Cronkhite-Canada syndrome complicated with pulmonary embolism:A case report

BACKGROUND Cronkhite-Canada syndrome(CCS)is a rare disease,that causes gastrointestinal polyps,ectodermal abnormalities,and gastrointestinal symptoms.CCS is prone to thromboembolism,but clinical workers have not yet established a clinical consciousness of preventing thromboembolism.The present case illustrates pulmonary embolism(PE)complicated by CCS.CASE SUMMARY A 46-year-old male patient presented with mucus,purulent,and bloody stool.Ectodermal changes included skin pigmentation,alopecia,and nail dystrophy.Colonoscopy revealed the presence of multiple polyps.After a comprehensive evaluation,the patient was diagnosed with CCS.During the disease,he was also diagnosed with pulmonary embolism,Riehl's melanosis,and intestinal flora imbalance.After symptomatic treatment with omeprazole,mesalazine,rivaroxaban,nutritional support,and regulation of intestinal flora,the patient’s symptoms were significantly relieved.CONCLUSION CCS complicated with PE was reported for the first time in China in this study.Despite the fact that CCS is extremely rare,patients with CCS should be classified as a high-risk venous thromboembolism(VTE)population,and emphasis should be placed on venous thromboembolism risk assessment and stratification,deep venous thromboembolism screening,prevention of VTE,and careful long-term follow-up.

Research progress on the clinical diagnosis and treatment of COPD with pulmonary embolism

Chronic obstructive pulmonary disease(COPD)is one of the most common and important diseases leading to the death of elderly patients in the world at present.It is characterized by continuous airflow restriction and irreversible chronic airway obstruction,which can easily lead to a variety of complications and accompanying symptoms,greatly affecting the quality of life of individuals and increasing the economic burden of families and society.Pulmonary embolism(PE)is one of the complications of COPD,which can lead to pulmonary blood circulation and respiratory failure,with a high risk of death.However,because its clinical symptoms overlap with the symptoms of acute exacerbation of COPD and lack of specific clinical manifestations and laboratory tests,it is easy to be misdiagnosed and ignored,thus delaying the treatment of patients and affecting the prognosis.This article will elaborate on the clinical diagnosis and treatment of chronic obstructive pulmonary disease combined with pulmonary embolism,providing certain value for early identification of COPD combined with PE patients and the severity of the condition.

Anticoagulation therapy for pulmonary embolism involving a myxoma mimicking, giant type C thrombus: A case report

Right heart thrombus(RHTh) with concurrent acute pulmonary embolism(PE) is rare and can seriously destabilize hemodynamics, leading to an emergency situation with high mortality. Diagnosis and treatment of RHTh with acute PE are not yet standardized. There are few reports of acute PE concurrent with RHTh and even less is known about patients with a right heart mural thrombus. For physicians, the diagnostic choice and treatment of these patients are particularly difficult due to the lack of knowledge. Here, we report a rare case of partial mural RHTh(type C RHTh) with acute PE. The mural mass in the right heart was initially diagnosed as atrial myxoma according to transthoracic echocardiography(TTE), and both pulmonary embolus and the mural mass were completely absorbed after administering Rivaroxiban. This case suggests that TTE alone is insufficient to identify and diagnoses a right heart mural mass such as this. However, novel oral anticoagulants may be effective at alleviating PE with type C RHTh.

Massive pulmonary embolism in Klippel-Trenaunay syndrome after leg raising:A case report

