3. Sudden death due to pulmonary thromboembolism after car driving: a case report

An autopsy case of sudden death due to pulmonary thromboembolism after a car trip is reported. A 56-year-old Japanese man with hypertension and atrial fibrillation suddenly died immediately after having driven for two and a half hours. At autopsy, the pulmonary arteries were found to be filled with dark-red, coiling thrombi consisting of fibrin and red blood cells. In the dilated right popliteal vein, a thrombus consisting of fibroblasts, a large number of collagen fibres, and newly formed capillaries was attached to the vessel wall. The cause of death was determined to be pulmonary embolism due to the thrombus of the right popliteal vein. Two and a half hours of prolonged sitting while driving a car encouraged thrombus formation. We believe that this case, the first autopsy case of fatal pulmonary thromboembolism after a car trip to be reported, highlights the importance of predicting venous thrombosis of the leg or fatal venous thromboembolism after a car trip.     

Deep venous thrombosis of the lower extremity: US evaluation

The sensitivity of duplex ultrasonography (US) for detecting deep venous thrombosis of the lower extremity was compared with that of venography in a prospective study of 54 patients. Doppler analysis of the common femoral vein and US imaging of the deep venous system from the common femoral vein to the popliteal vein was performed. Common femoral vein response to the Valsalva maneuver was recorded. Sonographically visible thrombi and abnormal vein compressibility were 91% sensitive for the common femoral vein, and 94% sensitive for the superficial femoral or popliteal veins, with no false-positive examinations. Abnormal Doppler flow and abnormal response of the common femoral vein to the Valsalva maneuver enabled thrombi to be detected only in the common femoral and iliac veins. Combined data allowed accurate diagnoses in all patients with deep venous thrombosis proximal to the deep calf veins. US should be the screening examination of choice for evaluating patients with suspected lower extremity deep venous thrombosis.     

Distribution of thrombi in acute lower extremity deep venous thrombosis: implications for sonography and CT and MR venography

OBJECTIVE: Our objective was to determine the typical distribution of thrombi in acute lower extremity deep venous thrombosis as a means of evaluating the validity of imaging techniques that only include the common femoral and popliteal veins, but not the superficial femoral vein. MATERIALS AND METHODS: The results of 2704 lower extremity venous sonograms, obtained in 2026 consecutive patients over a 4-year interval, were reviewed retrospectively. The distribution of acute deep venous thromboses across various lower extremity venous segments was analyzed for this population, which consisted of both symptomatic and asymptomatic patients. RESULTS: Of 2704 lower extremities studied with duplex sonography, acute deep venous thrombosis was identified in 269 (9.9%). Of these 269 cases, acute deep venous thrombosis was isolated to the superficial femoral vein in 60 (22.3%). The remaining 209 cases (77.7%) showed thrombus that extended into the common femoral or popliteal veins (or both). CONClUSION: An abbreviated imaging study that evaluates only the common femoral and popliteal veins would fail to identify more than 20% of lower extremity acute deep venous thromboses in a population like ours. Although evaluation of the superficial femoral vein requires additional time and resources, evaluation of this segment may prevent a substantial number of thrombi from being missed.     

Deep venous thrombosis: detection by high-resolution real-time ultrasonography

High-resolution real-time ultrasonography was performed in 11 patients with clinically suspected deep venous thrombosis (DVT) of the lower extremity. Contrast venography was performed in all patients within 24 hours of sonographic examination. The common femoral vein at the groin and the popliteal vein in the popliteal fossa were evaluated for presence or absence of intraluminal soft-tissue mass (thrombi), compressibility of the veins, and response to performance of the Valsalva maneuver. Of the 11 patients, six were shown to have DVT by contrast venography. In all six cases there was complete agreement between sonography and contrast venography as to the presence or absence of thrombi in the common femoral vein or the popliteal vein.     

