经导管祛栓术治疗急性肺动脉栓塞

目的：探讨经导管栓子祛除术治疗急性肺动脉栓塞的临床疗效。方法：对24例急性肺动脉栓塞的病人，经肺动脉造影明确诊断，通过旋转猪尾导管碎栓、抽吸导管抽吸和局部溶栓来开通肺动脉。观察临床症状、动脉血氧分压（PaO2)、肺动脉平均压（PAPm）和肺动脉开通情况。结果：术后症状即刻缓解者23例，完全开通者20例，与术前相比PaO2明显升高（P＜0．05），PAPm明显降低（P＜0．05），并发脑出血1例，死亡2例，22例病人存活。结论：经导管栓子祛除术治疗急性肺动脉栓塞是安全有效的方法。     

急性大面积肺动脉栓塞的介入治疗及疗效评价

目的 评价经血管栓子祛除术治疗急性大面积肺动脉栓塞的疗效和安全性.方法 对12例经CT肺血管造影或血管造影证实为大面积肺动脉栓塞患者,经肺动脉行传统介入器材碎栓、吸栓及局部溶栓联合治疗,观察临床症状、体征,血气分析及血流动力学改变,肺动脉开通情况以及有无并发症.结果 介入治疗后血管开通良好、症状即刻缓解9例,2例术后数天内症状逐步好转.PaO2术前(54.92±6.17)mmHg,术后达(90.91±1.62)mmHg,SaO2术前(85.17±8.39)%,术后达(95.75±1.96)%,差异有统计学意义(P均<0.01),休克指数明显下降(1.26±0.18/0.67±0.14,P<0.01),Miller评分明显降低(21.75±4.35/13.83±5.69,P=0.0001),mPAP显著下降[(35.59±7.68)mmHg/(30.04±7.93)mm Hg,P=0.001].1例因栓塞面积大,术后3 d死亡,术后并发脑出血1例,3 d后死亡.结论 经肺动脉行血管祛栓综合治疗急性大面积肺动脉栓塞是一种安全有效的方法 .     

Severity assessment of acute pulmonary embolism: role of CT angiography

Helical CT has gained wide acceptance in the noninvasive diagnosis of acute pulmonary embolism (APE) and has therefore largely replaced conventional pulmonary angiography as well as ventilation perfusion scan in the work-up of patients suspected of nonsevere pulmonary embolism (PE). Massive PE is life-threatening; its occurrence may require aggressive treatment such as thrombolysis or embolectomy. Identification of patients suffering from major thromboembolic events based solely on clinical grounds may, however, be difficult. Acute right heart failure is the principal cause of circulatory collapse and death for patients with massive PE, and rapid and specific diagnosis and therapy are required in such patients. Bedside echocardiography, a commonly performed first-line examination, demonstrates signs of cor pulmonale, if present, and can identify large central thrombi. However, echocardiography has limitations. In this review, our goal is to discuss the potential role of CT in assessing patients with severe APE. CT evaluation is based on the direct quantification of pulmonary arterial bed obstruction using various scores and the evaluation of morphological heart changes indicating acute cor pulmonale.     

Percutaneous catheter and guidewire fragmentation with local administration of recombinant tissue plasminogen activator as a treatment for massive pulmonary embolism

The purpose of this article is to report four patients with massive pulmonary embolism treated with percutaneous catheter and guidewire fragmentation and local administration of recombinant tissue plasminogen activator (r-TPA). Four patients with massive pulmonary embolism initially underwent pulmonary angiography. Thrombus fragmentation was performed with both standard angiographic guidewires and catheters followed by local infusion of 41–200 mg of r-TPA. Pulmonary angiography was repeated after treatment. All patients survived with improvement in their clinical status and eventual discharge from hospital. Angiography in all patients post treatment demonstrated improvement in pulmonary perfusion (mean Miller score before treatment 22.5; mean Miller score after treatment 5.75). No patient had a significant complication. Mechanical fragmentation of the thrombus followed by local infusion of r-TPA was an effective treatment for massive pulmonary embolism in these four patients with no significant complications. Received: 9 February 1998; Revision received: 7 July 1998; Accepted: 7 September 1998     

Radiographic techniques for balloon-occlusion pulmonary angiography.

Pulmonary angiography was performed in 125 patients with suspected pulmonary embolism. Standard angiographic techniques were combined with balloon occlusion of pulmonary arterial branches using a double lumen catheter and contrast material injection distal to the occlusion. Vessel opacification was fluoroscopically monitored and images obtained with either a conventional cut-film camera, a spot-film camera, or cineangiography. Balloon-occlusion angiography improved image quality and contributed substantially to the radiographic diagnosis of pulmonary embolism in most patients. The technique is useful in patients too ill to undergo conventional angiography and may be performed at the bedside.     

