64层螺旋CT对肺动脉血栓栓塞症诊断价值的探讨

【目的】探讨64层螺旋CT（SCT）扫描对肺动脉血栓栓塞症（PTE）的诊断价值。【方法】选择22例PTE患者的64层SCT肺动脉成像资料,分析PTE栓子的形态特征和PTE间接征象。【结果122例中,血栓全部表现肺动脉内充盈缺损,共126个栓子,其中栓子位于主肺动脉为2个,左右肺动脉干内13个,肺叶动脉49个,肺段及以下62个;除外主肺动脉的2个栓子,右侧77个,左侧47个,其中表现为中心型充盈缺损25个、附壁型充盈缺损79个、完全闭塞型分别为22个。PTE间接征象：“肺少血”征2例、“马赛克”征3例,肺大片实变3例,肺梗塞10例,肺动脉扩张4例,胸腔积液12例。【结论]64层螺旋CT血管成像诊断PTE简便、安全、准确性高,是PTE一种重要而可靠的临床诊断方法。     

多层螺旋CT肺动脉造影及多方法三维重建技术在肺栓塞诊断中的临床价值

目的:探讨多层螺旋CT肺动脉造影及多方法三维重建技术在肺栓塞诊断中的临床价值。材料与方法:回顾性分析我院2007年1月-2010年5月临床拟诊为肺栓塞,并经16层螺旋CT肺动脉造影及多平面重组(MPR)、容积再现(VRT)、最大密度投影(MIP)多方法三维重建确诊的41例病例。结果:41例病例均得到满意图像,CT肺动脉造影对肺动脉主干、左右肺动脉干及叶、段、亚段肺动脉显示良好,41例病例共发现栓子512个,其中肺动脉主干2个,右肺动脉干63个、左肺动脉干54个、叶动脉105个、段及亚段288个。直接征象表现为各级肺动脉内不同形态的充盈缺损,间接征象表现为因肺动脉栓塞所致的肺梗塞、肺动脉高压、支气管动脉扩张、右心功能不全及局限性的肺纹理稀疏、胸腔积液等的影像学表现。结论:多层螺旋CT肺动脉造影及多方法三维重建技术安全、迅速、无创、敏感性、特异性、分辨率高可作为临床诊断肺栓塞及复查疗效的首选影像学方法。     

Acute pulmonary emboli associated with guidewire change of a central venous catheter

The potential complications of percutaneous venous catherizations are many and include pneumothorax, subclavian and carotid artery puncture, hematoma, air embolism, catheter malposition, catheter fragment embolization, venous thrombosis and infection. This case report describes a patient who developed angiographicallydocumented pulmonary emboli associated with the changing of a central venous catheter over a guidewire using Seldinger technique. This episode adds the possibility of acute pulmonary emboli to the list of potential complications from central venous catherizations.     

Spontaneous showering of tumor emboli in a patient with advanced primary lung cancer: a case report

ABSTRACT: Extension of primary lung tumors into the left atrium via pulmonary veins is a well-documented phenomenon. Peripheral arterial embolism and cerebral embolism originating from a primary lung neoplasm are rare events. We report a case of simultaneous acute bilateral lower limb ischemia, bilateral renal infarction, splenic infarction and cerebral infarction as a result of multiple emboli originating from primary lung malignancy invasion of the left atrium. An emergent embolectomy revealed pathologic features of the extracted thrombus that were identical to the pulmonary neoplasm.     

Expression of tissue factor in rabbit pulmonary artery in an acute pulmonary embolism model

BACKGROUND:

Tissue factor (TF) is the initiation factor of the extrinsic coagulation pathway, and plays a critical role in the process of thrombosis. This study aimed to investigate the expression of TF and to explore their clinical effect on the pulmonary artery after acute pulmonary thromboembolism.

