球囊导管取栓术治疗急性下肢动脉栓塞患者的体会

目的探讨球囊导管取栓术治疗急性下肢动脉栓塞患者的临床疗效。方法回顾性分析祈福医院2013年1月至2018年12月应用球囊导管微创取栓术治疗的78例急性下肢动脉栓塞患者的临床资料。结果治愈60例,治愈率为89.6%,患肢血供恢复。好转7例(10.4%),肢体缺血症状明显好转。全部患者无截肢。死亡1例(2.6%)。结论球囊导管取栓术是治疗急性动脉栓塞的有效方法,患者一经确诊应尽早手术取栓,有利于提高其保肢率和降低病死率。     

Could Chronic Mesenteric Originated Hypoxia Insult Produce Opposite Pathologic Features： Hypoplasia and Hyperplasia of the Intestine

Chronic ischemia produces corresponding tissue hypoplasia. However, here we report a distinctive hypertrophy of the intestine due to chronic mesenteric insufficiency, which was confirmed by angiography in two patients with opposite characteristic pathologic presentation of intestine. During surgery of the first patient, an approximately 60cm long ileum with sausage consistency and cyanosis color was identified proximal to the caecum; wall-attached thromboembolism material and the hypertrophied segment of ileum were removed. In the other patient, the intestine wall was paper thin; after aorto-mesenteric bypass the intestine wall grew thicker. Post operative recovery of both patients was uneventful. The commonly observed situation after a long-standing hypoxic insult in a setting of chronic mesenteric ischemia is that the target tissue will at least develop a slight hypoplasia. However, the cases we present here had either pronounced hyperplasia or severe hypoplasia. We thus report it, expecting to identify a special mechanism to explain this paradox.     

Pulmonary hypertension due to tumor emboli: A report of three autopsy cases with morphological correlations to radiological findings

Three cases of pulmonary hypertension caused by tumor emboli to the lungs are described. Two of the three cases had a clinical diagnosis of pulmonary thromboembolism until surgical embolectomy, and the other had a diagnosis of primary pulmonary hypertension. Autopsy disclosed chondrosarcoma, choriocarcinoma and gastric cancer as the primary tumors, respectively. Pulmonary vascular obstruction due to tumor embolism leading to pulmonary hypertension is a previously rare clinical entity, and obstructed pulmonary vessels are believed to tend to be small vessels. We compared the autopsy and radiological findings and concluded that pulmonary tumor embolism involved not only the small peripheral arteries but also the segmental and/or lobar arteries.     

急性缺血性脑卒中伴心房颤动患者行 机械取栓的临床疗效及预后因素

〔摘 要〕 目的：研究机械取栓治疗急性缺血性脑卒中（AIS）伴心房颤动患者的疗效及预后因素。 方法：选取北 京市红十字会急诊抢救中心 2020 年 2 月至 2021 年 12 月期间收治的 90 例 AIS 伴心房颤动患者,均行机械取栓治疗, 入院时、治疗后 24 h、7 d、90 d 评估患者的美国国立卫生研究院卒中量表（NIHSS）评分,并在治疗 90 d 后评估患 者的预后效果,参考改良 Rankin 修订量表（mRS）评价,并对影响预后的危险因素总结分析。 结果：入院时所有患 者 NIHSS 评分为（11.25 ± 2.34）分,治疗后 24 h 的 NIHSS 评分为（8.21 ± 1.52）分,治疗后 7 d 的 NIHSS 评分为 （5.12 ± 0.93）分,治疗后 90 d 的 NIHSS 评分为（3.06 ± 0.54）分,NIHSS 评分逐渐下降,差异具有统计学意义 （P ＜ 0.05）。预后良好组、预后不良组患者比较,年龄、高血压、糖尿病、血糖、收缩压、舒张压、侧支循环建立情况、 开始治疗时间、血管再通时间及入院 NIHSS 评分比较,差异具有统计学意义（P ＜ 0.05）;多因素 logistic 回归分析 显示,导致 AIS 伴心房颤动患者机械取栓术后预后不良的独立危险因素有：年龄≥ 60 岁、高血压、未建立侧支循环、 血管再通时间≥ 4 h、入院 NIHSS 评分≥ 14 分,差异具有统计学意义（P ＜ 0.05）。 结论：机械取栓术治疗 AIS 伴 心房颤动患者可减缓神经功能缺损程度,导致患者预后不良的独立危险因素是年龄≥ 60 岁、高血压、未建立侧支循环、 血管再通时间≥ 4 h、入院 NIHSS 评分≥ 14 分,故临床需引起高度重视。     

