Systemic thrombolysis using tissue plasminogen activator for a patient with paradoxic embolism: a case report

When thrombotic material that originates from deep venous thrombosis of the lower extremities is washed out into the pulmonary vasculature, pulmonary embolization occurs. Pulmonary embolism and associated acute peripheral ischemia suggest the diagnosis of paradoxic embolism, which is most often associated with a patent foramen ovale. Therapeutic options include anticoagulation, mechanical/chemical thrombus dissolution, inferior vena cava filtration, and closure of the intracardiac defect. The diagnosis and treatment are described of an elderly female who presented with lower extremity deep venous thrombosis and massive pulmonary embolism complicated by paradoxic emboli to the left subclavian artery as well as the celiac artery.     

Pas de chirurgie sans échographie préalable en cas de thrombose veineuse superficielle clinique : à propos d’un cas d’embolie paradoxale grave

Lower limbs superficial venous thrombosis (LLSVT) is usually considered as common and of a benign prognosis. LLSVT can, however, be responsible for major thromboembolic complications: lower limbs deep vein thrombosis (LLDVT) and pulmonary embolism (PE). We report a case of a LLSVT complicated with a massive bilateral PE and an ischemic cerebral stroke, occurring immediately after a varicose vein surgery. Venous ultrasonography of the lower limbs must be systematically performed in case of LLSVT, in order to evaluate the presence of an associated LLDVT. A rigorous diagnostic and therapeutic approach is the only way to optimize the treatment of this disorder, and to avoid the occurrence of dramatic venous thromboembolic complications.     

Paradoxic aortic arch embolization with occlusion of the supraaortic arteries.

Pulmonary embolization usually occurs when thrombotic material that originates from deep venous thrombosis of the lower extremities is washed out into the pulmonary vasculature via the blood stream. However, in the presence of a patent foramen ovale (PFO), systemic paradoxic embolization may also occur (Am J Surg 176 (1998) 158). Here, we report on the case of a patient with a PFO, who developed paradoxic embolization of the aortic arch following deep venous thrombosis and massive pulmonary embolism.     

Inferior vena cava filters prevent pulmonary emboli in patients with metastatic pathologic fractures of the lower extremity

The records of 47 consecutive patients with metastatic pathologic fractures of the lower extremity were analyzed with respect to thromboembolic complications. All patients were unable to receive pharmacologic deep venous thrombosis prophylaxis, and were stratified into two groups, based on use of an inferior vena cava filter. Group I (n = 24) consisted of patients who had an inferior vena cava filter plus mechanical deep venous thrombosis prophylaxis (compression stockings and sequential compression boots); Group II (n = 23) consisted of a group of patients receiving only mechanical deep venous thrombosis prophylaxis. All patients had routine lower extremity venous duplex imaging preoperatively, postoperatively, and before hospital discharge. At final followup, patients were examined for deep venous thrombosis and reviewed for thromboembolic events. At a mean followup of 11.5 months, Group I had two detectable deep venous thromboses and no pulmonary emboli; Group II had one detectable deep venous thrombosis and five pulmonary embolisms. In Group II, 40% (two of five) of pulmonary embolisms were fatal, yielding an 8.7% (two of 23) group mortality rate. Overall, the entire group had an approximately 17% deep venous thrombosis rate. Only 6.4% (three of 47) of deep venous thromboses were detectable by standard duplex imaging. The majority of deep venous thromboses (five of eight, 62.5%) were nondetectable by duplex imaging. Overall, a 4.3% (two of 47) death rate was attributable to pulmonary embolism. In contrast, an 8.6% (four of 47) mortality rate occurred in Group II alone. All pulmonary embolisms occurred in patients who did not receive an inferior vena cava filter. The majority of venous thromboses (62.5%) were not detectable on duplex scanning, therefore were thought to arise from the pelvic venous system. Complications related to inferior vena cava filter insertion were minimal. For patients with metastatic pathologic fractures of the lower extremities who are unable to receive pharmacologic deep venous thrombosis prophylaxis, the use of inferior vena cava filters, in conjunction with standard mechanical deep venous thrombosis prophylaxis, is a procedure that has a low risk and is useful adjunct to prevent fatal pulmonary embolisms.     