BACKGROUND Klippel-Trenaunay syndrome(KTS)is a rare congenital disorder characterized by a combination of capillary malformations,soft-tissue or bone hypertrophy,and varicose veins or venous malformations.The syndrome predisposes patients to hypercoagulable states,including venous thromboembolism and pulmonary embolism(PE).CASE SUMMARY A 12-year-old girl with KTS was scheduled excision of verrucous hyperkeratosis in the left foot and posterior aspect of the left leg and left thigh and excision of a cutaneous hemangioma in the right buttock.After induction,the surgeon elevated the patient’s leg for sterilization,whereupon she experienced a massive PE and refractory cardiac arrest.Extracorporeal membrane oxygenation(ECMO)was performed after prolonged resuscitation,and she had a return of spontaneous circulation.After this episode,the patient was discharged without any neurologic complications.CONCLUSION The mechanism of PE,a lethal disease,involves a preexisting deep vein thrombosis that is mechanically dislodged by compression or changing positions and travels to the pulmonary artery.Therefore,patients predisposed to PE should be prescribed prophylactic anticoagulants.If the patient has unstable vital signs,resuscitation should be started immediately,and extracorporeal cardiopulmonary resuscitation should be considered in settings with existing ECMO protocols,expertise,and equipment.Awareness of PE in patients with KTS while leg raising for sterilization is critical.

Advances in Research of Post Embolism Syndrome after Transarterial Chemoembolization(TACE)for Hepatocellular Carcinoma

This article reviews the concept and clinical manifestations of post embolism syndrome after transarterial chemoembolization(TACE),and the prevention or timely intervention of post embolism syndrome in advance is expected to reduce its incidence and degree in clinical treatment,and to improve the quality of treatment of Hepatocellular Carcinoma Carcinoma(HCC).

Evolving paradigm of thrombolysis in pulmonary embolism:Comprehensive review of clinical manifestations,indications,recent advances and guideline

Thrombolytic therapy has been the mainstay for patients with pulmonary embolism(PE).Despite being linked to a higher risk of significant bleeding,clinical trials demonstrate that thrombolytic therapy should be used in patients with moderate to high-risk PE,in addition to hemodynamic instability symptoms.This prevents the progression of right heart failure and impending hemodynamic collapse.Diagnosing PE can be challenging due to the variety of presentations;therefore,guidelines and scoring systems have been established to guide physicians to correctly identify and manage the condition.Traditionally,systemic thrombolysis has been utilized to lyse the emboli in PE.However,newer techniques for thrombolysis have been developed,such as endovascular ultrasound-assisted catheter-directed thrombolysis for massive and intermediatehigh submassive risk groups.Additional newer techniques explored are the use of extracorporeal membrane oxygenation,direct aspiration,or fragmentation with aspiration.Because of the constantly changing therapeutic options and the scarcity of randomized controlled trials,choosing the best course of treatment for a given patient may be difficult.To help,the Pulmonary Embolism Reaction Team is a multidisciplinary,rapid response team that has been developed and is used at many institutions.Hence to bridge the knowledge gap,our review highlights various indications of thrombolysis in addition to the recent advances and management guidelines.

Cardiac arrest secondary to pulmonary embolism treated with extracorporeal cardiopulmonary resuscitation:Six case reports

BACKGROUND Massive pulmonary embolism(PE)results in extremely high mortality rates.Veno-arterial extracorporeal membrane oxygenation(VA-ECMO)can provide circulatory and oxygenation support and rescue patients with massive PE.However,there are relatively few studies of extracorporeal cardiopulmonary resuscitation(ECPR)in patients with cardiac arrest(CA)secondary to PE.The aim of the present study is to investigate the clinical use of ECPR in conjunction with heparin anticoagulation in patients with CA secondary to PE.CASE SUMMARY We report the cases of six patients with CA secondary to PE treated with ECPR in the intensive care unit of our hospital between June 2020 and June 2022.All six patients experienced witnessed CA whilst in hospital.They had acute onset of severe respiratory distress,hypoxia,and shock rapidly followed by CA and were immediately given cardiopulmonary resuscitation and adjunctive VA-ECMO therapy.During hospitalization,pulmonary artery computed tomography angiography was performed to confirm the diagnosis of PE.Through anticoagulation management,mechanical ventilation,fluid management,and antibiotic treatment,five patients were successfully weaned from ECMO(83.33%),four patients survived for 30 d after discharge(66.67%),and two patients had good neurological outcomes(33.33%).CONCLUSION For patients with CA secondary to massive PE,ECPR in conjunction with heparin anticoagulation may improve outcomes.