Pulmonary embolism: a case of sudden unexpected death in a psychiatric hospital

We report a case of suspected fatal physical abuse in which the cause of death was proved to be pulmonary embolism. A patient with mental retardation presenting aggressive behavior was admitted to a psychiatric hospital and was treated with major tranquilizers. She suddenly died subsequent to an angina-like attack. For several days before her death, she had been confined to her bed because of very low physical and mental activity. Bruises and abrasions were observed on the extremities, suggesting the recent restraints. There was no positive evidence of physical abuse. At autopsy, the cause of death was elucidated to be pulmonary embolism originating from thrombi in the left popliteal vein. This case indicates the risk of pulmonary embolism in immobilized patients in psychiatric hospitals.     

Thrombosis of the popliteal vein

Among 3,307 consecutive patients (3,556 legs) with deep venous thrombosis, 54 (1.5%) showed an isolated thrombus of the popliteal vein on phlebography. The majority of those had a history of “effort” or long lasting flexion during air or bus travel. Forty-four percent suffered from pulmonary embolism as the first sign of deep venous thrombosis. Functional phlebography demonstrated the primary site of thrombosis at folds forming in the vein wall at flexion. In order to further elucidate the pathogenetic mechanism, 158 popliteal veins were examined phlebographically in different functional states revealing age-related characteristic wall patterns of rings and folds in flexion causing transient impairment of flow. Complementary morphological studies of 120 popliteal veins during autopsy showed a transverse rippling of the vein wall caused by intimal fibrosis and partial atrophy of the media corresponding to the phlebographic findings. It is concluded that microtrauma during effort in combination with impaired venous backflow and fibrotic transformation of the venous wall can lead to thrombus formation in the popliteal vein.     

Popliteal Venous Aneurysm: A Rare Cause of Recurrent Pulmonary Emboli and Limb Swelling

Popliteal venous aneurysm is a rare cause of recurrent pulmonary embolism, although the true incidence of aneurysm is probably underestimated. One-third of patients suffer further embolic events despite therapeutic anticoagulation. We report the case of a 59-year-old male who presented with recurrent PEs over a period of 12 years despite anticoagulation therapy. A thrombophilia screen and abdominal ultrasound were normal at that time. He reattended with recurrent pulmonary emboli, left calf swelling, and a mass in his left popliteal fossa causing limitation of knee movement. Venous duplex and MRI of his popliteal fossa demonstrated a thrombosed true popliteal venous aneurysm with popliteal and superficial femoral vein occlusion. In view of the mass effect we proceeded to surgical excision of his aneurysm after prophylactic placement of an IVC filter. The patient regained normal knee function with intensive inpatient physiotherapy. He has been recommenced on lifelong anticoagulant. The presentation, investigation, and management of the condition are briefly discussed. We suggest that a bilateral lower limb duplex is performed to exclude venous aneurysm in all patients presenting with pulmonary embolism in which an underlying source cannot otherwise be identified and no thrombophilic tendency is detected.     

Floating thrombi: diagnosis and follow-up by duplex ultrasound.

The clinical features and evolution of floating thrombi (FT) diagnosed by duplex ultrasound were examined. In 76 consecutively diagnosed above-knee deep venous thromboses the prevalence of FT was 18%. Of 44 FT diagnosed in 39 patients, 18 (39%) were located in the common femoral, 12 (26%) in the popliteal and seven (15%) in the external iliac veins. Serial duplex examinations revealed that 31% of FT in the iliofemoral segment disappeared 33% remained unchanged and 36% adhered to the vein wall within 2 weeks following diagnosis. After 3 months, 87% of the floating segments had disappeared, irrespective of the localization or therapeutic regimen. Thirteen patients experienced pulmonary embolism before (12/13) or following (4/13) diagnosis of floating thrombosis; three of four superficial femoral vein FT embolized. Fifteen per cent of the patients with FT died during the study period and 28% of the thrombi were associated with a malignant neoplasm; the incidence of malignancy was 60% in superficial and 39% in common femoral vein FT.     