下肢手术后有症状的下肢深静脉血栓形成

目的：探讨下肢手术后有症状的下肢深静脉血栓形成的临床特点,早期诊断方法和预防措施,方法：对5例支手术后发生有症状的下肢深静脉血栓形成患者的临床表现和彩色多普勒结果进行分析。结果：下肢手术后小腿出现疼痛是下肢深静脉血栓形成最早出现并具有很高诊断价值的临床特点,手术后肢体加压包扎是一促进下肢深静脉血栓形成的可能因素。结论：下肢手术后出现小腿后侧疼痛时应考虑下肢深静脉血栓形成的可能,彩色多普勒检查可明确诊断,对高危患者围手术期应采取综合预防措施。     

Massive pulmonary embolism presented as sudden cardiac arrest in the immediate postoperative period after laparoscopic hysterectomy

A rare case of postoperative cardiac arrest in an otherwise healthy, 49-year-old female patient who had a laparoscopic hysterectomy, is presented. The cause of cardiac arrest was due to massive pulmonary embolism, which was detected by transesophageal echocardiography. Laparoscopic surgery is regarded as a less invasive procedure and provides a lower risk for postoperative complications. However, our is a case reminer that pneumoperitoneum may interfere with venous flow of lower extremities and predispose one to deep vein thrombosis or pulmonary embolism.     

重视腹部外科手术后下肢深静脉血栓形成和肺栓塞的防治

肺栓塞是下肢深静脉血栓形成最严重的并发症,对部分病人而言是一种隐匿性威胁。腹部外科手术后下肢深静脉血栓形成和肺栓塞并不少见,应该引起临床医生的足够重视。应建立以“防”为主的观念,对具有危险因素的病人采取积极的预防措施。同时临床医生应熟悉下肢深静脉血栓形成和肺栓塞的早期临床表现,结合病史和易患因素综合分析,提高警惕,及时诊断,减少误诊和漏诊。一旦明确诊断,则应积极采取各种有效措施进行合理治疗,将快速康复外科的理念应用于治疗过程中,争取达到更快更好的恢复。     

Nonpharmacologic thromboembolic prophylaxis in total knee arthroplasty.

Deep venous thrombosis is the most common complication in patients having elective total knee replacement. Pneumatic compression devices play an important role in the prophylaxis of deep venous thrombosis and effectively decrease the risk of distal deep venous thrombosis. The combination therapy with pharmacologic agents has the benefit of decreasing the rate of proximal deep venous thrombosis and therefore is recommended. In the absence of clinical data, recent in vivo flow studies suggest that calf or combined foot and calf compression are superior to foot compression alone. Epidural anesthesia in comparison with general anesthesia decreases the incidence of thromboembolic disease after total knee arthroplasty. Although hypotensive anesthesia and intraoperative heparin have been proven to substantially lower the incidence of deep venous thrombosis after total hip arthroplasty, the current literature does not support its application during the implantation of a total knee replacement. Pneumatic compression devices are an important part of deep venous thrombosis prophylaxis especially in the early postoperative period considering that pharmacologic anticoagulation is contraindicated in the first 12 hours after spinal anesthesia and in the presence of an epidural line.     

急性下肢深静脉血栓形成合并淋巴回流障碍

目的:探讨急性下肢深静脉血栓形成合并淋巴回流障碍的发病率及临床特征.方法:以超声诊断为主作为淋巴回流障碍的诊断标准,将115例下肢深静脉血栓形成患者分为合并淋巴回流障碍组及对照组,分析两组患者临床特点.结果:下肢深静脉血栓形成合并淋巴回流障碍者61例(53%).临床特点为:女性患者较多,好发于左下肢,肿胀程度较重,在血栓形成范围较广泛的临床类型中常见.结论:下肢深静脉血栓形成患者具有较高的淋巴回流障碍并发率,根据临床特点及超声检查可以做到早发现、早治疗.     