Pulmonary Thromboembolism in a Soccer Player after COVID-19 Infection: Case Report

Background:Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2),which causes COVID-19,is characterized by an increased risk of thromboembolic events.However,more than 80%of patients are asymptomatic or have only minor/mild symptoms.In addition,diagnosing thromboembolism in athletes is challenging,as symptoms can be confused with musculoskeletal complaints or physical deconditioning.Case presentation:Here we report the case of a previously healthy 34-year-old professional soccer player with COVID-19 infection and genetic predisposition to thrombosis.At baseline,he was fit,had no symptoms,did not require hospital admission due to a COVID-19 infection,and was started on a five-day course of azithromycin and dexamethasone therapy.After 10 days of returning to professional activity,he developed pulmonary embolism following a COVID-19 infection during a physical exercise session.Angiotomography showed positive acute and subacute pulmonary thromboembolism,being treated with rivaroxaban 20 mg/day continuously.The shared decision-making between the medical team and the athlete was not to return to professional soccer,given the quantifiable risk.Considerations:This case illustrates the potential risk of COVID-19-induced pulmonary thromboembolism,which can be affected by genetic predisposition and dexamethasone therapy or the consequences of COVID-19.In this clinical period,the athlete’s condition may be overlooked due to the masking effects of other clinical conditions and physical abnormalities.The residual effects of COVID-19 disease can appear late,requiring caution and follow-up by the medical team before releasing the athlete into a training program.

Role of NT-proBNP and Troponin I in Assessing the Severity of Pulmonary Embolism

Introduction: Pulmonary embolism is a diagnostic and therapeutic emergency that can be life-threatening. Its mortality is largely attributable to severe forms classically defined by clinical and morphological criteria. The aim of this study is to establish the role of two cardiac biomarkers (NT-proBNP and troponin) in assessing the severity of pulmonary embolism. Patients and Methods: We conducted a descriptive and analytical cross-sectional study. Data collection was retrospective over the period from January 1, 2011 to December 31, 2021. All patients hospitalized for pulmonary embolism in two cardiology referral clinics in Cotonou (Atinkanmey Polyclinic and CICA Clinic) were included. Results: The hospital prevalence of pulmonary embolism was 9.08%. The mean age was 52.6 years, with extremes of 18 and 92 years. The sex ratio was 0.73. Pulmonary embolism was severe according to hemodynamic, morphological and sPESI criteria in 12%, 24% and 39% of cases respectively, and mortality was 61.53%. Mean NT-ProBNP and troponin I levels were significantly higher in patients with severe criteria than in those without. NT-proBNP and troponin had good specificity for predicting cardiovascular arrest (99% and 90%), shock (100% and 98%), and hypotension (99% and 96%). NT-proBNP has the best positive predictive values in relation to the occurrence of shock (100%) and right ventricular dilatation (93%). The best correlation coefficient was obtained between right ventricular dilatation and NT-proBNP (0.78). Conclusion: NT-proBNP and troponin I are good biomarkers for predicting the severity of pulmonary embolism and allowing therapeutic adaptation when they are elevated.

Peripheral primitive neuroectodermal tumor of the kidney presenting with pulmonary tumor embolism: A case report

Peripheral primitive neuroectodermal tumor(PNET) of the kidney is a rare, aggressive tumor known for its recurrence and metastatic potential. Despite the frequency of venous extension to the renal veins and inferior vena cava, pulmonary tumor embolism at the initial presentation is not common. We report a case of 22-year-old female with PNET of the kidney who presented with tumor embolism in the inferior vena cava(IVC) and bilateral pulmonary artery. The patient underwent surgical resection and histopathological analysis confirmed the presence of tumor within the IVC and pulmonary arteries. The patient received adjuvant chemotherapy and is currently doing well on follow-up.