METHODS:

Thirty-four Japanese white rabbits (Level II animals) supplied by Tianjin Medical University were randomly assigned into: group A, specimens of the pulmonary artery taken 3 hours after pulmonary embolism (n=8); group B, specimens of the pulmonary artery taken 8 hours after pulmonary embolism (n=8); group C, specimens of the pulmonary artery taken 24 hours after pulmonary embolism (n=8); and control group, pseudo-operations performed without injection of autologous blood clots (n=10). The animal model of pulmonary thrombo-embolism was established by injection of autologous blood clots into the jugular vein through a 5F catheter, and was confirmed by digital subtraction angiography. The mRNA expression of TF in different parts of the pulmonary artery was accessed by RT-PCR. The q test was used if there was a significant difference in a given continuous variable among the three groups assessed by ANOVA. The experiment equipment was supplied by the State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital, the Chinese Academy of Medical Sciences and Peking Union Medical College.

RESULTS:

The TF expression in the specimen adjacent to emboli was stable at 3, 8 or 24 hours after embolism. The mRNA expression of TF at 3 and 8 hours after embolism was lower in the specimens taken from the distal end of the morbid pulmonary artery than those adjacent to emboli. While at 24 hours after embolism, there were similar mRNA levels in specimens either adjacent or distal to emboli.

CONCLUSION:

The high level of TF expression in pulmonary artery tissue adjacent to emboli could lead to locally increased coagulation activity, indicating the necessity of initiating anti- coagulation treatment as soon as possible after acute pulmonary embolism.KEY WORDS: Pulmonary embolism, Tissue factor, Pulmonary, Gene expression, Thrombus, Anticoagulation, Thrombolysis, Rabbits     

64层螺旋CT血管造影三维重建在肺栓塞检查中的临床应用

目的评价肺血管成像在肺栓塞中的临床应用价值。方法19例拟诊肺栓塞、4例拟诊冠心病患者行64层螺旋CT肺动脉造影,在工作站上对原始薄层图像进行后处理观察肺动脉栓子分布情况,其中5例同时行DSA检查,并与64层螺旋CT检查结果进行比较。结果全部病例三维肺血管图像均能充分显示肺动、静脉的空间关系与解剖细节,不但能准确、直观地观察肺血管,而且能明确诊断肺动脉栓塞及有无侧支循环形成。23例患者中检出肺动脉栓塞16例,共发现肺动脉栓子264处,其中段及段以上栓子149处,亚段及以下5~6级分支115处,血栓栓塞血管直径最小者1mm。1例上肢和胸侧壁因锁骨下静脉血栓明显侧支循环形成,1例左上肺静脉左房入口和左心耳内附壁血栓形成。5例同时行DSA检查,对肺段及段以下肺动脉栓子检出率,64层CT和DSA相比,均具有统计学差异。结论64层CT肺动脉造影对肺动脉主干、亚段及以下5~6级分支肺栓塞具有很好的应用价值,为肺部血管性疾病诊断与治疗提供重要依据。     

Should thrombolysis be contraindicated in patients with cerebral arteriovenous malformations?

OBJECTIVES: To report the successful and uncomplicated use of systemic thrombolysis for massive pulmonary embolism in a patient with a known cerebral arteriovenous malformation and to suggest that the presence of an unruptured arteriovenous malformation or aneurysm should not be considered an absolute contraindication to systemic thrombolysis. DESIGN: Case report. SETTING: A 16-bed adult neurologic/medical intensive care unit in a university hospital. PATIENTS: A patient developed a massive pulmonary embolism the morning after elective cerebral embolization of a large unruptured cerebral arteriovenous malformation. INTERVENTION: Radial artery catheterization, arterial blood gas measurements, mechanical ventilation, vasopressors, pulmonary perfusion scan, echocardiogram, head computed tomography, heparin therapy, and systemic recombinant tissue plasminogen activator therapy. MEASUREMENT AND MAIN RESULTS: The patient required emergent mechanical ventilation and vasopressor support for respiratory and hemodynamic failure. Echocardiogram showed acute right heart failure, and pulmonary perfusion scan demonstrated massive pulmonary embolism. Despite intravenous heparin therapy, the patient had worsening hypotension and acidosis and we therefore treated with recombinant tissue plasminogen activator. Within the next day the patient was weaned from vasopressor support and extubated. Neurologic examination remained normal, and follow-up head computed tomography revealed no evidence of intracranial hemorrhage. CONCLUSION: Known arteriovenous malformations or aneurysms are considered a contraindication to thrombolysis, although the true risk of thrombolysis-precipitated intracranial hemorrhage is unknown. We believe that this risk is low in the setting of a previously unruptured arteriovenous malformation or aneurysm. The decision to use systemic thrombolysis in a patient with a known vascular malformation should be individualized.     