Magnetic resonance venography in the diagnosis and management of May-Thurner syndrome

Isolated left lower extremity swelling secondary to left iliac vein compression was first described by McMurrich in 1908, and defined anatomically by May and Thurner in 1957 and clinically by Cockett and Thomas in 1965. The left iliac vein is usually located posterior to the right iliac artery and can be compressed between the artery and the fifth lumbar vertebrae. Symptoms include left lower extremity edema, pain, varicosities, venous stasis changes, and deep venous thrombosis. Evaluation of these patients historically included a venous duplex scan to rule out deep venous thrombosis and an abdominal computed tomography scan to rule out pelvic mass. This paper describes the use of magnetic resonance imaging and venography in the evaluation of patients with isolated left lower extremity swelling. A retrospective analysis of a series of 24 patients who presented with symptomatic left lower extremity edema was performed. Infrainguinal deep venous thrombosis and valvular reflux was evaluated by duplex scan. The presence of suprainguinal deep venous thrombosis and pelvic mass was evaluated by magnetic resonance imaging. Magnetic resonance imaging was used to define the anatomic characteristics of the May-Thurner syndrome. Patients identified with the syndrome were treated either conservatively with lower extremity compression and elevation or with angioplasty and stenting. Follow-up of this subset of patients was performed with clinical assessment of the resolution of their symptomatic lower extremity edema as well as quality of life assessments via phone interviews. Twenty-four patients were evaluated for isolated left lower extremity swelling. Seven patients had positive results on duplex scans for deep venous thrombosis. Magnetic resonance imaging results demonstrated 1/24 (4%) had a pelvic mass compressing the iliac vein; 2/24 (8%) patients had iliac vein thrombosis; 1/24 (4%) patients with a history of deep venous thrombosis demonstrated a long stenotic segment of the left iliac vein unrelated to its association with the right iliac artery; 9/24 patients (37%) had anatomic evidence of May-Thurner syndrome; and 2/24 patients (8%) had isolated left lower extremity swelling of unknown etiology. Five patients diagnosed with May-Thurner syndrome were treated conservatively with compression stockings and leg elevation. Four patients with May-Thurner syndrome underwent iliac vein angioplasty and stenting. Technical success was 100%. On clinical follow-up, the patients with May-Thurner syndrome have had improvement/resolution of their symptoms. There have been no complications from either therapy. May-Thurner syndrome is a clinical entity of left iliac vein compression by the right iliac artery, resulting in isolated left lower extremity swelling and may be a precipitating factor for iliofemoral deep venous thrombosis. Magnetic resonance imaging is the best modality for diagnosis of this entity as it can rule out the presence of pelvic masses and deep venous thrombosis while simultaneously demonstrating the anatomy characteristic of this syndrome.     

Detection of deep venous thrombosis by impedance plethysmography.

Ninety-eight limbs in sixty-seven patients supected of having lower extremity deep venous thrombosis were evaluated by physical examination, venous impedance plethysmography (IPG), and venography. Diagnosis based on physical signs commonly associated with deep venous thrombosis was false-positive in 43 to 66 per cent and false-negative in 26 to 73 per cent when compared with evidence obtained by venography. The overall accuracy of IPG was 94 per cent, with false-positive results occurring in 10 per cent and false-negative results in 4 per cent. IPG is sufficiently accurate to be considered a reliable screening test for lower extremity deep venous thrombosis.     

