肺血栓栓塞症超声心动图诊断

目的 肺血栓栓塞症是心血管急症，应提高对其认识和超声心动图诊断水平；方法 对12例以超声心动图首先诊断的肺血栓栓塞症进行回顾性总结，6例手术或尸检证实；结果 肺血栓栓塞症临床表现多样化，超声心动图直接依据是肺动脉主干及左右分支内血栓回声；间接征象为右房室腔扩大及肺动脉高压；深静脉血栓是栓子来源常见病因，血管彩色多普勒血流显像对深静脉血栓有确诊价值；结论 超声心动图对肺血栓栓塞症具有重要诊断价值，并有助于临床与急性心肌梗塞、主动脉夹层动脉瘤和心包填塞进行鉴别。     

Obstructive sleep apnoea secondary to superior vena cava thrombosis in a patient with activated protein C resistance

Summary Question of the Study Only five cases of superior vena cava (SVC) thrombosis as a cause of obstructive sleep apnoea (OSA) have as yet been reported. In this study, we aimed to describe an additional case and to review the literature on this subject.
Patients and Methods Based on the medical records, the case history of a 58-year-old man with OSA due to SVC thrombosis is presented. Furthermore, PubMed articles were browsed with the search items 'sleep apnoea' and 'superior vena cava thrombosis'.
Results The patient complained of the development of facial swelling and plethora during the previous 2  months. Furthermore, he reported the recent onset of snoring and excessive daytime sleepiness. Computed tomography of the thorax and mediastinal phlebography showed SVC thrombosis. Polysomnography demonstrated moderate to severe OSA. The cases of OSA secondary to SVC thrombosis already reported in the literature were mainly caused by mediastinal tumours compressing the SVC. In the present case, we found activated protein C (APC) resistance as the underlying disease. From the literature, it is known that therapies aimed at recanalization or relief of the SVC might lead to reversal of the OSA. In our patient, recanalization of the SVC was not possible and thus he had to be treated by continuous positive airway pressure therapy.
Conclusion In summary, we report on the rare occurrence of OSA due to SVC thrombosis. In the present case we found APC resistance as the underlying disease, which has not yet been reported in the literature.     

Rupture of a pulmonary artery aneurysm

Pulmonary artery aneurysm (PAA) is a very rare disease. Such aneurysms are distinguished according to their form (saccular and fusiform) and origin (congenital and acquired). A case is reported of PAA rupture in a female patient, aged 58, that had long been ill with a rheumatic mitral valvular disease. A number of conditions favoured the origination of PAA and its disruption. They are: the existence of combined rheumatic heart disease, widespread posttuberculous pneumosclerosis with pulmonary emphysema and thrombosis of the right pulmonary artery as a result of chronic cardiovascular failure.     

Pulmonary thromboendarterectomy: a clinicopathologic study of 200 consecutive pulmonary thromboendarterectomy cases in one institution

Approximately 2000 patients underwent pulmonary thromboendarterectomy (PTE) to date at University of California, San Diego. We retrospectively reviewed the clinicopathologic manifestations of 200 consecutive PTE cases from June 2004 to February 2006 with an emphasis on the histopathologic spectrum of chronic thromboembolic disease. Pathology reports and all histologic sections of study cases were examined. Pertinent clinical data were obtained from operative reports and medical records. In the study group, there were 2 cases (1 man, 1 woman) of pulmonary artery sarcomas and 1 case of metastatic tumor emboli from a testicular germ cell tumor. Two patients (both women) showed histologic evidence of arteritis without clinically apparent systemic vasculitis. The remaining 195 PTE patients with chronic thromboembolic disease consisted of 97 women and 98 men with a mean age of 52 (range, 17-83) and 51 (range, 16-82), respectively. Bilateral PTE was performed in 191, and unilateral PTE was performed in 4 (right and left, 2 each) patients. History of deep vein thrombosis was noted in 38.5%, and coagulation abnormalities were documented in 16.4% of these 195 cases. Grossly, the volumes of PTE specimens were greater in men than in women and on the right side than on the left in both men and women. Microscopically, the thrombi were recent fibrinous clot in 0.8%, mixed fibrinous and organizing in 45%, and old organized in 54.2% of specimens. Inflammation within the thrombi was usually mild but moderate and severe inflammation was found in 13.4% and 1.3% of specimens, respectively. Exuberant epithelioid granulomas were seen within the thrombi in one patient who had a history of sarcoidosis. Collections of foamy histiocytes and/or cholesterol clefts were found in 45%, and calcification was present in 11.5% of specimens. One case revealed diffuse myofibroblastic proliferation in a highly inflammatory background containing numerous plasma cells, reminiscent of inflammatory myofibroblastic tumor. In summary, pathology of PTE specimens in our study group encompassed remodeling of thrombi at various stages with variable degrees of inflammation and cellularity, granulomas associated with sarcoidosis, a rare case showing features of inflammatory myofibroblastic tumor, primary or metastatic malignancy, and isolated pulmonary arteritis.     