Acute pulmonary embolism: diagnostic value of digital subtraction angiography

Digital subtraction angiography (DSA) performed via a peripheral vein was compared prospectively with selective conventional pulmonary angiography (CPA) in 54 patients suspected of having pulmonary embolism (PE). All patients also underwent ascending venography. In contrast to the conventional pulmonary angiograms, all of which were considered satisfactory, 13 of 54 digital subtraction angiograms (24%) were technically unsatisfactory. The interpretable digital subtraction angiograms had 81% sensitivity and 64% specificity. With DSA, one cannot exclude the diagnosis of PE on the basis of normal angiograms (27% false-positive results) as one can with perfusion scanning. On the other hand, DSA showed good sensitivity (94%) in medium to major PE. Therefore it may be the technique of choice in the screening of life-threatening PE for which curative emergency treatment with thrombolytic agents or embolectomy is often necessary.     

CT angiography findings of the left atrium and right ventricle in patients with massive pulmonary embolism

OBJECTIVE: The purpose of this study was to show the imaging findings of the left atrium and right ventricle on CT angiography in patients with massive pulmonary embolism. CONCLUSION: Massive pulmonary embolism can cause abrupt acute pulmonary arterial hypertension, right ventricular dysfunction, and decrease in left ventricular preload. Patients with these findings on CT angiography can have a poorer prognosis than those without these imaging findings. Consequently, recognizing anatomic changes such as right ventricular dilation or septal bowing, decrease in size of left atrium and pulmonary veins (a manifestation of decreased pulmonary venous return) would be useful for risk stratification at the time of massive pulmonary embolism.     

Comparison of lung scintigraphy and CT angiography in the diagnosis of pulmonary embolism

In our institution, as in others, pulmonary angiography is not used in the diagnosis of pulmonary embolism because of its perceived risks. We compared the results on lung scintigraphy and computed tomography angiography (CTA) in 116 consecutive patients with suspected pulmonary embolism. In 14 patients with normal lung scans 13 (93%) were also normal with CTA. In the 73 patients with low probability lung scans only five (7%) demonstrated pulmonary embolism with CTA. In 12 patients with high probability lung scans 11 (92%) demonstrated pulmonary embolism on CTA. However, in the 17 patients with intermediate probability lung scans, 10 (58.8%) showed embolism with CTA. We conclude that wherever practicable lung scans should be performed in all patients due to its relatively low radiation burden and that CTA be performed in patients with intermediate probability scans due to the high incidence of pulmonary embolism. Patients with either a normal scan or high probability scan should be treated appropriately. In patients with low probability scans CTA should be performed in those with a high clinical suspicion of thromboembolism.     

Unresolved major pulmonary embolism: Importance of follow-up lung scan in diagnosis

Unresolved major pulmonary embolism (UMPE) is an uncommon condition which causes pulmonary hypertension, cor pulmonale and death. An accurate and prompt diagnosis of UMPE is very important in the management of such patients with pulmonary embolectomy. Follow-up lung scans can lead to earlier diagnosis of UMPE, especially in patients who have a history of acute pulmonary embolism and present with pulmonary hypertension, respiratory insufficiency and cor pulmonale. We report a case of UMPE strongly suggested by follow-up lung scans and subsequently confirmed by pulmonary angiography and postmortem examination.     

Unresolved major pulmonary embolism: importance of follow-up lung scan in diagnosis

Unresolved major pulmonary embolism (UMPE) is an uncommon condition which causes pulmonary hypertension, cor pulmonale and death. An accurate and prompt diagnosis of UMPE is very important in the management of such patients with pulmonary embolectomy. Follow-up lung scans can lead to earlier diagnosis of UMPE, especially in patients who have a history of acute pulmonary embolism and present with pulmonary hypertension, respiratory insufficiency and cor pulmonale. We report a case of UMPE strongly suggested by follow-up lung scans and subsequently confirmed by pulmonary angiography and postmortem examination.     

Reliability of selective pulmonary arteriography in the diagnosis of pulmonary embolism

To test the reliability of conventional selective pulmonary arteriography in the diagnosis of pulmonary embolism, three angiographers reviewed the arteriograms of a series of 60 patients retrospectively, independently, and without benefit of additional data. Pulmonary arteriograms had been interpreted as positive for pulmonary embolism in 25 of these patients during their hospitalizations. Angiographers A, B, and C judged the arteriograms of 24, 29, and 25 patients, respectively, as positive for pulmonary embolism. Mean interobserver agreement was 86%. Interobserver agreement was not associated significantly with the quality of the arteriogram or with selective injection of a lobar vs a pulmonary artery, but was associated strongly with the magnitude of thromboembolism. All angiographers agreed that the arteriograms were positive in 18 cases of pulmonary embolism graded as massive, lobar, or segmental, but agreed in only two of 15 cases graded as subsegmental. We conclude that conventional selective pulmonary arteriography is reliable in the detection of embolus in segmental or larger pulmonary arteries. Observer disagreement becomes considerable for embolus limited to subsegmental pulmonary arteries, indicating that emboli of this size are at the resolution limit of the technique.     