Clinical probability and risk analysis of patients with suspected pulmonary embolism

BACKGROUND: Pulmonary embolism(PE) is one of the most frequent diseases that could be missed in overcrowded emergency departments as in Turkey. Early and accurate diagnosis could decrease the mortality rate and this standard algorithm should be defi ned. This study is to fi nd the accurate, fast, non-invasive, cost-effective, easy-to-access diagnostic tests, clinical scoring systems and the patients who should be tested for clinical diagnosis of PE in emergency department.METHODS: One hundred and forty patients admitted to the emergency department with the fi nal diagnosis of PE regarding to anamnesis, physical examination and risk factors, were included in this prospective, cross-sectional study. The patients with a diagnosis of pulmonary embolism, acute coronary syndrome or infection and chronic obstructive pulmonary disease(COPD) were excluded from the study. The demographics, risk factors, radiological fi ndings, vital signs, symptoms, physicallaboratory fi ndings, diagnostic tests and clinical scoring systems of patients(Wells and Geneva) were noted. The diagnostic criteria for pulmonary emboli were: fi lling defect in the pulmonary artery lumen on spiral computed tomographic angiography and perfusion defect on perfusion scintigraphy.RESULTS: Totally, 90(64%) of the patients had PE. Age, hypotension, having deep vein thrombosis were the risk factors, and oxygen saturation, shock index, BNP, troponin and fi brinogen levels as for the biochemical parameters were signifi cantly different between the PE(+) and PE(–) groups(P<0.05).The Wells scoring system was more successful than the other scoring systems.CONCLUSION: Biochemical parameters, clinical findings, and scoring systems, when used altogether, can contribute to the diagnosis of PE.

Evaluation of computed tomography obstruction index in guiding therapeutic decisions and monitoring percutanous catheter fragmentation in massive pulmonary embolism

In the present study, we evaluated computed tomography pulmonary angiography （CTPA） in guiding therapeutic decisions and monitoring patients undergoing percutaneous catheter fragmentation in acute massive pulmonary embolism. From Jan 2003 to Dec 2009, 35 patients were diagnosed with acute massive pulmonary embolism by CTPA （TO） and treated with percutaneous catheter fragmentation. The severity was assessed by CT obstruction index （Qanadli index） and compared with Miller index. CTPA, oxygen saturation （SaO2） and pulmonary artery pressure were performed as follow-up index. The mean percentage of Qanadli index was （55 ± 13）% （range, 40%- 75%）, and Miller index was （62 ± 15）% （range, 45%-85%）. Correlations between them were statistically significant （r = 0.867, P 〈 0.0001）. The Qanadli index showed significant reduction [TO： （55±13）%; TI： （12±10）%; P 〈 0.001] in 33 patients. Significant correlation was observed between the Qanadli index, SaO2 （r = 0.934）, and pulmonary artery pressure （r = 0.813）. The Qanadli index provides an accurate method for distinguishing massive pulmonary embolism from sub-massive pulmonary embolism. It can be used to determine therapeutic options and monitor clinical outcomes.

Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study

BACKGROUND: There is controversy regarding whether saddle main pulmonary artery(MPA) embolism represents a high risk of deterioration in non-high-risk acute pulmonary embolism(PE) patients. This study aims to address this issue by conducting a propensity score matching(PSM) study.METHODS: A total of 727 non-high-risk acute PE patients were retrospectively evaluated. We evaluated the Bova score and risk stratification to examine the risk of deterioration. Deterioration defined as any adverse event within 30 days after admission. Computed tomographic pulmonary angiography was used to identify the embolism type. All patients were matched into four subgroups by PSM according to age, sex, Bova score, and risk stratification:(1) MPA and non-MPA embolism;(2) non-saddle MPA and non-MPA embolism;(3) saddle MPA and non-saddle MPA embolism;(4) saddle MPA and non-MPA embolism. Correlations were analyzed using Cox regression analysis, and deterioration risk was compared between subgroups using Kaplan-Meier analysis.RESULTS: Cox regression analysis revealed that MPA embolism was correlated with deterioration, regardless of whether saddle MPA embolism was included or excluded. Saddle MPA embolism was not correlated with deterioration, regardless of comparison with non-saddle MPA embolism or non-MPA embolism. Patients with MPA and non-saddle MPA embolism presented a high risk for deterioration(logrank test=5.23 and 4.70, P=0.022 and 0.030, respetively), while patients with saddle MPA embolism were not at a high risk of deterioration(log-rank test=1.20 and 3.17, P=0.729 and 0.077, respetively).CONCLUSIONS: Saddle MPA embolism is not indicative of a high risk of deterioration in nonhigh-risk acute PE patients.