Nonsurgical removal of intravascular fragmented catheter

Embolization of a fragmented catheter in the vasculature is a serious complication. In two patients with catheter fragment emboli, one in the pulmonary artery and one in the right jugular vein, a nonsurgical technique was effective in removing the fragments. Because nonoperative techniques are simple, safe and cost-efficient, they should be considered the method of choice for managing this complication.     

THE EFFECT OF MULTIPLE EMBOLI OF THE CAPILLARIES AND ARTERIOLES OF ONE LUNG

1. Injection of a suspension of potato starch cells into the left branch of the pulmonary artery, in quantity sufficient ordinarily to give rise to markedly accelerated respirations, resulted in no change in respiratory rate. 2. A method for injecting substances into the pulmonary artery or its branches without interfering with the blood flow to the lungs has been described. 3. Injection of similar material into one lung when the other is excluded from the circulation either by ligation or by temporary clamping does give rise to rapid and shallow breathing (from a rate of 10 to 15 per minute to one of 60 or over) identical in character to that brought about by introducing emboli into both lungs. 4. A method for clamping and releasing the pulmonary artery or its branches in a dog breathing normally with closed thorax has been devised. This is described in detail in another paper. 5. After rapid breathing has been initiated by the effect of emboli lodged in the arterioles and capillaries of the right lung, reestablishing the circulation in the other lung by releasing the clamp on its artery may or may not restore the respiratory rate to its original, normal level. 6. This discrepancy in results has not been correlated with any difference in oxygen saturation of the arterial blood, or in carbon dioxide tension or pH of its plasma. 7. It is, however, believed to be related to the gross and microscopic anatomy of the lung of which the artery has been temporarily clamped. Photomicrographs are published, showing in one dog (No. 3), in which the respiratory rate returned to normal, a normal histological picture of the left lung, and in another dog (No. 4), in which the rate remained rapid after release of the clamp, a picture characterized by congestion and dilatation of arterioles and capillaries. 8. The fact that accelerated respirations result from emboli in the pulmonary capillaries and arterioles only after a certain quantity of material has been introduced, and the fact that emboli in one lung do not occasion accelerated respirations unless the circulation through the other lung is occluded or abnormal, leads us to the conclusion that the phenomenon is not an irritative stimulus due to foreign bodies, but is in some manner related to (a) diminution of the pulmonary vascular bed, (b) resistance to the blood flow through the lungs or (c) congestion or dilatation of the arterioles and capillaries of the lungs.     

Surgical repair of a coronary artery aneurysm associated with coronary artery fistula – a case report

Coronary artery aneurysm is a relatively rare disorder that is usually discovered as a secondary finding in patients undergoing coronary artery angiography. Coronary artery fistulas are relatively more frequent than rare aneurysms and are often associated with other cardiac abnormalities. The etiology of aneurysms is mostly atherosclerotic, and they are less frequently associated with other acquired or congenital diseases, such as Kawasaki disease, connective tissue diseases, septic emboli, arteritis, and iatrogenic disease. We report a 70-year-old woman with a rare combination of a coronary artery aneurysm associated with a coronary artery fistula, which drained into the pulmonary artery. The diagnosis of our patient was made by selective coronary angiography and confirmed by computed tomography angiography. The patient was treated surgically because of the symptomatic course of the disease.     