Acquired anomalous intrapulmonary venous connection secondary to pulmonary venous stenosis

An unusual case of acquired development of anomalous intrapulmonary venous connection with pulmonary venous stenosis is presented. Appearances on a chest radiograph resembled the "scimitar" sign in a patient with previous surgery for partial anomalous pulmonary venous return. Spiral CT and pulmonary arteriography showed stenosis of the right upper pulmonary vein and an anomalous intrapulmonary venous connection between the right upper pulmonary vein and the right lower pulmonary vein. We consider the slow progression of pulmonary vein stenosis led to anomalous intrapulmonary venous connection as an intrapulmonary collateral.     

Multiple intra-abdominal venous thrombosis in ulcerative colitis: role of MDCT for detection

Patients with ulcerative colitis are at increased risk for venous thrombosis. We report herein the case of a 28-year-old woman who developed multiple intraabdominal venous thrombosis, including partial Budd-Chiari syndrome in association with intracranial venous thrombosis and pulmonary embolism during the relapse of a known ulcerative colitis. Multidetector-row computed tomography (MDCT) allowed depiction of multiple intraabdominal sites of thrombosis including right and medial hepatic veins, left portal vein, splenic vein and left ovarian vein and demonstrated complete resolution of the multiple thrombi after anticoagulant therapy. The association of partial Budd-Chiari syndrome with other thrombi involving portal, splenic and ovarian veins in association with ulcerative colitis, has, to our knowledge never been reported yet. In addition, the potential role of MDCT in the detection of possible multiple thrombosis in patients with ulcerative colitis has never been emphasized.     

经腘静脉置管接触性溶栓治疗急性下肢深静脉血栓形成应用价值研究

目的探讨经患侧腘静脉置管接触性溶栓(CDT)治疗急性下肢深静脉血栓形成(DVT)的临床疗效。方法回顾性分析自2012年3月至2017年3月收治的39例应用经患侧腘静脉CDT治疗急性DVT患者的临床资料。所有患者均在腔静脉滤器保护下经患侧腘静脉置管CDT。记录置管成功率,健、患肢周径差值,静脉血栓评分,静脉再通率,深静脉瓣膜保存率,介入治疗并发症与下肢深静脉血栓形成后综合征(PTS)的发生率等指标并评价疗效。结果所有患者均穿刺置管成功,置管成功率为100.0%(39/39)。患者治疗前后的健、患肢周径差值分别为(6.12±1.03)cm与(2.55±0.76)cm,差异有统计学意义(P<0.05),肢体肿胀消退明显。患者治疗前后静脉血栓评分为(5.73±0.94)分与(2.13±1.60)分,差异有统计学意义(P<0.05),血栓消融明显,静脉再通率为(64.23%±16.21%)。39例患者中,1例患者出现置管处炎症,1例患者出现穿刺处血肿,1例患者溶栓后出现髂静脉狭窄并行髂静脉支架植入术治疗,即介入治疗并发症的发生率为7.7%(3/39)。随访6~12个月,34例患者完成随访,随访率为87.2%(34/39),无DVT复发与肺栓塞发生。深静脉瓣膜保存率为(76.14%±9.15%),PTS的发生率为15.4%(6/39)。结论应用经患侧腘静脉CDT治疗急性DVT安全有效。     

George W. Holmes Lecture. Deep venous thrombosis and pulmonary embolism: correlative evaluation and therapeutic implications.

