Catheter embolism

With the increasing utilization of intravenous catheters, complications from their use may be anticipated. We report the case of one such complication, a venous catheter fragment embolization. A review of the literature addressing catheter embolization is provided. Specific recommendations are offered to the emergency physician in an effort to minimize such untoward occurrences.     

围手术期肺栓塞的评估及其护理干预

通过分析、总结我院外科、妇科、骨科术后两年来由急性肺栓塞引发猝死的9例病因,阐述了运用护理程序进行评估,发挥护士主观作用,对发现的病情变化进行分析和有效的评估,制定护理计划,加强术后宣教,提高工作人员的防范意识,对预防围手术期肺栓塞的发生起着重要的作用.     

围手术期肺栓塞的评估及其护理干预

通过分析、总结我院外科、妇科、骨科术后两年来由急性肺栓塞引发猝死的9例病因，阐述了运用护理程序进行评估．发挥护士主观作用，对发现的病情变化进行分析和有效的评估，制定护理计划，加强术后宣教．提高工作人员的防范意识，对预防围手术期肺栓塞的发生起着重要的作用。     

Thrombolysis for pulmonary embolism

More than 10 years ago, thrombolytic therapy with urokinase and streptokinase for pulmonary embolism was found to have considerable advantages over standard heparin therapy. After the introduction of alteplase, a recombinant tissue plasminogen activator, further studies confirmed this benefit. However, thrombolytic therapy for pulmonary embolism has not gained universal acceptance, even though it now has U.S. Food and Drug Administration approval. Clear advantages of thrombolytic therapy over conventional heparin therapy are improved pulmonary capillary blood volume, accelerated clot lysis and accelerated pulmonary perfusion. Earlier reversal of right-sided heart failure, a lower incidence of recurrent pulmonary embolism, a reduced risk of chronic pulmonary hypertension and reduced mortality have been claimed as advantages, but these have not been adequately proved. A recent survey suggests that about half of all patients with pulmonary embolism are potential candidates for thrombolytic therapy. In a subset of patients with hemodynamic compromise, thrombolysis has definite advantages over heparin therapy.     

Catheter intervention for carotid and cerebrovascular diseases

Catheter intervention for carotid and cerebrovascular diseases is rapidly developing treatment modality as another vascular diseases. Recent advancement has been based on stent technology. In the carotid field, self-expanding stents have been widely used, and now embolic protection devices (EPDs) were used in all cases to prevent intraprocedural embolic complication. Current approved EPDs were categorized to distal filter type, Angioguard RX and FilterWire EZ and distal balloon type, Percusurge Guardwire. In 2010, CREST study showed CAS and CEA are both safe and useful as carotid revascularization. Another important intervention is recanalization therapy for acute stroke. Merci, mechanical thrombectomy device, is approved in 2010 and this device indicated for contra- or failed iv rt-PA therapy. Multi MERCI trial showed successful recanalization is most important factor for favorable outcome. Embolization for intracranial aneurysms is also important therapy in neuro-intervention. Detachable coils and adjunctive technique, balloon assist embolization, double catheter technique, and another techniques, have been used in this treatment. Self-expanding stents have been used in recent years. In 2010, Enterprise was approved in Japan and recommended to use for 7 mm or more larger wide neck unruptured aneurysms. Although there is not enough clinical evidence and appropriate devices for intracranial vessels, it seems to be a potentially effective in the future.     

Catheter ablation for atrial fibrillation and intervention for pulmonary vein stenosis in a patient with Fontan circulation

Incidence of atrial fibrillation (AF) is high in patients with congenial heart disease. However, management of AF is challenging in these patients. Although radiofrequency catheter ablation (RFCA) is effective therapeutic option for AF, RFCA for AF is not common in patients who underwent Fontan operation. We present a 24‐year‐old woman with paroxysmal AF, who underwent lateral tunnel Fontan operation for functional single ventricle. Circumferential pulmonary vein isolation was successfully performed. However, significant pulmonary vein stenosis developed after RFCA. Pulmonary vein stenosis was successfully treated by transcatheter intervention.     

Thrombophlebitis and pulmonary embolism with surgical intervention in the third trimester.

A case of acute deep vein thrombophlebitis and pulmonary embolism in late gestation has been presented with a discussion of diagnostic modalities, therapeutic regimens, and theoretical considerations. It is our belief that aggressive medical management is best accomplished by giving heparin intravenously as the primary anticoagulant. When medical management is best accomplished by giving heparin intravenously as the primary anticoagulant. When medical management is not effective or if embolism occurs, surgical intervention, consisting of vena caval clipping and ovarian vein ligation with scrupulous attention to detail, is indicated. Further, support to prophylaxis of abruptio placenta secondary to the mechanism espoused by Mengert et al is added by the course of this patient.     

