Pulmonary emboli in sclerotherapy for peripheral vascular malformations under general anesthesia; a report of two cases

Sclerotherapy with absolute ethanol and/or polidocanol is a well-established therapeutic modality for the treatment of peripheral vascular malformations, although systemic complications such as hemoglobinuria and pulmonary embolism could occur. We report two cases of pulmonary embolism associated with sclerotherapy for peripheral vascular malformations. Two patients, a 17-year-old man and a 17-year-old woman, undergoing absolute ethanol sclerotherapy for vascular malformations of the leg developed pulmonary embolism after injection of ethanol. Pulmonary embolism, suspected by the clinical symptoms such as hypoxia and hypocapnia, was confirmed by the pulmonary scintigraphy showing minimal pulmonary defects. Hemoglobinuria was also observed with injection of ethanol. Patients recovered rapidly with heparin and urokinase therapy. The review of perioperative complications with sclerotherapy for peripheral vascular malformations in our institution for past four years revealed that complications were observed in 18 out of 88 patients (20.5%), and in 32 out of 183 cases (17.5%). Major complications were hemoglobinuria, pulmonary embolism, shivering and delayed emergence from general anesthesia. We conclude that sclerotherapy for vascular malformations under general anesthesia is a risky procedure and this must be carefully managed with keen monitoring of Spo2 and Etco2.     

Case of epidural hematoma developed after extraction of the epidural catheter and heparin injection in a patient with pulmonary embolism after colectomy

A 65-year-old man underwent transversal colectomy for colon cancer under combined epidural and general anesthesia. On the 1st postoperative day, he developed consciousness loss and low SpO2 (< 90%) after walking, and pulmonary embolism was diagnosed by CT-scan and pulmonary scintigraphy. His consciousness and hemodynamic state recovered, and anticoagulation therapy was started after extraction of the epidural catheter. Heparin 5000 units was injected and continuous injection was started. Five hours after the extraction of the catheter, he developed paraplegia and analgesia below L1, and epidural hematoma was found with magnetic resonance imaging (MRI). Emergent laminectomy was performed and the hematoma was removed. The day after laminectomy, injection of heparin was started and 1 g x day(-1) of methylpredonisolone administered for 3 days. His paraplegia did not improve after the laminectomy. We discussed about pulmonary embolism and epidural hematoma.     

Safety of a clinical surveillance protocol with 3- and 6-week warfarin prophylaxis after total joint arthroplasty

The charts of 1869 patients were reviewed for the occurrence of deep venous thrombosis (DVT) and pulmonary embolism after total hip or knee arthroplasty. Prophylaxis consisted of 3 (group 1; n=1235) or 6 (group 2; n=634) weeks low-dose warfarin, pneumatic compression boots worn by patients in the hospital, mobilization on the first postoperative day, and a clinical surveillance protocol. Venous ultrasound or ventilation/perfusion lung scintigraphy (V/Q) was performed only if patients became symptomatic. patients. Twenty-three (1.8%) patients were positive for DVT. Ventilation/perfusion lung scintigraphy was performed on 25 patients, and 5 (0.4%) patients were positive for pulmonary embolism. In group 2, 117 patients were evaluated for DVT, and 19 (3%) patients had positive results determined by ultrasound. Twenty-five patients were evaluated with V/Q and only 1 (0.16%) patient was positive for pulmonary embolism. No patient developed a fatal pulmonary embolism or postphlebitic syndrome. This prophylaxis protocol is an efficient and cost-effective method for the prevention of significant events after surgery.     

Postoperative leg vein thrombosis and pulmonary embolisn after upper abdominal operations. A prospective study with 125I fibrinogentest and pulmonary scintigraphy.

The incidence of postoperative deep venous thrombosis in the lower limbs and of pulmonary embolism has been studied in 49 patients operated upon for gallbladder and gastric diseases. 125I fibrinogen test was performed preoperatively and usually five times postoperatively. Pulmonary scintigraphy was also performed preoperatively and usually twice after the operation. An attempt was made to evaluate the prophylactic effect of Dextran 40. Only one patient developed a deep vein thrombosis without clinical signs. Postoperative pulmonary embolism was found in 13 patients, all but one clinically silent. The second postoperative pulmonary scintigraphy showed that the emboli had disappeared or diminished in 6 patients. Because of the low number of patients with deep venous thrombosis the prophylactic effect of Dextran 40 could not be assessed. The present investigation showed that the incidence of deep venous thrombosis in the legs was low after operations in the upper part of the abdomen while the incidence of pulmonary embolism was high. No connection between leg vein thrombosis and pulmonary embolism could be demonstrated.     