Could the number of CT angiograms be reduced in emergency department patients suspected of pulmonary embolism?

BACKGROUND:This study was undertaken to identify the prevalence of pulmonary embolism(PE) in the emergency department(ED) of an urban teaching hospital and also to test a Bayesian model in estimating the number of CT pulmonary angiography(CTA) expected to be performed in an emergency department.METHODS:The data for this study was obtained through a retrospective review of electronic medical records for all ED patients suspected of PE who underwent chest CTA or ventilation perfusion scanning(V/Q) between 2009 and 2010.The data is presented as means and standard deviation for continuous variables and percentages with 95%confidence intervals(95%CI) for proportions.The prevalence of PE was used as pre-test probability in the Bayesian model.Post-test probability was obtained using a Fagan nomogram and likelihood ratios for CTA.RESULTS:A total of 778 patients(560 females) with mean age of 50 years(range 18-98 years)were enrolled(98.3%underwent chest CTA and 1.7%underwent V/Q scan).A total of 69 patients had PE,rendering an overall prevalence of 8.9%(95%CI,7.1%to 11.1%) for PE.We calculated that132 CTA's per year could be avoided in our institution,without compromising safe exclusions of PE(keeping post-test probability of PE below 2%).CONCLUSIONS:Despite differences in our patient populations and /or study designs,the prevalence of PE in our institution is about average compared to other institutions.Our proposed model for calculating redundant chest CTA is simple and can be used by institutions to identify overuse of CTA.

Role of Pulmonary Embolism Response Team in patients with intermediate-and high-risk pulmonary embolism:a concise review and preliminary experience from China

Intermediate-and high-risk pulmonary embolism(PE)is a life-threatening medical emergency with high morbidity and mortality.Many of the treatment options for PE involve clinicians from multiple disciplines.Pulmonary Embolism Response Teams(PERTs)have been developed to coordinate the multidisciplinary team of clinicians to streamline the decision making process and develop individualised treatment plans in a timely fashion.The first PERT was established in 2012 and subsequently multiple centres worldwide have introduced this model for the management of intermediate-and high-risk PE.In this review,we evaluate the organisational structure and algorithms of different PERT services and compare data from pre-and post-PERT services to determine the impact of PERT on outcomes.We consider the cost and time implications of this multidisciplinary 24-hour service and suggest areas for further research and review.

Choriocarcinoma-associated pulmonary thromboembolism and pulmonary hypertension： a case report

Cases of pulmonary embolism and pulmonary artery hypertension caused by choriocarcinoma represent a rare clinical emergency. We report a case of a 25-year-old woman who presented with pulmonary embolism and hyper- tension and died soon after complete pulmonary embolectomy. A related literature review revealed that almost all of these patients had previously experienced a spontaneous abortion （average, 6 months） and were not pregnant.

Perioperative Management of Case of Gynecological Malignancy with Bilateral Deep Venous Thrombosis of Lower Limbs Along with Pulmonary Embolism

We describe the anaesthetic management of 45 year female patient with pre-existing deep venous thrombosis (DVT) and pulmonary embolism (PE) who was subsequently scheduled for an laparotomy. Before planning the surgical procedures, adequate anticoagulation must be achieved to prevent further complications of DVT, thromboembolism, and pulmonary embolism in particular. The risk of stopping the anticoagulation prior to surgery must be considered and adequately discussed with the patient and surgeons. The anaesthetic plan must be selected keeping in mind the coagulation status and the need of anticoagulation in the postoperative period.