Endovascular interventions for acute pulmonary embolism

Massive pulmonary embolism (PE) is a highly lethal condition with clinical manifestations of hemodynamic instability, acute right ventricular (RV) failure, and cardiogenic shock. Submassive PE, as defined by RV failure or troponin elevation, can result in life-threatening sequelae if treatment is not initiated promptly. Current treatment paradigm in patients with massive PE mandates prompt risk stratification with aggressive therapeutic strategies. With the advent of endovascular technologies, various catheter-based thrombectomy and thrombolytic devices are available to treat patients with massive or submassive PE. In this article, a variety of endovascular treatment strategies for PE are analyzed. The authors' institutional experience with ultrasound-accelerated thrombolytic therapy as well as catheter-directed thrombolytic therapy in patients with acute massive PE during a recent 10-year period is discussed. Finally, clinical evidence on the utilization of catheter-based interventions in patients with massive and submassive PE is also analyzed.     

Mechanical circulatory assist for pulmonary embolism

Optimal management of acute pulmonary embolism remains controversial, despite advances in thrombolytic therapy. Haemodynamic instability and, in particular, right ventricular dysfunction is associated with poor outcomes. Urgent surgical embolectomy has been the treatment of choice in this category of patients. We present two cases in which percutaneous cardiopulmonary support (PCPS) was used as an adjunct to thrombolytic therapy for progressive circulatory collapse secondary to massive acute pulmonary embolism. This experience suggests that PCPS may offer an attractive option for a condition which continues to carry significant morbidity and mortality.     

Nonspecific tests for pulmonary embolism.

Many tests have been proposed as useful in the diagnostic evaluation of suspected PE, but nonspecific tests for PE can only add to the level of suspicion one has for the diagnosis. As Anderson indicates, "virtually all clinical and laboratory findings neither diagnose nor exclude the diagnosis of PE. They merely serve to heighten suspicion of the diagnosis and prompt the clinician to pursue additional diagnostic studies." D-dimer measurement is promising as a test to exclude PE in young healthy out-patients, and further study and improvements in technology, can clarify the usefulness of the different methods of performing this assay. For now, diagnostic algorithms for PE should continue to incorporate multiple tests and decision points, but the standard remains specialized imaging techniques.     

Diagnosing pulmonary embolism

Diagnosing pulmonary embolus (PE) remains one of the great challenges of emergency medicine. The diagnosis relies on a balance of probabilities rather than any definitive test. The probability is based on history, examination and investigations. The principal investigations are chest X-ray, arterial blood gas, electrocardiograph, ventilation perfusion scan, ultrasound and angiography where necessary. Newer techniques such as CT scan and magnetic resonance imaging will become more useful as the technology improves. Transoesophoegeal echocardiography is an important investigative tool for massive PE. Thrombolysis is increasingly being used in the management of PE and the higher risk of adverse outcome should be balanced against the probability of false positive results and the use of invasive angiography.     

Trophoblastic pulmonary embolism

Trophoblastic embolism is subclinical in normal pregnancy, pronounced in eclampsia, and massive in hydatidiform mole. Self-limited acute respiratory distress arises in 3% to 10% of molar pregnancies at the time of uterine evacuation. Infrequently death occurs; the principal findings are trophoblastic emboli in the pulmonary arterioles, edema of the lungs, and dilatation of the right side of the heart. Hyperthyroidism may develop, and fibrin may line the alveolar walls. Pathogenetic mechanisms include heart failure, hyperthyroidism, dilutional anemia, and pulmonary arteriolar blockage. Infusions of fluid and whole blood tend to cause pulmonary overload, which may precipitate right-sided heart failure. Preferred therapy consists of diuresis and ventilatory support, especially with oxygen under positive end-expiratory pressure.     

Massive pulmonary embolism

An otherwise healthy 48-year-old woman presented in respiratory extremis from massive pulmonary embolism and promptly arrested. She underwent open-chest cardiopulmonary resuscitation followed by portable partial cardiopulmonary bypass and embolectomy but could not be resuscitated. Massive pulmonary embolism is frequently a desperate situation, but aggressive therapy with thrombolysis or embolectomy (in patients with contraindications to thrombolysis) may be lifesaving.