Multiple paradoxical embolisms caused by central venous catheter thrombus passing through a patent foramen ovale: A case report

BACKGROUND To date,this is the first case of a paradoxical embolism(PDE)that concurrently manifested in the coronary and lower limb arteries and was secondary to a central venous catheter(CVC)thrombus via a patent foramen ovale(PFO).CASE SUMMARY Here,we report a case of simultaneous coronary and lower limb artery embolism in a PFO patient carrier of a CVC.The patient presented to the hospital with acute chest pain and lower limb fatigue.Doppler ultrasound showed a large thrombus in the right internal jugular vein,precisely at the tip of the CVC.Transthoracic and transesophageal echocardiography confirmed the existence of a PFO,with inducible right-to-left shunting by the Valsalva maneuver.The patient was administered an extended course of anticoagulation therapy,and then the CVC was successfully removed.Percutaneous PFO closure was not undertaken.There was no recurrence during follow-up.CONCLUSION Thus,CVC-associated thrombosis is a potential source for multiple PDE in PFO patients.

Suspected cerebrovascular air embolism during endoscopic esophageal varices ligation under sedation with fatal outcome: A case report

BACKGROUND Air embolism is a very rare,yet serious and potentially fatal complication of digestive endoscopic treatment.Air embolism is the result of air directly entering the arteries or veins.However,to recognize neurological dysfunction under sedation can be difficult.Therefore,it is extremely important to identify high-risk groups and take preventive measures.CASE SUMMARY Herein,we report a 74-year-old female patient with esophageal varices who suffered from consciousness disturbance after the third endoscopic ligation of esophageal varices under sedation.Combined with the patient’s imaging examination results and medical history,we highly suspected that the patient had developed paradoxical cerebral air embolism during endoscopic ligation.We learned that the patient died at a later follow-up.In order to be able to identify and prevent the occurrence of air embolism early,we summarize and analyze the risk factors,pathogenesis,clinical manifestations,prevention and treatment options of gastrointestinal endoscopy complicated by cerebral air embolism.CONCLUSION Electroencephalographic monitoring helps to recognize the occurrence of air embolism in time and increase the patient's chance of survival.

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.

Ischemic Stroke Due to Paradoxical Embolism in a Patient with Patent Foramen Ovale, Bilateral Distal Deep Vein Thrombosis and Platypnea-Orthodeoxia Syndrome: A Case Report

Patent foramen ovale (PFO) is a common congenital cardiac defect. It is usually asymptomatic, but it can be associated with relevant clinical manifestations such as cryptogenic stroke and platypnea-orthodeoxia syndrome. We present the case of a patient with hemodynamically significant carotid artery stenosis who underwent endarterectomy for a transient ischemic attack (TIA). After surgery, the patient presented an ischemic stroke due to M2 occlusion treated with mechanical thrombectomy. During hospitalization, a distal bilateral deep vein thrombosis was found. The patient developed respiratory failure due to a massive right-to-left shunt through a large PFO (platypnea-orthodeoxia syndrome). These findings are consistent with the hypothesis that the TIA and the subsequential ischemic stroke were related to paradoxical embolism rather than atherothromboembolism. The aim of our case report is to raise awareness of the possible complications of such a common finding as PFO.

Acute inferior ST-segment elevation myocardial infarction cryptogenic stroke caused by a paradoxical embolism with pulmonary embolism and previous a concomitant

A 61-year-old woman was hospitalized for a chief complaint of sudden chest tightness with sweating for two hours. The chest tightness and sweating occurred suddenly and without remission after a morning stool. Electrocardiography showed a complete atrioventricular （AV） block and arc-like elevation of the ST-segment in leads Ⅱ, Ⅲ, AVF, V7-V9, and V3R-V5R, at about 0.05-0. 15 mV. After being administered 1 mg of atropine in the emergency room （ER）, the patient was admitted to the cardiology department. The patient had been found in a cyanotic state two years previously, but did not receive any treatment; she was diagnosed with a transient ischemic attack （TIA） 1.5 years previously because of limb dyskinesia accompanied by slurred speech.

Suspected cerebral arterial gas embolism during a laparoscopic Nissen fundoplication

We present the first case report known to us of a suspected cerebral arterial gas embolism(CAGE) leading to transient left-sided hemiparesis after a laparoscopic Nissen fundoplication. During the operation there was no evidence of hemodynamic compromise and the endtidal carbon dioxide level and oxygen saturation had been within normal limits. Radiological studies and transesophageal echocardiography showed no abnormalities. We conclude that CAGE can occur during uncomplicated laparoscopic surgery even in the absence of demonstrable intracardiac shunts.

