonary embolism is very rarely reported early after cardiac surgery, most probably due to full heparinisation during cardiopulmonary bypass. We report a 66-year-old man without thromboembolic history who presented three days after a coronary artery bypass grafting procedure with acute dyspnoea and haemodynamic instability. A CT scan confirmed paracentral bilateral pulmonary embolism requiring an urgent and successful embolectomy. Review of the literature confirms that pulmonary embolism may occur in up to 3% of post-cardiopulmonary bypass patients. The possibility of pulmonary embolism must be taken into consideration in post-cardiopulmonary bypass patients with acute onset of chest pain and respiratory insufficiency.     

原发性肝癌经导管肝动脉化疗栓塞术后肺栓塞4例临床分析

目的分析原发性肝癌经导管肝动脉化疗栓塞（TACE）术后并发肺栓塞的临床特点,探讨发生机制、早期诊断和治疗方法。方法2000年1月至2007年12月,在我院接受TACE的原发性肝癌患者31869人次,其中术后出现肺栓塞患者4例。回顾性分析该4例患者的临床特点及发病机制、诊断、治疗方式。结果TACE术后并发肺栓塞例数占同期我院TACE例数的0．02％;出现肺栓塞时间为术后0．5h～5d,患者表现为呼吸困难、紫绀、心悸、胸痛、黄疸、血尿及血PO2、SatO2下降等肺栓塞症状;本组死亡2例,死亡率50％。结论肺栓塞是原发性肝癌患者TACE术后的严重并发症,是碘油阻塞为主的多种栓塞因素共同作用的结果。本病起病急骤,死亡率高。肺动脉造影及D—Dimer是早期明确诊断的重要方法。     

Pulmonary embolism after operative treatment of proximal humeral fractures

There have been multiple studies on the prevalence of pulmonary embolism, the probability of death from a pulmonary embolism, and the risk factors for the development of pulmonary embolism after lower extremity and pelvic trauma. However, there is no information on the risk of pulmonary embolism after the surgical management of proximal humeral fractures. A review of 137 consecutive patients who underwent operative treatment for acute, isolated proximal humeral fractures at our institution between January 1, 1998, and December 31, 2003, was performed to identify all who sustained a pulmonary embolism. Postoperatively, 7 patients sustained a pulmonary embolism that was confirmed by computed tomography. Of these, 4 had been treated with a hemiarthroplasty and 3 had undergone open reduction-internal fixation. The overall incidence of pulmonary embolism in this series was 5.1%. None of the patients sustained a fatal pulmonary embolus. These data suggest that the rate of pulmonary embolism after operative treatment of proximal humeral fractures is not low. This study raises the question of whether prophylactic anticoagulation is needed after routine proximal humeral repair.     

急性肺动脉栓塞外科治疗 (附5例报告)

５例急性肺动脉栓塞并发肺源性心脏病及呼吸功能衰竭病人行肺动脉切开取栓术。２例病人术后长期存活，心功能由ＩＶ级改善为Ｉ级，并口服华法林治疗未发生再栓塞；２例病人术中死于右肺出血；１例病人手术成功，顺利脱离呼吸机，术后亦行口服华法林抗凝治疗，但于术后第４天死于肺动脉再栓塞。结论：适时而恰当的手术决策是提高手术疗效的关键，术后除抗凝治疗外，还需要在下腔静脉内置入滤网才能更有效地预防再栓塞