Fatal Massive Pulmonary Embolism Following a Minor Ankle Injury as a Rare Cause of Sudden Unexpected Death: A Case Report

Venous thromboembolism is a condition that includes both deep vein thrombosis and pulmonary thromboembolism. Pulmonary thromboembolism is a condition that is familiar to forensic pathologists for its common cause of sudden unexpected death. Fatal pulmonary thromboembolism following deep vein thrombosis has been previously reported as a consequence of major ankle injury but not following minor ankle injury. Here, I report the case of sudden unexpected death in a 54-year-old female without known underlying risk factors for venous thromboembolism, except for a history of minor injury at her left ankle, which possibly caused local vascular wall damage with subsequent deep vein thrombosis and eventual massive pulmonary thromboembolism.     

Deep venous thrombosis following transurethral resection of the prostate: diagnosis by phleborheography.

Deep venous thrombosis is a potential complication of transurethral resection of the prostate. We evaluated 150 paients undergoing transurethral resection of the prostate for benign and malignant disease to determine the postoperative incidence of deep vein thrombosis, using phleborheography as the instrument of detection. Phleborheography is an accurate, inexpensive, non-invasive method that uses low pressure transducers to detect volumetric changes in the lower extremity through recording cuffs. A 4.6 per cent incidence of deep venous thrombosis was detected by this technique. At the time this complication was discovered no patient exhibited clinical signs of thrombophlebitis, which reinforces the belief that clinical diagnosis alone is not a reliable screening technique for deep venous thrombosis. Anticoagulant therapy appears to be effective and safe in the treatment of this postoperative complication.     

Is upper extremity deep venous thrombosis underdiagnosed in trauma patients?

It has been suggested that upper extremity deep venous thrombosis (UEDVT) is as common and dangerous as lower extremity deep venous thrombosis. Pulmonary embolism (PE) is often found with no evidence of associated lower extremity deep venous thrombosis and could have originated from UEDVT. Routine screening is well accepted for lower extremity deep venous thrombosis but not for UEDVT. We hypothesized that UEDVT in trauma is frequent but undetected; therefore, routine screening of trauma patients at risk will increase the UEDVT rate and decrease the PE rate due to early diagnosis and treatment. We evaluated the incidence of UEDVT and PE over 6 months before (Group BEFORE) and 6 months after (Group AFTER) implementing a policy of screening patients at high risk for deep venous thrombosis with Duplex ultrasonography. Group BEFORE was evaluated retrospectively and group AFTER prospectively. There were 1110 BEFORE and 911 AFTER patients. The two groups were similar. Of the AFTER patients, 86 met predetermined screening criteria and were evaluated routinely by a total of 130 Duplex exams. One patient in each group developed UEDVT (0.09% vs. 0.11%, P = 1.00). The brachial vein was involved in both patients. Six BEFORE (0.54%) and 1 AFTER (0.11%) patients developed PE (P = 0.137). The single AFTER patient with PE was not screened for UEDVT because he had no high-risk criteria. UEDVT is an uncommon event with unclear significance in trauma. Aggressive screening did not result in a higher rate of UEDVT diagnosis, nor an opportunity to prevent PE.     

Venous duplex scanning in the diagnosis and treatment of progressive superficial thrombophlebitis

Venous duplex scanning, employing both B-Mode imaging and Doppler waveform analysis, is a valuable noninvasive technique for the evaluation of venous disorders of the lower extremities. During the past three years, 442 venous duplex scans were performed in our laboratory, evaluating both the deep and superficial venous systems. Sixty-four scans revealed deep venous thrombosis; twenty studies revealed superficial thrombophlebitis. A subgroup of six studies revealed progressive thrombophlebitis approaching or involving the deep venous system. Three of these six studies documented progression of superficial thrombophlebitis extending into the deep venous system, producing limited deep venous thrombosis. All six patients were treated with venous excision and local venous thrombectomy. None of the patients developed deep venous thrombosis on follow-up venous duplex scans. We conclude that venous duplex scanning is a valuable noninvasive method in the detection of progressive superficial thrombophlebitis. Therefore, prompt therapy may prevent the development of deep venous thrombosis and its sequelae. Additionally, venous duplex scanning provides a method for noninvasive follow-up of the results of therapy.Presented at the Fifteenth Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1990, Los Angeles, California.     