Thromboembolic complications after major abdominal surgery: effect of thoracic epidural analgesia

In a prospective study of 50 patients subjected to major abdominal surgery, the frequencies of postoperative deep vein thrombosis and pulmonary embolism were analysed. The patients were randomized to one of two groups receiving either neurolept anaesthesia or neurolept anaesthesia combined with thoracic epidural analgesia. Five patients were excluded. No special anti-thrombotic prophylaxis was administered. Deep vein thrombosis was diagnosed with the 125I-fibrinogen test and pulmonary embolism with pre- and postoperative lung perfusion scintigraphy combined with lung X-ray. Patients with positive scintigraphy were subjected to pulmonary angiography for verification of the diagnosis. Deep vein thrombosis was treated when diagnosed. The frequency of deep vein thrombosis was equal in both groups (38%). No patient with pulmonary embolism was recorded during the first seven days after operation. It is concluded that the addition of thoracic epidural analgesia to neurolept anaesthesia does not alter the postoperative frequency of deep vein thrombosis in patients subjected to major abdominal surgery. Early diagnosis and treatment of postoperative deep vein thrombosis might prevent pulmonary embolism. Problems encountered in the diagnosis of postoperative pulmonary embolism are discussed.     

A clinico-pathological study of fatal pulmonary embolism in a specialist orthopaedic hospital

A study of post-mortem examinations performed between 1970 and 1979 at a specialist orthopaedic hospital revealed that the overall mortality rate due to pulmonary embolism was 0.23% and that pulmonary embolism was responsible for 19.1% of hospital deaths. The majority of these fatalities occurred following operation for either fractured proximal femur or total hip replacement. During the decade, 928 patients were operated upon for fractured proximal femur, none received prophylactic anticoagulation therapy and the mortality rate due to pulmonary embolism was 17.7%. However, the yearly mortality rate decreased with time and this change was attributed to earlier operation and early mobilisation. Over the same period, 3016 patients underwent total hip replacement, 20% were anticoagulated prophylactically; the mortality rate due to pulmonary embolism was 0.63%. In those patients who died of pulmonary embolism, post-mortem evidence of deep vein thrombosis was usually found, but no relationship between site of thrombosis and side of operation was observed. Pulmonary embolism was diagnosed in only a few patients although on later consideration at least a third of patients had symptoms suggestive of previous emboli. Possible improvements in diagnosis are discussed and a more rational approach to prophylactic anticoagulation suggested.     

Cerebral arterial air embolism following CT-guided lung needle marking. Report of a case

We report a case of survival following a temporary cerebral air embolism, which occurred immediately after CT guided lung needle marking. A 24-year-old man was referred to our hospital for resection of a pulmonary nodule. To localize the tumor, lung needle marking under CT guidance was performed. Almost immediately, the patient experienced symptoms of cerebral arterial air embolism. The following day, the symptoms diminished, and a brain CT showed no abnormal lesions. A video-assisted thoracoscopic wedge resection was performed as scheduled, the patient's postoperative course was uneventful, and he was discharged in relatively good condition.     

Air embolism following computed tomography-guided lung needle marking; report of a case

We report air embolism following computed tomography (CT)-guided lung needle marking. A 55-year-old man was admitted to our hospital with left pulmonary tumor, characterized as ground glass opacity (GGO). To localize the tumor, lung needle marking under CT guidance was performed. Almost immediately, the patient experienced symptoms of cerebral arterial air embolism. CT revealed air in the left ventricle. About 2.5 hours later the symptoms and the air disappeared. Three days later a video-assisted thoracoscopic wedge resection was performed. The patient's postoperative course was uneventful, and he was discharged in good condition.     