暂时介入性肺切除治疗急性大面积肺栓塞的实验研究

目的 尝试应用经气道球囊导管栓塞术稳定大面积肺栓塞动物模型的生命体征.方法 健康绵羊27只,应用自体血凝块或自制可脱落球囊栓塞右肺动脉建立肺栓塞动物模型.18只动物模型当SaO_2较栓塞前下降≥25%时,于相应的右主支气管放置球囊干预,5只制作肺栓塞动物模型成功后对照观察,4只制作肺栓塞动物模型后未达到干预指标.有创监测肺动脉压、外周动脉压、中心静脉压、心率、SaO_2、PaO_2、PaCO_2等.结果 23只动物成功建立了急性肺栓塞模型,心率、呼吸加快,SaO_2平均在30 min之内下降≥25%,肺动脉压升高.18例实验组进行干预,肺动脉压下降、SaO_2和PaO_2升高,与对照组比较有统计学意义(P<0.05).结论 动物实验证实球囊阻塞气道可作为大面积肺栓塞急救,为其后的溶栓等治疗争取时间.     

64层螺旋CT肺动脉造影在肺动脉栓塞诊断中的应用

目的 探讨64层螺旋CT肺动脉造影(CT pulmonary angiography,CTPA)对肺动脉栓塞(pulmonary embolism,PE)的诊断价值.方法 回顾分析24例肺动脉栓塞患者的64层螺旋CT增强图像,将原始图像复制到EBW4.0工作站,对肺动脉主干及分支进行多平面重建(MPR),最大密度投影(MIP)及容积重建(VR)分析.结果 24例患者中,共检出了76处肺动脉及其分支的栓子.其中,左、右肺动脉主干14处(右主干10处、左主干4处),肺叶动脉24处,肺段动脉26处,亚肺段动脉12处.CT表现为肺动脉主干或分支内混合性、附壁性、中心性充盈缺损,可分为完全性或部分性.结论 64层CTPA具有准确、高效、无创等优点,可直观、立体地观察到肺动脉血栓的大小、分布、范围及类型,是临床诊断及观察疗效的首选方法,有望成为肺动脉栓塞检查的“金标准”.     

A case report of primary pulmonary artery intimal sarcoma

Primary pulmonary artery sarcoma is a rare tumor that mimics pulmonary embolism. Patients may present with cough, dyspnea, chest pain, and weight loss. The diagnosis is challenging. Herein, we report a case of 29-year-old female patient who had presented with dyspnea, fatigue for 2 weeks. Computed tomography pulmonary angiography scan suggests pulmonary embolism. We decided to perform surgical embolectomy. The histopathological results, however demonstrated primary pulmonary artery intimal sarcoma. The patient died 1-month post-surgery because of respiratory and circulatory failure.     

Percutaneous removal of pulmonary artery emboli with Hydrolyser catheter in pigs.

OBJECTIVE: To evaluate the efficacy and safety of the Hydrolyser catheter for percutaneous treatment of massive pulmonary embolism in pigs. MATERIALS AND METHODS: Twelve pigs, each weighing between 55 kg and 89 kg, were used. Radioopaque 9 cm x 0.8 cm and 4.5 cm x 0.8 cm clots, produced by mixing pig blood with iodinated contrast agent in vacutainers, were injected via the jugular vein until central pulmonary embolism (main and proximal lobar arteries) was obtained with significant systemic and pulmonary hemodynamic modifications. From a femoral approach, the 7-French Hydrolyser thrombectomy catheter was run over a 0.025-inch (0.64-mm) guide wire to remove the pulmonary emboli. Hemodynamic, gasometric and angiographic monitoring was performed before and after treatment. The procedure's safety and completeness of emboli removal was assessed by cardiopulmonary autopsy. RESULTS: Three of the 12 pigs died during embolization. Thrombectomy was therefore performed in 9, and central emboli could be obtained in 7 of the 9. The Hydrolyser could be manipulated only in central pulmonary arteries and could aspirate only central emboli in 5 of the 7 pigs that had them. Despite minimal angiographic improvement seen in these 5, there was no significant hemodynamic and gasometric improvement after treatment. The procedure induced an increase in free hemoglobin blood levels. Autopsies revealed an average of 2 endothelial injuries per pig (mainly adherent endocardial thrombi) in both nontreated (n = 3) and Hydrolyser-treated (n = 9) groups. CONCLUSION: The Hydrolyser thrombectomy catheter can be promptly positioned and easily steered in central pulmonary arteries. It can be used to partially remove central emboli, but not peripheral pulmonary emboli. Most of the injuries observed may not have been strictly related to Hydrolyser use. The pig might not be a suitable animal model for treatment of massive pulmonary embolism.     