Cerebral infarction leading to hemiplegia: A rare complication of acute pancreatitis

Peripancreatic vascular thrombosis is a known complication of acute pancreatitis (AP) and chronic pancreatitis. However, hemiplegia resulting from cerebral infarction due to cerebral arterial thrombosis is a rare complication of AP. Here, we report a case of alcohol related severe AP with multi-organ dysfunction, which was complicated by large left sided middle cerebral artery territory infarct - leading to right sided hemiplegia in a 48-year-old male patient. The neurological and vascular thrombotic complications of pancreatitis, their pathogenesis and management are discussed in brief.     

SB203580对急性肺栓塞后肺动脉高压及MCP-1表达的影响

 目的：观察单核细胞趋化蛋白1(monocyte chemoattractant protein-1, MCP-1)与急性肺栓塞（pulmonary thromboembolism, PTE）后肺动脉高压形成的关系;探讨p38丝裂原活化蛋白激酶（mitogen-activated protein kinase, MAPK）特异性抑制剂SB203580对急性PTE后肺动脉高压及MCP-1表达的影响。方法：采用自体血栓回输法复制Sprague-Dawley大鼠急性PTE模型;将大鼠随机分成5组,每组观察1 h、4 h和8 h 3个时点;急性PTE模型复制前1 h,分别对MCP-1中和抗体C1142组及SB203580组进行药物预处理;在1 h、4 h和8 h检测各组肺动脉平均压力（mean pulmonary artery pressure, MPAP）和MCP-1 mRNA及蛋白表达。结果：（1）在相同时点,急性PTE组MPAP和MCP-1 mRNA及蛋白表达均较溶剂对照组显著升高（P<005）;（2）在相同时点,C1142组及SB203580组MPAP和MCP-1 mRNA及蛋白表达均较急性PTE组显著降低（P<005）。结论：（1）急性PTE后MCP-1的大量表达参与急性PTE性肺动脉高压的形成;（2）SB203580可能通过p38 MAPK信号转导通路,下调MCP-1表达,降低急性PTE肺动脉压力。     

Deep femoral artery aneurysm presenting as lower limb swelling: a case report

We report a rare case of lower limb swelling due to compression of the superficial femoral vein by a solitary deep femoral artery aneurysm. The patient was a 58-year-old man presenting with acute swelling of the right lower limb caused by deep venous thrombosis. A multi-detector computed tomographic scan (CT) confirmed the diagnosis of a deep femoral artery aneurysm and revealed no evidence of aneurysms or occlusive lesions in the other arteries. Aneurysmectomy and ligation of the deep femoral artery were successfully performed. Preoperative multi-detector CT scanning is a valuable, non-invasive diagnostic tool to delineate not only the state of the aneurysm, but also that of the distal arterial tree.     