A case of suspected pulmonary air embolism in endoscopic neurosurgery

Sudden reduction in end-tidal PCO2 and SpO2 occurred during the endoscopic third ventriculostomy in a patient with hydrocephalus under general anesthesia. We suspect that it was caused by pulmonary air embolism. A 63-year-old female was scheduled for endoscopic third ventriculostomy under general anesthesia. Endoscopic manipulation caused hemorrhage from chorioid plexus 21 minutes after the procedure was begun, and intraventricular irrigation was performed to achieve hemostasis. In the subsequent 3 minutes, end-tidal PCO2 declined from 26 mmHg to 15 mmHg (PaCO2 39.6 mmHg), and SpO2 declined from 98% to 92% (PaO2 69.2 mmHg). Nitrous oxide was discontinued immediately because pulmonary air embolism was suspected and the oxygen concentration was increased to 100%. At the same time the surgical procedure was discontinued. After 15 minutes, end-tidal PCO2 recovered to 25 mmHg, and SpO2 recovered to 98% (PaO2 136.5 mmHg), and surgery was resumed. The patient recovered from anesthesia. The chest X-p at the end of operation, and pulmonary scintigraphy on the following day revealed no abnormal findings, but brain CT demonstrated a large quantity of air in both lateral ventricles.     

Therapeutic effects of thromboembolectomy and caval Günther filter insertion in chronic pulmonary embolism

Two cases of chronic-stage pulmonary embolism which had occurred at least one month before the operation were presented. Pulmonary thromboembolectomy under the cardiopulmonary bypass was performed and followed by the insertion of Günther filter to prevent recurrence of embolism. Both cases revealed severe obstruction occupying over 50% of the pulmonary arteries which were presented by the remarkable increase of pulmonary arterial systolic pressures up to 100 and 80 mmHg respectively. After thrombectomy the pulmonary artery pressure declined to 45 and 28 mmHg, even though the pulmonary embolism was in subchronic state. The respiratory symptoms and abnormal findings on the ECG and chest X-ray were also improved. Since the phlebothrombosis of the inferior limb might be the cause of pulmonary embolism, the insertion of the filter in the inferior vena cava was thought to be indispensable for the prevention of recurrence.     

Screening and Treatment of Pulmonary Embolism After Total Hip Replacement

The effect of anticoagulative treatment of pulmonary embolism was studied in 63 patients out of 348 operated on with total hip replacement. Screening diagnosis of pulmonary embolism was obtained from ^99mTc perfusion scintigraphy in combination with ^99mTc-microaerosol ventilation scintigraphy and chest radiogram. the administration of heparin and warfarin was associated with hemorrhagic side effects in 7 per cent. the final outcome of surgery, however, was not interfered with. Fatal pulmonary embolism occurred in one patient (0.3 per cent) in whom the diagnosis had been missed.     

Pulmonary embolism after placement of an Esmarch bandage for ankle surgery

We report the case of a woman scheduled for surgical fixation of an ankle fracture who developed a pulmonary embolism during application of an Esmarch compression bandage for exsanguination of the limb. Tracheal intubation and mechanical ventilation were needed to reanimate the patient and surgery had to be postponed 15 days. Orthopedic surgery, pneumatic tourniquets for providing a bloodless field and other risk factors contribute to the development of pulmonary embolism, which is often fatal. Accurate diagnosis by plasma D-dimer determination and imaging (perfusion scintigraphy, vascular Doppler ultrasound, echocardiography and pulmonary angiography) is discussed, along with therapeutic approaches to consider when managing pulmonary embolism.     

Hochrisikolungenembolie

High risk pulmonary embolism commonly presents with a variety of symptoms and is an acute life-threatening event. In patients showing unclear acute circulatory distress, pulmonary embolism should be quickly ruled out by computed tomography or echocardiography. The diagnostic steps and surgical treatment of pulmonary embolism in a 25-year-old female patient suffering from acute circulatory insufficiency resulting in cardiac arrest within 11?min after emergency hospital admission are reported. Due to the reasonable suspicion of acute right heart decompensation, systemic perfusion was re-established by cardiopulmonary bypass after cardiopulmonary resuscitation for 41?min. Sternotomy and surgical embolectomy were performed. The patient was successfully extubated the following day and despite the long resuscitation time the outcome was excellent without any neurological deficit. Recent publications addressing the advantages of primary embolectomy versus intravenous thrombolysis in acute circulatory distress caused by pulmonary embolism are discussed. Primary surgical treatment including cardiopulmonary bypass for right ventricular relief and re-establishing of systemic perfusion is recommended for patients with pulmonary embolism undergoing cardiopulmonary resuscitation.     