Pulmonary Cement Embolism after Kyphoplasty

Abstract: An 80‐year‐old female with a history of osteoporosis was evaluated for sudden onset axial low back pain with bilateral lower extremity weakness, hyperreflexia, pain, urinary retention, and decreased rectal tone. Computed tomography of the lumbar spine revealed L1 compression fracture, retropulsion of bone causing spinal canal compromise with associated severe central canal stenosis. Following cement kyphoplasty of L1 with polymethyl methacrylate, the patient developed tachycardia and dyspnea. Chest radiograph and computed tomographic pulmonary angiogram revealed a large collection of hyperdense material within the right lower lobe pulmonary artery, consistent with pulmonary cement emboli. Management and imaging are discussed.     

A Rare Cause of Myocardial Infarction: Acute Inferoposterior Myocardial Infarction After Successful Intravenous Thrombolytic Treatment of Mechanical Mitral Prosthetic Valve Thrombosis

Prosthetic valve thrombosis is a rare and dreaded complication of patients with mechanical valves, particularly those in the mitral position. A 45-year-old female with status post prosthetic mitral valve replacement was admitted to the hospital with acute pulmonary edema. Echocardiography showed mitral valve thrombosis which was treated with tissue plasminogen activator (t-PA). During t-PA infusion she developed acute inferoposterior myocardial infarction. Coronary angiography showed normal coronary arteries. Presented case had acute inferoposterior myocardial infarction secondary to coronary emboli after the successful thrombolytic treatment of prosthetic mitral valve thrombosis.     

Acute rheumatic fever mimicking an acute coronary syndrome

An elevated troponin measurement does not always reflect myocardial ischaemia secondary to obstructive coronary artery disease. Troponin levels can also be elevated in other disease states including pulmonary emboli, myo‐pericarditis, acute rheumatic fever, and in the critically ill. Thus, patients presenting with chest pain and electrocardiological and biochemical evidence of myocardial necrosis are not always suffering from an acute coronary syndrome.     

肺动脉CT血管成像对肺栓塞的诊断价值

【目的】探讨肺动脉CT血管成像（CTA）在肺栓塞（PE）诊断中的临床应用价值。【方法】回顾性分析2013年1月至2015年12月本院收治的67例疑似PE患者的肺动脉CTA检查资料,以病理学诊断结果为依据,对67例疑似 PE患者的临床表现、病变的CTA 影像特征、误诊情况及其栓子特点进行综合分析。【结果】67例疑似PE患者,经肺动脉CTA诊断出PE患者63例,经病理学确诊62例 PE患者,误诊率仅为15．8％,不存在漏诊的情况。62例PE患者,其中9例为肺动脉主干、叶、段肺动脉多部位栓塞,累及主肺动脉12例、右肺动脉19例、左肺动脉22例。通过肺动脉CTA扫描62例PE患者共检查出78个栓子,包括59个血栓,脂肪栓11个,空气栓5个,其他3个。血栓来源广泛,其中来至于盆腔及下肢深静脉血栓分别为24个和19个。【结论】肺动脉CTA在诊断PE时不仅可直接显示出栓子的位置、形状、病程时间及其间接征象,同时还可诊断同PE具有相似病症的疾病,误诊和漏诊率低,且可协助寻找栓子的来源,为患者的临床溶栓治疗提供依据。     

Pulmonary emboli from therapeutic sodium hyaluronate

A patient presented with shortness of breath and pleuritic pain shortly after bilateral knee synovial injections with sodium hyaluronate (HA). He was discharged after a brief hospitalization without a diagnosis when no Doppler or radiologic evidence of deep vein thrombosis or pulmonary emboli was found. Radiologic studies found patchy ground glass opacities that were predominantly peripheral in disposition, with prominent septal lines in the lungs; a subsequent pulmonary function test showed a reduced diffusing capacity of the lung for carbon monoxide (D(LCO)). These results prompted a lung biopsy that revealed multiple emboli composed of HA and fibrin in medium size pulmonary arteries, enlarged lymphatic vessels, and a bone marrow embolus. This is the first report of HA emboli following therapeutic HA injections and demonstrates that pulmonary function tests can be used to infer the reduction in pulmonary vascular area consequent to pulmonary emboli, and so can contribute to the detection of pulmonary emboli in unusual presentations.     