Anesthetic management for intraoperative acute pulmonary embolism during inferior vena cava tumor thrombus surgery:A case report

BACKGROUND Acute pulmonary embolism(APE)is a rare and potentially life-threatening condition,even with early detection and prompt management.Intraoperative APE required specific ways for detecting since classic symptoms of APE in the awake patient could not be observed or self-reported by the patient under general anesthesia.CASE SUMMARY A 44-year-old man with a history of hepatic cell carcinoma was admitted for radical nephrectomy and tumor thrombectomy due to a newly found kidney tumor with inferior vena cava(IVC)tumor thrombus.APE that occurred during tumor thrombectomy with hypercapnia and desaturation.The capnography combined with the transesophageal echocardiography(TEE)provided a crucial differential diagnosis during the operation.The patient was continuously managed with aggressive intravenous fluid resuscitation and blood transfusion under continuous cardiac output monitoring to maintain hemodynamic stability.He completed the surgery under stable hemodynamics and was extubated after percutaneous mechanical thrombectomy by a certified cardiologist.There were no significant symptoms and signs or obvious discomfort in the patient’s self-report during visits to the general ward.CONCLUSION Under general anesthesia for IVC tumor thrombus surgery,a sudden decrease in end-tidal carbon dioxide is the initial indicator of APE,which occurs before hemodynamic changes.When intraoperative APE is suspected,TEE is useful in the diagnosis and monitoring before computer tomography pulmonary angiogram.Timely clinical impression and supportive treatment and intervention should be conducted to obtain a better prognosis.

Diagnosis and Treatment Options for Pulmonary Embolism (PE) in the Acute Care Setting

Thromboembolic diseases continue to be one of the most prevalent medical problems today and can lead to life-threatening conditions, such as pulmonary embolism (PE). Currently, PE diagnosis and treatment are a challenge because of acute onset right ventricular strain with right-sided heart failure, sudden death, pulmonary infarction, and cardiogenic shock, which limit the time for therapeutic success.?The aim of this study was to evaluate our perception, knowledge, and concerns regarding PE, discuss the importance of promptly diagnosing PE to provide appropriate treatment options for this life-threatening condition, list the most common clinical manifestations present when PE is suspected, and review the clinical approach to patients with suspected PE in an inpatient setting.?In addition, this study reviews the risk stratification of patients with PE and treatment options beyond anticoagulation, compares new treatment options for patients presenting with acute symptomatic PE, and compares aspiration catheters (10 F Pronto .035” and 14 F XL extraction catheter (Vascular Solutions, Minneapolis, MN)) and ultrasound-assisted catheter-directed thrombolysis (USAT) versus systemic thrombolysis.This literature review was limited by the quality and number of studies available regarding new treatment options for patients presenting with acute symptomatic PE. Thus, more studies are needed to prove the validity of newer treatment options being trialed, such as aspiration catheters (10 F Pronto .035” and 14 F XL extraction catheter) and USAT, with the hope that further studies will guide patient management and increase our understanding of next generation aspiration catheters, which may provide novel insights on treating acute symptomatic PE.

A fast-track diagnostic and therapeutic strategy for acute pulmonary embolism patients at peri-operational period

Acute pulmonary embolism(APE) in operation room is a constant,lethal but treatable disease.A fast determination of APE in an operation room is currently difficult due to a non-specificity on its signs,symptoms,electrocardiograph findings,arterial blood gas abnormalities and chest X-rays.Clinically,an APE can automatically originate from a small and clinically asymptomatic embolus to massive,proximal emboli with shock during a scheduled surgery period.An accurate,brief and prompt diagnostic and therapeutic strategy for APE in a peri-operation period is crucial for anesthesiologists to make a decision on an appropriate clinical intervention to improve patients' outcomes.The purpose of this mini-review article is to illuminate a fast-track diagnostic and therapeutic strategy for APE patients in a perioperative period through a hybrid of the high sensitive and high specific viable diagnostic modality of D-dimer assay in conjunction with necessary emergent pulmonary angiography(EPA),including digital subtraction angiography(DSA),or a spiral computed tomography angiography(sCTA) for APE patients' diagnosis and treatment during operation.The postulated fast-track diagnostic and therapeutic strategy can effectively confirm or exclude highly suspected APE and simultaneously provide fast therapeutic opportunities for APE patients at an operative period.