Acute Massive Pulmonary Embolism Following High Ligation Combined with Compression Sclerotherapy for Varicose Veins

A case of acute pulmonary embolism following high ligation and compression sclerotherapy for varicose veins is reported. A 54-year-old women developed superficial varicosities and stasis pigmentation on her left leg 1 year prior to her first visit to hospital. No deep vein thrombosis was detected by ascending phlebography performed 3 months prior to operation. High ligation combined with compression sclerotherapy was performed for the varicose veins. One day after treatment, the patient complained of chest pain and discomfort, and then collapsed. Perfusion scintigraphy revealed multiple embolisms in the bilateral lungs. The patient recovered after aggressive anticoagulant and thrombolytic therapy. Although pulmonary embolism is a rare complication of sclerotherapy, it is potentially one of the most serious.     

Postoperative pulmonary embolism in neurosurgical practice: report of two cases

Pulmonary embolism following postoperative deep venous thrombosis is a very serious complication with a high mortality rate. Though this disorder has been thought to be rare in Japanese, its occurrence seems to be increasing recently because of changes in eating habits, increase of average age and the frequent practice of venous catheterization. Two cases of the pulmonary embolism following deep venous thrombosis after surgery are reported, and possible causes of the deep venous thrombosis are discussed. Case 1: A 48 year-old obese female was operated on for a posterior fossa dural arteriovenous malformation. On the 4th postoperative day, she developed a pain and swelling in the left leg and low back pain. On the 18th postoperative day, she fell into a state of shock following the sudden onset of a severe back pain and respiratory distress. After diagnosis of the pulmonary embolism, she was immediately treated with urokinase, warfarin and aspirin. Her obesity was considered to be one of the risk factors of the postoperative deep venous thrombosis. Case 2: A 62 year-old female with a ruptured cerebral aneurysm could not get out of bed because of postoperative mental disturbance. A central venous pressure catheter was inserted into the right femoral vein for two weeks postoperatively. One month after surgery, she complained of swelling and a dull pain in the right leg without cardiorespiratory symptoms. Lung perfusion scintigraphy showed asymptomatic pulmonary embolism. She was treated immediately. Both long bed rest and femoral venous catheterization were considered as risk factors possibly leading to deep venous thrombosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anesthesia for patients with unexpected pulmonary embolisms due to a large abdominal tumor obstructing with inferior vena cava]

Several reports have highlighted the risk of pulmonary embolisms during the preoperative period in patients with large abdominal tumors obstructing the inferior vena cava. We describe a patient who developed pulmonary embolism just before surgery. A 68[correction of 64]-year-old female was scheduled to undergo elective resection of a large abdominal tumor under general anesthesia. She had no signs of deep venous thrombosis, but on the day of the operation, pulmonary embolism developed suddenly. Anticoagulant therapy was performed. Capnography and pulmonary artery pressure were monitored during the perioperative period to detect the recurrence of pulmonary embolism. The percutaneous cardio-pulmonary support (PCPS) was also prepared. The operation was performed successfully. In this patient, the pulmonary embolism occurred suddenly during the preoperative period, even though we had ruled out the existence of deep venous thrombosis. This case report emphasizes the risk of pulmonary embolism in any patient with a large abdominal tumor obstructing the inferior vena cava. This case of a large abdominal tumor suggests that capnography, monitoring of pulmonary artery pressure and preparation of a PCPS in case of pulmonary embolism during surgery are necessary even in patients without signs of deep venous thrombosis.     

Role of spiral volumetric computed tomographic scanning in the assessment of patients with clinical suspicion of pulmonary embolism and an abnormal ventilation/perfusion lung scan.