Color Doppler Flow Imaging For Deep Venous Thrombosis Screening in Patients Undergoing Pelvic Lymphadenectomy and Radical Retropubic Prostatectomy for Prostatic Carcinoma

Patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy are traditionally considered to be at high risk for postoperative venous thromboembolic complications. A prospective deep venous thrombosis screening regimen was initiated at our medical center in 1990 following 2 cases of fatal pulmonary embolism that occurred after hospital discharge. During a 3-year period 245 consecutive patients undergoing radical retropubic prostatectomy for prostate cancer were screened postoperatively for lower extremity deep venous thrombosis using ultrasound duplex scanning with color Doppler flow imaging. The results were correlated only with the development of clinical deep venous thrombosis. No additional diagnostic modalities were used to confirm a normal venous system in asymptomatic patients.

Venous thromboembolic complications were encountered in 9 of the 245 patients (3.6 percent). In 2 patients deep venous thrombosis was associated with nonfatal pulmonary embolism. Only 2 of the 9 cases of deep venous thrombosis were detected by color Doppler flow imaging screening. The striking decrease in the incidence of deep venous thrombosis following radical prostatectomy in the last decade and the low yield of screening at a single point in time may warrant reconsideration of the need for deep venous thrombosis screening among patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostate cancer.     

周期性充气加压预防下肢手术后深静脉血栓

目的 探讨单独使用周期性充气加压（ＩＰＣ）预防下肢手术后深静脉血栓（ＤＶＴ）的效果。方法１９９７年１０月￣１９９８年８地４０例下肢手术患者使用ＩＰＣ预防ＤＶＴ。其中人工全髋关节置换术２４例,髋滑动加压鹅头钉术１２例,人工全膝关节表面置换术４例。术前超声多普勒证实双下肢无ＤＶＴ,术后开始使用ＩＰＣ,术后当天持续使用ＩＰＣ８小时,术后第１天起每隔６小时使用ＩＰＣ一次,每次２小时,直至出院,整个疗程至少     

Duplex ultrasonography in patients suspected of postoperative pulmonary embolism following total joint arthroplasty

Duplex ultrasonography of the deep venous system of the lower extremities is often utilized in the diagnostic evaluation of total hip and knee arthroplasty patients suspected of pulmonary embolism in an attempt to identify the embolic source. A retrospective review of 135 patients who were clinically suspected of pulmonary embolism after 71 total knee arthroplasties and 64 total hip arthroplasties was performed. Of the 35 patients diagnosed with pulmonary embolism, 2 (5.7%) had deep venous thrombosis identified by duplex ultrasonography. The routine use of this imaging modality is not an effective strategy for identifying clinically significant deep venous thrombosis that leads to pulmonary embolism. A negative duplex ultrasound result should not preclude an extensive evaluation for pulmonary thrombosis in symptomatic patients.     

Deep venous thrombosis and pulmonary embolism after surgical treatment of ankle fractures: a case report and review of literature

Deep vein thrombosis and pulmonary embolism are major complications that can occur after ankle injuries. We present the case of a patient with an ankle fracture who developed deep vein thrombosis and massive pulmonary embolism after surgical treatment of the ankle fracture. A review of the published data on this topic is presented. The treating physician should assess patients with ankle fracture for their risk of developing a venous thromboembolic event on an individual basis and provide thromboprophylaxis for those with an increased risk of developing such complications.     

髂静脉压迫综合征的研究进展

髂静脉压迫综合征是导致下肢静脉高压的重要因素,常表现为下肢静脉曲张、下肢深静脉血栓形成。随着医学诊断技术及认识的提高,越来越多的髂静脉压迫患者被识别。目前关于髂静脉压迫综合征合并有下肢静脉曲张或下肢深静脉血栓形成的治疗,存在一定分歧。笔者对髂静脉压迫综合征的新认识、诊断方法及治疗进展进行综述。