Deep venous thrombosis and pulmonary embolism are significant causes of morbidity and mortality in the United States; estimates range from 120,000 to 150,000 deaths annually. Although usually symptomatic, deep venous thrombosis can be clinically occult, in part due to incomplete obstruction or in part related to duplication, triplication, and fenestration anomalies, primarily of the superficial femoral or popliteal vein. Additionally, pulmonary emboli caused by deep venous thrombosis may be clinically silent. Because of therapeutic implications, especially indications for insertion of inferior vena caval filters, comprehensive assessments of both the disease process (i.e., deep venous thrombosis) and the complication (i.e., pulmonary emboli) are important. Thus, when a pulmonary embolus is the presenting process, correlative assessment of deep venous thrombosis, even in the absence of symptoms or signs in the lower extremity, may be of therapeutic significance. Conversely, when deep venous thrombosis of the lower extremities involving the popliteal or superficial femoral vein is the presenting process, correlative assessment of the pulmonary circulation, even when no pulmonary symptoms or signs are present, may be of therapeutic significance. Relative to the diagnosis of pulmonary embolism, the roles of assays of D-dimer, ventilation-perfusion lung scans, and segmental occlusion studies of the pulmonary circulation are discussed. Finally, the indications for insertion of inferior vena caval filters above the renal veins are presented and examples are shown.     

Popliteal vein thrombosis secondary to popliteal artery aneurysm.

Two patients with popliteal vein thrombosis secondary to popliteal artery aneurysm are described. The association of venous abnormalities in 623 reported cases of popliteal artery aneurysm is reviewed. The high morbidity from popliteal vein thrombosis would seem to justify preoperative leg venography in patients with popliteal artery aneurysm.     

Phlebographic findings in venous thrombosis following total hip replacement

The specific appearance of venous thrombosis following total hip replacement was analysed by reviewing 45 positive phlebograms from 122 patients participating in a concurrent trial against thromboembolism. Almost all thrombi were asymptomatic and non-occlusive. Forty-four per cent of the thrombi were exclusively confined to the calf. The muscular veins were the most common location, followed by the fibular and posterior tibial veins. Ipsilateral thrombi predominated over thrombi in the non-operated leg. Thirty-six per cent were located in the ipsilateral thigh and the major part was found in the proximal part of the femoral veins. Nearly all were related to valve cusps, free-floating and were of small size. In 20 per cent, thrombi were found in both the calf and the thigh. Neither contralateral thigh thrombi, nor pelvic thrombi were found. Of 25 patients with pulmonary embolism, all but 3 asymptomatic, 64 per cent had thigh thrombi. A multifocal location of thrombi was present but two major types of thrombosis were distinguished; calf vein thrombosis probably due to venous stasis and femoral thrombosis caused by the local surgical trauma.     

静脉顺行造影在静脉畸形骨肥大综合征的应用

目的：探讨静脉顺行造影在静脉畸形骨肥大综合症（KTS）的应用价值。方法：对9例下肢静脉畸形骨肥大症患者行顺性静脉造影检查,其中有4例于术后复查顺性静脉造影,以评价静脉畸形的部位、狭窄的范围与程度。9例患者均行B超检查。结果：静脉造影显示本组9例患者中,1例胫腓干静脉狭窄,1例胫腓干静脉狭窄,1例胫腓干静脉狭窄并Guo静脉狭窄,4例静脉狭窄。4例行手术治疗的患者,于术后复查下肢静脉造影,显示浅静脉曲张较术前减少,深静脉通畅度改善。结论：静脉造影提供了明确的静脉畸形范围,从而对临床治疗提供可靠的依据;并有利于术前、术后对比,以评价疗效。     

Macroscopic vascular invasion in synovial sarcoma evident on MRI

We present a case of recurrent synovial sarcoma in the soft tissues of the calf, where MR imaging not only confirmed the diagnosis of tumour recurrence, but also demonstrated direct venous invasion and tumour thrombus within the popliteal vein and its tributaries. Venous invasion has particular relevance to synovial sarcoma prognostication and should be actively sought on MR imaging. To our knowledge this is the first reported case in the English literature of histologically proven macroscopic popliteal vein invasion from a synovial sarcoma demonstrated on MR imaging.     