Catheter-Directed Thrombolysis for Pulmonary Embolism: The State of Practice

Acute pulmonary embolism (PE) is a major public health problem. It is the third most common cause of death in hospitalized patients. In the United States, there are up to 600,000 cases diagnosed per year with 100,000-180,000 acute PE-related deaths. Common risk factors include underlying genetic conditions, acquired conditions, and acquired hypercoagulable states. Acute PE increases the pulmonary vascular resistance and the load on the right ventricle (RV). Increased RV loading causes compensatory RV dilation, impaired contractility, tachycardia, and sympathetic activation. RV dilation and increased intramural pressure decrease diastolic coronary blood flow, leading to RV ischemia and myocardial necrosis. Ultimately, insufficient cardiac output from the RV causes left ventricular under-filling which results in systemic hypotension and cardiovascular collapse. Current prognostic stratification strategy separates acute PE into massive, submassive, and low-risk by presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive, and low-risk acute PE have mortality rates of 25%-65%, 3%, and <1%, respectively. Current PE management includes the use of anticoagulation alone, systemic thrombolysis, catheter-directed thrombolysis, and surgical embolectomy. This article will describe the current state of practice for catheter-directed thrombolysis and its role in the management of acute PE.     

Open surgical embolectomy for cardiogenic cerebral embolism: Technical note and its advantages

Background and importanceIn cardiogenic cerebral embolism, early recanalization is the most important factor for good prognosis. However, endovascular thrombectomy often fails to achieve recanalization. We present an open surgical embolectomy technique and discuss its advantages.Clinical presentationA 79-year-old woman developed right hemiparesis and severe aphasia. Magnetic resonance imaging revealed an acute cerebral infarction caused by left middle cerebral artery (MCA) occlusion. We attempted endovascular thrombectomy but failed because it was impossible to guide the catheter to the occlusion site. Hence, we converted to open surgical embolectomy. Sylvian fissure was widely opened. After confirming the range of thrombosis using indocyanine green videoangiography (ICGVAG), the proximal and distal arteries were secured, and a temporary clip was placed on the distal M2 to prevent distal thrombosis migration. MCA was cut approximately 3 mm from the bifurcation, and thrombosis was removed using micro-forceps. The proximal clip was simultaneously inserted but was not clamped because the thrombus was extruded by proximal vascular flow. Immediately after removing the thrombus, intense bleeding occurred from the proximal flow. An assistant clamped the proximal artery using the prepared clip, and the incised area of MCA was sutured using 9-0 threads. We finally confirmed blood flow after recanalization using ICGVAG. The time from skin incision to recanalization was 27 min. After the procedure, the patient developed slight aphasia but had no hemiparesis and was later transferred to a rehabilitation hospital.ConclusionOpen surgical embolectomy may be a secondary rescue treatment option in the case of endovascular thrombectomy failure.     

Management of pulmonary embolism

Pulmonary embolism (PE) is a common condition with significant mortality and morbidity. Its occurrence frequently triggers referral to critical care services. Patients within critical care environments are also at elevated risk of developing venous thrombo-embolism and PE. This highlights the need for critical care clinicians to be confident in their approach to the patient with PE. Furthermore, the co-morbid conditions in this patient group may present additional challenges both in diagnosis (e.g. safe access to radiology) and management (e.g. relative contraindication to anticoagulation/thrombolysis in trauma or intracranial haemorrhage). This brief review summarizes the contemporary evidence base regarding both diagnosis and treatment strategies and draws upon this to suggest a simple algorithm for investigation, risk stratification and management, particularly tailored to patients within a critical care setting.     

Expanding the stroke team to include interventional cardiology

Team-based care has been emphasized as a strategy to improve and optimize outcomes for broad groups of patients who have presented with often complex medical conditions including large vessel cerebral occlusion. Although neurointerventionalists from different specialties perform mechanical embolectomy, which has become the standard of care for large vessel cerebral occlusion, these specialties are limited by relatively low numbers typically concentrated in a small number of sites. In this single center experience, approximately 50 patients with large vessel stroke were transferred out of an emergency room to other centers despite the availability of an experienced cardiologist with extensive carotid experience. Such transfer strategies typically result in delays in receiving reperfusion and, therefore, may decrease the success rates and substantial improvement that can be obtained by patients in this setting. Trained interventional cardiologists in centers with limited 24/7/365 coverage could achieve rapid revascularization and reperfusion saving lives. In order to accommodate the need for treating these patients, carotid stent trained cardiologists should enter the arena, learn mechanical embolectomy, and be supported by their colleagues from other disciplines on acute stroke care teams.