多层螺旋CT在肺栓塞诊断中的应用

目的探讨多层螺旋CT在肺栓塞诊断中的临床意义及价值, 分析其CT表现.方法应用多层螺旋CT机对27名肺栓塞病人进行肺动脉增强扫描, 将图像进行多平面(MPR)、曲面(CPR)及斜面(Oblique)重组再处理.结果 27例病人共发现肺动脉栓子146个,其中左及右肺动脉7个,肺叶动脉34个,肺段动脉99个,肺亚段动脉6个.结论多层螺旋CT增强扫描可清楚显示段以上肺动脉血栓栓子,具有方便、快捷、无创、准确的优点,对及时诊断和治疗有着重要的意义,并能有效评估溶栓治疗后的效果.     

肺动脉栓塞指数的研究进展

急性肺栓塞(acute pulmonary embolism,APE)是以各种栓子阻塞肺动脉及其分支为其发病原因的一组疾病或综合征,也是临床病死率较高的疾病之一。肺栓塞的诊断方法有螺旋CT、放射性核素肺通气/血流灌注(V/Q)显像、磁共振成像和磁共振肺动脉造影、肺动脉造影。螺旋CT中的多排螺旋CT肺动脉造影诊断肺栓塞的敏感性及特异性较高,因此广泛应用于临床。肺动脉栓塞指数(pulmonary artery obstruction index,PAOI)是通过螺旋CT的多排螺旋CT肺动脉造影进行计算的一种临床指标。本文就PAOI与APE危险分层,PaO2,PaCO2,P(A-a)O2,SaO2,RVd/LVd,MPAd,SVCd,肺动脉高压,D-二聚体等的相关性研究现状作一综述。     

Massive pulmonary embolism with large floating thrombus in the truncus of the pulmonary artery

A conservative strategy with anticoagulation led to spontaneous dissolution of a large floating thrombus (7.0x0.5 cm) in the truncus of the pulmonary artery in a 51-year-old woman with massive pulmonary embolism (pulmonary emboli in both lungs down to the level of the segmental arteries). Interventional therapy such as thrombolysis or pulmonary thrombectomy was not considered to be appropriate for this patient because of the risk of disrupture and embolization of parts of this large central thrombus. We believe that in certain cases with massive pulmonary embolism and large floating central thrombi a conservative strategy with anticoagulation may be appropriate. Such cases may be observed more often in the future using the technique of spiral computed tomographic angiography.     

Spontaneous fibrinolysis in pulmonary embolism

This study correlated levels of activated fibrinolysis with the presence, extent, and rate of resolution of angiographically documented pulmonary emboli. Pulmonary emboli demonstrable by angiography were associated with detectable fibrin split products in the serum of 24 of 25 patients. In the absence of increased fibrin split products, pulmonary emboli large enough to be demonstrated by angiography were found in only 2 of 25 positive pulmonary angiograms. Spontaneous resolution of pulmonary emboli could not be correlated with the the concentration or persistence of fibrin split products but did correlate well with the presence of a reversible precipitating cause.Thrombophlebitis in the absence of clinical evidence of pulmonary embolism was not associated with increased concentrations of fibrin split products in eight of nine patients. The one patient with increased fibrin split product concentration had evidence on lung scan of silent pulmonary embolism.     

Pulmonary emboli with respiratory failure

The diagnosis of pulmonary emboli may be difficult or delayed because of the clinical similarity to other acute medical events or from superimposed embolic phenomena in patients with pre-existing pulmonary and cardiovascular disease. The clinical presentation, diagnosis, and medical and surgical intervention in patients with massive emboli are discussed.