Large eustachian valve fostering paradoxical thromboembolism:passive bystander or serial partner in crime?

Catheter-based closure of patent foramen ovale(PFO)is more effective than medical therapy in the prevention of recurrent stroke[1].It is likely that a proportion of patients evaluated for potential transcatheter PFO closure has actually different anatomical variants particularly common in the right atrium such as eustachian valve,Chiari network,Thebesian valve and Crista Terminalis.Notably,the eustachian valve may represent an increased risk factor for left circulation thromboembolism beyond that associated with PFO size and shunting.Such patients may benefit the most from percutaneous closure procedure.

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).

肺栓塞动物模型(猪)V/Q SPECT显像与平面显像的对比

目的应用201Tl标记栓子制作肺栓塞动物模型(猪),比较肺V/QSPECT显像和平面显像的灵敏度、特异性和准确性,探讨肺通气显像在肺栓塞诊断中的意义及V/Q显像在亚肺段肺动脉栓塞(PE)诊断中的作用。方法16头试验用小型猪,栓塞前应用不同技术参数行99Tcm窗肺灌注平面及断层显像,每头猪分别置入0～3个栓子,栓塞后行99Tcm窗及201Tl窗双窗肺通气平面、断层显像及99Tcm窗肺灌注平面、断层显像。最后行X线平片或CT显像并进行肺脏解剖确定栓子位置。结果共可见栓子28个,其中17个位于左肺,11个位于右肺。平面显像的敏感性、特异性和准确性分别为75%、75%和75%,而断层显像的敏感性、特异性、准确性分别为100%、75%和96.9%。结论肺通气/灌注断层显像的灵敏度及准确性均较平面显像高,而特异性两者相同。同时行V/Q显像可提高肺栓塞的诊断率。V/QSPECT断层显像可提高亚肺段性PE的诊断率。选用低能通用准直器、平面显像矩阵128×128、断层影像Zoom1.46可较好的满足临床诊断需要。

RoPE量表联合超声卵圆孔高危特征在隐源性卒中的应用

目的探讨反常性栓塞风险(risk of paradoxical embolism,RoPE)量表联合多模态超声高危卵圆孔特征在隐源性卒中(cryptogenic stroke,CS)的应用价值。方法回顾性分析2021年1月至2022年5月温州医科大学附属第一医院确诊的卵圆孔未闭(patent foramen ovale,PFO)患者248例,根据脑部CT或磁共振成像结果,将诊断为不明原因卒中或短暂性脑缺血发作的患者纳入CS组(n=105),其余患者纳入非CS组(n=143)。采用多因素分析探讨PFO患者发生CS的超声影像特征,并与RoPE量表相结合建立综合评分。结果多因素Logistic回归分析显示,卵圆孔≥2mm、隧道长度≥8mm、原发隔高移动性、原发隔抖动、大量右向左分流(静息状态下)、合并永存下腔静脉瓣、左房间隔囊袋样结构均是PFO患者发生CS的独立危险因素(P<0.05)。综合评分诊断PFO患者发生CS的曲线下面积为0.872(95%CI:0.828~0.916),综合评分≥10分的PFO患者为CS的高危人群。结论RoPE量表联合多模态超声高危卵圆孔特征可用于CS病因的筛查与治疗方案的选择。

Current Concepts in the Diagnosis and Management of Pulmonary Embolism

Acute pulmonary embolism (PE) is one of the most common causes of cardiovascular death. Most often acute PE is associated with under diagnosis, misdiagnosis and delay in diagnosis and management leading to high morbidity and mortality. PE outcomes will improve with proper evaluation of clinical symptoms and signs, relevant diagnostic tests, identifying high-risk patients suitable for early re-perfusion with I.V. or catheter-directed thrombolytic therapy or surgical embolectomy and in some cases additional use of mechanical circulatory support. During clinical evaluation modified Geneva score, Well’s score, and Simplified pulmonary embolism severity index (sPESI) scores are useful in assessing PE and its adverse outcomes. Hestia criteria are useful in identifying suitable for outpatient management of PE. Long-term management of PE involves identifying patients prone for recurrence and CTPE with appropriate long-term prophylaxis using oral anticoagulants.

The Use of Low Molecular Weight Heparin for Venous Thromboembolism Prophylaxis in Medical Patients: How Much Are We Adherent to the Guidelines?