Spontaneous aortocaval fistula

Spontaneous aortocaval fistula is rare, occurring only in 4% of all ruptured abdominal aortic aneurysms. The physical signs can be missed but the presence of low back pain, palpable abdominal aortic aneurysm, machinery abdominal murmur and high-output cardiac failure unresponsive to medical treatment should raise the suspicion. Pre-operative diagnosis is crucial, as adequate preparation has to be made for the massive bleeding expected at operation. Successful treatment depends on management of perioperative haemodynamics, control of bleeding from the fistula and prevention of deep vein thrombosis and pulmonary embolism. Surgical repair of an aortocaval fistula is now standardised--repair of the fistula from within the aneurysm (endoaneurysmorraphy) followed by prosthetic graft replacement of the aneurysm. A case report of a 77-year-old woman, initially suspected to have unstable angina but subsequently diagnosed to have an aortocaval fistula and surgically treated successfully, is presented along with a review of literature.     

HUGHES-STOVIN SYNDROME

A 37-year-old female with multiple pulmonary aneurysms, thrombotic obstruction of the inferior vena cava and mural thrombosis in the right heart was reported. Arterial blood culture repeatedly examined had been negative. The patient died of massive hemoptysis. This case was equivalent to Hughes-Stovin syndrome and was the first female case of typical Hughes-Stovin syndrome.
Review of the literature revealed 9 typical cases of this syndrome and 5 atypical cases who had solitary intrapulmonary aneurysm. It was obscure whether the typical cases were essentially different from the atypical ones or not, but the cases with solitary pulmonary aneurysm might proceed to the cases with multiple ones, as shown in this case.
Pathogenesis of the syndrome has been controversial. In the present case, development of pulmonary aneurysms seemed to be closely related to thromboembolization derived from venous thrombosis due to artificial abortion.     

Guillain-Barre syndrome complicated by acute fatal rhabdomyolysis

Guillain-Barre syndrome (GBS) is a heterogenous group of peripheral-nerve disorders with similar clinical presentation characterized by acute, self-limited, progressive, bilateral and relatively symmetric ascending flaccid paralysis, which peaks in 2-4 weeks and then subsides. The usual complications, which occur in a patient of GBS are pneumonia, sepsis, pulmonary embolism, respiratory insufficiency and cardiac arrest. The clinical course of GBS complicated by acute rhabdomyolysis is extremely rare. We present the case of GBS with marked elevation in serum creatine kinase, serum myoglobin levels and persistent hyperkalemia as a result of associated acute rhabdomyolysis.     

急性肺血栓栓塞症兔TNF-α、IL-8、IL-10水平及地塞米松的影响

目的:探讨兔急性肺血栓栓塞症(PTE)时血浆及支气管肺泡灌洗液(BALF)中TNF-α,IL-8、IL-10的水平和地塞米松(Dex)的影响。方法:采用自体血栓回输法建立兔急性PTF模型。36只兔随机分为对照组、Dex治疗组和PTE模型组。用ELISA方法检测上述细胞因子(CK)水平,术毕肺组织行病理观察。结果:栓塞后上述CK均有升高,治疗后TNF-α、IL-8均有下降,IL-10变化不明显。组织病理学可见栓塞后肺动脉内血栓形成,肺组织萎缩、出血、炎性反应明显,Dex治疗后肺组织病理改变明显减轻。结论:PTE后促炎性CK在引起肺部炎性反应和肺组织及肺动脉病损中起了重要作用,抗炎治疗可以明显减轻CK引起的这种损伤。抗炎治疗能降低PTE急性期病死率,改善远期预后,CK可能起了很重要的作用。     

Case report: cytomegalovirus-induced thrombosis in an immunocompetent patient

Thrombotic manifestations of cytomegalovirus infection in immunocompetent individuals are rare. However, it has been postulated that cytomegalovirus infection can be both directly cytopathic and capable of inducing antiphospholipid antibodies due to shared "molecular mimicry" between cytomegalovirus virus antigens and antiphospholipid antibodies. The case of a previously well 30-year-old woman with primary cytomegalovirus infection complicated by splenic infarction and massive pulmonary embolus is described. The patient is unusual given the development of thromboses affecting both the arterial and venous circulation, associated with both transient anticardiolipin antibodies and persistently positive anti-β(2) glycoprotein I antibodies. The temporal relationship between the primary infection and thrombosis was suggestive of a pathogenic role for cytomegalovirus.     