BACKGROUND: A study was carried out to evaluate the potential place of spiral volumetric computed tomography (SVCT) in the diagnostic strategy for pulmonary embolism. METHODS: In a prospective study 249 patients with clinical suspicion of pulmonary embolism were evaluated with various imaging techniques. In all patients a ventilation/perfusion (V/Q) scan was performed. Seventy seven patients with an abnormal V/Q scan underwent SVCT. Pulmonary angiography was then performed in all 42 patients with a non-diagnostic V/Q scan and in three patients with a high probability V/Q scan without emboli on the SVCT scan. Patients with an abnormal perfusion scan also underwent ultrasonography of the legs for the detection of deep vein thrombosis. RESULTS: One hundred and seventy two patients (69%) had a normal V/Q scan. Forty two patients (17%) had a non-diagnostic V/Q scan, and in five of these patients pulmonary emboli were found both by SVCT and pulmonary angiography. In one patient, although SVCT showed no emboli, the angiogram was positive for pulmonary embolism. In one of the 42 patients the SVCT scan showed an embolus which was not confirmed by pulmonary angiography. The other 35 patients showed no sign of emboli. Thirty five patients (14%) had a high probability V/Q scan, and in 32 patients emboli were seen on SVCT images. Two patients had both a negative SVCT scan and a negative pulmonary angiogram. In one who had an inconclusive SVCT scan pulmonary angiography was positive. The sensitivity for pulmonary embolism was 95% and the specificity 97%; the positive and negative predicted values of SVCT were 97% and 97%, respectively. CONCLUSIONS: SVCT is a relatively noninvasive test for pulmonary embolism which is both sensitive and specific and which may serve as an alternative to ventilation scintigraphy and possibly to pulmonary angiography in the diagnostic strategy for pulmonary embolism.     

无水乙醇血管内治疗所致重大心肺并发症的研究现状与焦点问题

无水乙醇血管内治疗是目前针对颅外脉管畸形最有效的治疗方法,心肺衰竭是其最严重的致死性并发症,也是阻碍该技术开展的重要原因。目前,对于该技术导致的心肺衰竭的临床特点及发生机制尚存争议。我们回顾现有文献中涉及的可能的发生机制,如肺动脉高压、肺血栓、心脏抑制等,关注其发病特点、发生时机、无水乙醇用量、发生预测、预防措施等焦点问题,对上述内容进行系统性综述。     

Complications of hysteroscopical myomectomy: a report of two cases

Hysteroscopical myomectomy has recently become popular in Japan. We present two patients who developed water intoxication and air embolism during surgery. [Case 1] Hysteroscopical myomectomy was performed under general anesthesia in a 37-yr-old woman (ASA I). Three hours after the start of the surgery, the patient's serum sodium concentration dropped to 118 mEq.l-1. She was treated with furosemide and recovered without sequelae. [Case 2] A 39-yr-old woman (ASA I) was scheduled to have hysteroscopical myomectomy under spinal and epidural anesthesia. Forty-five minutes after the start of the surgery, the patient complained of severe back pain, her blood pressure decreasing to 40 mmHg, SpO2 decreased to 80%, and ECG showed atrial fibrillation. After administration of ephedrine 5 mg, she recovered within 20 min. No abnormality was observed in echocardiogram, although some negative spots were detectable in a lung scintigraphy. She was discharged without sequelae. The hysteroscopical procedure is considered a non-invasive surgery, but the cases presented here emphasize the necessity for close attention to complications, especially pulmonary embolism.     

Popliteal Venous Aneurysm—A Systematic Review

Background Popliteal vein aneurysm is a rare but potentially problematic disease with a risk of pulmonary embolism. Method A systematic literature search was performed. Results A total of 105 popliteal vein aneurysms were identified, with a slight female and left-sided preponderance. Dominating symptoms are caused by pulmonary embolism, followed by local symptoms with a palpable mass. In four patients arterial symptoms were reported. The most frequently used diagnostic test was phlebography, increasingly replaced by duplex ultrasonography in recent years. Because pulmonary embolism is a potential, it motivates surgical removal. In most cases excision and lateral suture is possible. Four fatal cases were reported. Unfortunately follow-up time and results are poorly documented. Conclusion Popliteal venous aneurysm is rare but should be considered as a local source of pulmonary embolism when no other explanation is found.