Pulmonary embolic disease: the roles of angiography and lung scanning in diagnosis.

The definitive diagnosis of pulmonary embolism remains difficult despite recent advances in nuclear medicine and angiography. In 10% of a selected series of 145 patients a negative chest x-ray and a positive lung scan was associated with no arteriographic evidence of pulmonary emboli. A normal perfusion lung scan excludes significant pulmonary embolism. When pulmonary arteriography is necessary, a biplane selective pulmonary angiogram should be performed and subselective injections may be required. Pulmonary arteriography is less of a threat to a patient suspected of having pulmonary embolic disease than inappropriate treatment.     

Helical CT for the evaluation of acute pulmonary embolism

OBJECTIVE: In this article, we review the current role of CT pulmonary angiography and indirect CT venography for the evaluation of pulmonary thromboembolic disease. CONCLUSION: With advances in MDCT technology, evaluation of pulmonary thromboembolic disease can now be performed with combined CT pulmonary angiography and CT venography as a "one-stop-shopping" test. CT pulmonary angiography is cost-effective, is accurate, has high interobserver agreement, and has an added advantage of detecting other life-threatening diseases in the chest that mimic pulmonary embolism.     

犬急性大块肺动脉栓塞动物模型的建立

目的制作一种适合器械祛栓试验使用的犬急性大块肺栓塞动物模型。方法7只杂种犬,体外制作动物自体血栓,采用经皮股静脉穿刺置入导管,选择性插入一侧肺动脉中央分支动脉后注入制作好的自体血凝块,栓塞一侧肺动脉中央分支动脉,栓塞前后检测血气、肺动脉压及肺动脉造影。实验存活动物于12h后处死,取两侧肺组织进行病理检查。结果1只注射血栓时造成两侧肺栓塞死亡,1只在栓塞12h后肺动脉有部分再通;其余各只均成功栓塞至靶肺动脉的中央分支动脉。结论该方法制作急性大块肺栓塞的动物模型是可行和可重复的,可以为相关试验提供急性大块肺动脉栓塞动物模型。     

Detection of central pulmonary embolism on computed tomography densitometry images before computed tomography pulmonary angiography

OBJECTIVE: The purpose of this article is to describe the imaging findings of acute central pulmonary embolism on computed tomography (CT) densitometry images performed before contrast-enhanced CT pulmonary angiography. METHODS: A retrospective review was conducted of reports from all CT pulmonary angiograms performed at our institution, and cases of acute central pulmonary embolism, defined as those with clot in the main, left, or right pulmonary arteries, were identified. Images of positive studies were reviewed on a picture archiving and communications system (PACS) workstation. RESULTS: A total of 1282 CT pulmonary angiograms were obtained for evaluation of possible acute pulmonary embolism, and 1 combined CT aortogram and pulmonary angiogram was performed for aortic dissection and acute pulmonary embolism. Two hundred fourteen (16.7%) examinations positive for acute pulmonary embolism were identified, 26 (12.1%, 2.0% of total examinations) of which had central clots. Of the 26 patients with central acute pulmonary embolism, 12 (46.1%, 5.6% of all positive studies and 0.9% of all CT pulmonary angiograms) had clots that were visible on the densitometry images. CONCLUSION: Although an uncommon finding, acute central pulmonary embolism can be detected on CT densitometry performed to optimize opacification of the pulmonary arteries for CT pulmonary angiography and may prove useful in selected clinical situations.     

Experimental impeller fragmentation of iliocaval thrombosis under tulip filter protection: Preliminary results

Purpose To assess the efficacy of catheter fragmentation of massive caval thrombosis and of filter protection against procedure-related pulmonary embolism. Methods In 10 sheep, a self-expanding tulip-shaped filter made from Wallstent mesh (diameter 25 mm) was introduced from the right jugular approach into the proximal inferior vena cava. Experimentally induced massive iliocaval thrombosis was fragmented by an impeller catheter (expanded diameter 14 mm), which was advanced coaxially through the sheath of the expanded filter. Post-procedural cavography and pulmonary angiography were performed to document the extent of caval recanalization and pulmonary embolism. Results In all cases, impeller fragmentation cleared the inferior vena cava and the iliac veins of thrombi completely. Fragments washed downstream were trapped in the filter. In two of the first cases, parts of the clots caused pulmonary embolism before the filter was in place. Further events were avoided by a modification of the experimental setup. Except for some small peripheral perfusion defects in two cases, pulmonary angiograms did not show any incidence of pulmonary embolism. Conclusion Our preliminary results suggest that impeller fragmentation of iliocaval thrombi under tulip filter protection is effective and does not cause significant pulmonary embolism.