Multiple organ dysfunction syndrome,an unusual complication of heroin intoxication: a case report and review of literature

Multiple organ dysfunction syndrome (MODS) has rarely been described in patients with heroin intoxication. Here, we report a rare case of MODS involving six organs, due to heroin intoxication. The patient was a 32-year-old Chinese man with severe heroin intoxication complicated by acute pulmonary edema and respiratory insufficiency, shock, myocardial damage and cardiac insufficiency, rhabdomyolysis and acute renal insufficiency, acute liver injury and hepatic insufficiency, toxic leukoencephalopathy, and hypoglycemia. He managed to survive and was discharged after 10 weeks of intensive care. The possible pathogenesis and therapeutic measures of MODS induced by heroin intoxication and some suggestions for preventing and treating severe complications of heroin intoxication, based on clinical evidence and the pertinent literature, are discussed in this report.     

Advancement of prophylaxis and therapy for venous thromboembolism

Recently in Japan, venous thromboembolism (VTE) [deep vein thrombosis (DVT)/pulmonary thromboembolism (PTE)] has increased with the Westernization of eating habits and aging of society. In the West, the prophylaxis guidelines have been discussed for many years. Unfortunately, Japan falls far behind the West in this area. Therefore, the necessity of thromboprophylaxis in Japanese people should be emphasized based on reliable VTE studies in Japan. In orthopedic surgery, prospective multicenter studies in Japan indicate that the incidence of DVT/PTE in total hip or knee replacement surgery and hip fracture surgery were almost equal to those in Western people. Furthermore, a multi-center, prospective epidemiological study in Japan revealed that the incidence of VTE following major abdominal surgery was 24.3%. We developed Japanese Guidelines for VTE prophylaxis based on the 6th ACCP guideline in 2004. The incidence of perioperative PTE in Japan has been investigated by the Japanese Society of Anesthesiologists since 2002. The rate of perioperative PTE was estimated to be 4.41 per 10,000 operations in 2002, and 4.76 in 2003; however, it decreased to 3.61 immediately after the guideline for thromboprophylaxis was issued and the management fee for PTE prophylaxis became covered by health insurance in April 2004. Furthermore, it markedly decreased in 2005. However, mechanical prophylaxis is not sufficient to prevent PTE, and advanced prophylaxis by anticoagulants, such as low-molecular-weight heparin/selective Xa inhibitor along with unfractionated heparin (UFH)/vitamin K antagonists (VKA) will be essential. The advanced revised guidelines for VTE prophylaxis based on our clinical evidence will be established in the near future. As for treatment for VTE, anticoagulant and thrombolytic therapies are essential. In cases with VTE, UFH followed by VKA (INR: 1.5-2.5) is standard. In cases of PTE with shock, thrombolytic therapy such as tissue plasminogen activator or urokinase, catheter intervention, or surgical procedures under pericutaneous cardiopulmonary support should be selected based on the severity of PTE.     

Pseudoaneurysm of the membranous septum, case report and review of the literature

Pseudoaneurysm (dissecting aneurysm) of the membranous septum is a rare occasion. Clinically, aneurysms and pseudoaneurysms not only have the potential to reduce ventricular size, but also can be further complicated by rupture of the aneurysm and by promoting tricuspid insufficiency, aortic valve prolapse, ventricular outflow tract obstruction, and bacterial endocarditis. We describe a case in which a pseudoaneurysm of the membranous septum was identified protruding into the left outflow tract.     