Fatal thromboembolism following physical restraint in a patient with schizophrenia

Fatal thromboembolism during physical restraint in patients suffering from psychotic disorders is a very rare occurrence. In the case we present here, the criteria used in forensic pathology for the age determination of venous thrombi are applied to a case of pulmonary embolism in a patient suffering from schizophrenia who died after physical restraint. The possible association between conventional antipsychotic drugs and deep venous thrombosis, followed by pulmonary embolism, in a man with no predisposing risk factors, as well as the question concerning the appropriateness of medical care, are discussed.     

Where is the most common site of DVT? Evaluation by CT venography

Purpose

Our aim was to clarify the common site of deep venous thrombosis (DVT) in patients suspected of having pulmonary embolism using computed tomography pulmonary angiography with computed tomography venography (CTV).

Materials and methods

We evaluated 215 patients. For all studies, 100?ml of 370?mg?I/ml nonionic contrast material was administered. CTV were scanned with helical acquisition starting at 3?min in four-slice multidetector-row computed tomography (MDCT) or 5?min in 64-MDCT after the start of contrast material injection. The site of DVT was divided into iliac vein, femoral vein, popliteal vein, or calf vein. Calf vein was divided into muscular (soleal and gastrocnemius) and nonmuscular (anterior/posterior tibial and peroneal) veins. The 2?×?2 chi-square test was used.

Results

One hundred and thirty-seven patients showed DVT; the muscular calf vein was more prevalent than other veins (P?Conclusions Our study showed that the most common site of DVT was the muscular calf vein.     

经腘静脉顺行穿刺治疗下肢静脉血栓的探讨

目的：探讨经腘静脉顺行穿刺治疗下肢静脉血栓的可行性及优越性。方法：下肢静脉血栓患者19例，经对侧股静脉放置下腔静脉滤器后，使用骨科止血带加压成功穿刺腘静脉，15例顺行插管抽血栓，4例使用Amplatz血栓清除器（ATD）。结果：19例均获成功，栓塞血管复通达100％。临床症状消失，无症状性复发。结论：下肢静脉血栓中使用骨科止血带后可有效地提高顺行穿刺腘静脉成功率，是下肢静脉溶栓治疗的有效方法。     

MRA of the lower extremities in patients with pulmonary embolism using a blood pool contrast agent: initial experience

PURPOSE: To evaluate the feasibility of blood pool contrast-enhanced magnetic resonance angiography (MRA) to visualize the arterial and venous vessel tree and to detect deep venous thrombosis (DVT) of the lower extremities. MATERIALS AND METHODS: Nine consecutive patients with pulmonary embolism (mean age = 46 +/- 9) were randomized to various doses of NC100150 (between 0.75 and 6 mg of Fe/kg of body weight). A T1-weighted (T1W) 3D gradient recalled echo (GRE) sequence (TE = 2.0 msec, TR = 5.0 msec) was used. Two observers blinded to the dose of contrast agent assessed image quality, contrast attenuation, and appearance of thrombi. RESULTS: Qualitative assessment of overall MRA image quality and semiquantitative vessel scoring revealed good to excellent delineation of venous and arterial vessel segments independent of the dose of NC100150. However, quantitative region of interest analysis revealed a significantly higher signal-to-noise ratio (SNR) in the high-dose group than in the mid- and low-dose groups of NC100150 (P < 0.01). Between dose groups, the SNR was independent of vessel type (artery or vein) and vessel segment localization (proximal or distal). All seven venous thrombi (mean length = 7.2 +/- 0.95 cm) were characterized by a very low signal intensity (SI), which was only 16.6 +/- 7% of the SI in adjacent venous segments (P < 0.0001). CONCLUSION: High-quality MR angiograms of the lower extremities can be obtained using low concentrations of NC100150 in combination with a strong T1W 3D GRE sequence. The obvious delineation of venous thrombi suggests that this technique may be potentially used as a noninvasive "one-stop shopping" tool in the evaluation of thromboembolic disease.