A case of pentacuspid pulmonary valve

A pentacuspid pulmonary valve is a rare congenital anomaly. The present report describes a case of pentacuspid pulmonary valve encountered during the autopsy of a 50-year-old man with a ruptured abdominal aortic aneurysm. The pentacuspid pulmonary valve had three relatively equal cusps and two smaller cusps. In this case, a tricuspid aortic valve was identified with normal structure and no evidence of heart failure was found clinically or pathologically.     

Thrombolytic Therapy Complemented by ECMO: Successful Treatment for A Case of Massive Pulmonary Thromboembolism with Hemodynamic Collapse

Pulmonary thromboembolism (PTE) is a common clinical condition related to significant mortality. Furthermore, patients with PTE presenting with right heart thrombus show higher mortality due to rapid hemodynamic deterioration. But the optimal treatment of massive PTE is controversial although various methods have been developed and improved. Here, we presented a case of 56-yr-old woman with massive PTE showing hemodynamic collapse, who was successfully treated with extracorporeal membrane oxygenation (ECMO) adjunct to thrombolytic therapy even without thrombectomy. ECMO was useful for resuscitation and stabilization of the cardiopulmonary function. In conclusion, thrombolytic therapy complemented by ECMO may be an effective treatment option for acute massive PTE with hemodynamic instability.

Graphical Abstract

相似文献   

Acute pulmonary thromboembolism after distal gastrectomy: an appraisal of the guidelines for preventing pulmonary thromboembolism/deep vein thrombosis

We report a case of acute pulmonary thromboembolism after gastrectomy. A 67-year-old woman was found to have gastric cancer and a giant lipoma in the ascending colon. We performed distal gastrectomy and enucleation of the ascending colon lipoma. On postoperative day 9, an acute pulmonary thromboembolism developed, and thrombolytic therapy was urgently performed. The 2004 Japanese guidelines for preventing pulmonary thromboembolism/deep vein thrombosis are discussed in relation to the present case.     

Assessment of Inflammatory Biomarkers and Oxidative Stress in Pulmonary Thromboembolism: Follow-up Results

Instability in circulation, hypoperfusion, hypoxia, and ischemia in pulmonary thromboembolism (PTE) may occur as a result of failure in pulmonary circulation. All these conditions cause inflammation and oxidative stress. We aimed to investigate inflammatory markers, asymmetric dimethylarginine (ADMA) levels, and the oxidant-antioxidant balance in patients with PTE. This study was conducted as a prospective case-control study. Thirty-eight patients with PTE enrolled to the study. Age- and gender-matched 38 healthy subjects without risk factors for pulmonary embolism were selected as control group. Venous blood samples were obtained from the PTE patients during the initial diagnosis and at the first month of treatment and from the control subjects. Interleukine-6 (IL-6), tumor necrosis factor alpha (TNF-α), total antioxidant status (TAS), total oxidant status (TOS), and ADMA levels were measured for all the samples. The results of patients and healthy subjects were compared. The mean age of the control group was 51.81?±?15.18 years, and the mean age of the patients was 52.90?±?18.22 years (p?=?0.770). Deep venous thrombosis was present in 68 % of the patients. While we found significant differences between the patient and control groups in terms of IL-6, TAS, TNF-α, ADMA and oxidative stress index (OSI) values (p?=?0.001, p?=?0.011, p?=?0.038, p?=?0.028, and p?=?0.024, respectively), the TOS value was not different between the groups (p?=?0.080). The ADMA, TNF-α, TAS, TOS, and OSI values of the patients during the initial diagnosis and at the first month of treatment were not different (p?>?0.05). The results of this study indicate an increased inflammation, endothelial damage, and oxidative stress in PTE. No difference at the first month of therapy suggests ongoing processes. We consider that these markers may be useful in the diagnosis and follow up of PTE.     

肺动脉高压的血栓栓塞的机制

肺动脉高压是一种严重的临床疾病,常常并发血栓形成,其背后的机制可能与缺氧,内皮功能异常,炎症因子激活,血小板活化及凝血功能异常有关。本文拟探讨肺动脉高压患者的血栓形成机制,为临床治疗和预防肺动脉高压并发的血管栓塞提供理论依据。