Background: Venous thromboembolism (VTE) is a common complication seen during or after hospitalization that manifests as deep venous thrombosis (DVT) and/or pulmonary embolism (PE). PE is considered the commonest preventable cause of death during and/or after hospitalization. Thus, pharmacological and mechanical methods are used to prevent VTE in hospitalized patients. Despite the availability of guidelines for VTE prophylaxis, it is crucial to assess the adherence and adaptation of the institution to these guidelines. Purpose: This study aimed to investigate adherence to the American College of Chest Physicians (ACCP) 2012 VTE prophylaxis guidelines in hospitalized medical patients in a tertiary care hospital in the United Arab Emirates. Methods: An observational prospective design was utilized in this study. To achieve the purpose, primary and secondary end points were identified to be the core of the investigation. The primary end points were: the incidence of bleeding, VTE, and cardiovascular events. While the secondary end points were: dose and indication validity for prophylaxis, VTE and bleeding risk assessments, adverse drug events (ADE) other than bleeding, appropriate monitoring when on low molecular weight heparin (LMWH) and the presence of contraindication at the time of prescribing LMWH. Results: 16 patients (20%) out of the total 80 met one or more of the primary end points. The vast majority of patients (81.25%) developed bleeding, while VTE was seen in one case only during hospitalization. 11 patients (13.75%) received LMWH while a contraindication was present. 15 patients (18.75%) who were prescribed LMWH had an International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score of ≥7. However, 5 out of 13 patients (38.46%) who developed bleeding had a bleeding score of ≥7, and the relationship between bleeding score of ≥7 and the development of bleeding was statistically significant (p = 0.047). When investigating the doses that were utilized, 40% were prescribed an inappropriate dose. Conclusion: Various factors played a role in the inappropriateness of VTE prophylaxis such as;poor adherence to VTE guidelines, inappropriate dosing and monitoring, and not evaluating the bleeding risk. Hence, to be able to achieve effective VTE prophylaxis, these factors need to be addressed through adherence to and adaptation of the ACCP 2012 VTE prophylaxis guidelines.

Successful outcome of massive carbon dioxide embolism during laparoscopic hepatectomy

Carbon dioxide embolism is a rare but severe complication of laparoscopic hepatectomy.We reported a case of massive carbon dioxide embolism that developed into a rare paradoxical gas embolism during laparoscopic hepatectomy and resulted in reduced muscular power of the left upper extremity,severe pleural effusion and hypoalbuminemia after surgery.Fortunately,the patient fully recovered with positive prevention and postoperative treatment.This case report highlights that the surgeon and anaesthesiologist must be aware of the risks and the importance for prompt treatment when massive carbon dioxide embolism occurs.

Acute Pulmonary Embolism, Multiple Coronary Thrombosis, and Thrombi in the Left Ventricle and Ascending Aorta in a Patient with COVID-19 Infection

Both arterial and venous thromboembolic events are common in patients hospitalized in intensive care units with severe COVID-19. These patients often have laboratory findings consistent with a hypercoagulable state, suggesting widespread thrombosis and fibrinolysis, as well as elevated levels of D-dimer, von Willebrand factor (VWF), and factor VIII. There is increasing evidence that these thromboembolic events are associated with worse outcomes. We present the case of a 61-year-old man admitted for bilateral pneumonia due to COVID-19 infection, who developed during his hospitalization;Bilateral pulmonary thromboembolism, an acute myocardial infarction due to multiple coronary thrombosis, an intracavitary thrombus and thrombus in the ascending aorta. The patient was treated with systemic fibrinolysis and full doses of anticoagulation for pulmonary embolism, an emergency primary percutaneous coronary intervention (PCI) was performed with the implant of a drug eluting stent (DES) in the left anterior descending artery (LAD). Triple therapy with aspirin, clopidogrel and heparin was maintained until discharge. After the patient discharge, aspirin was stopped and treatment with clopidogrel and dabigatran was maintained for three months. In a subsequent outpatient control, the thrombi of the left ventricle and the ascending aorta resolved.

Clinical treatment strategy of acute cerebral infarction complicated with pulmonary embolism: a case report

This article describes the clinical characteristics of a case of cerebral infarction complicated with pulmonary embolism(PE),and elaborates the therapeutic strategies of intravenous thrombolysis and anticoagulation.Treatment remedies:the medical history and examination data of a patient with aphasia and right hemiplegia were collected.After intravenous thrombolysis and pulmonary artery CTA(computed tomographic angiography),the patient was found to have low blood oxygen saturation and PE.And the patient was treated with anticoagulant therapy.Post treatment evaluating:cerebral hemorrhage was excluded by craniocerebral CT(computed tomographic),and left basal ganglia infarction was diagnosed.After thrombolysis,the symptoms of aphasia and hemiplegia were significantly improved.For PE,after anticoagulant therapy,the patient’s breathing was stable and blood oxygen saturation was normal.For deep venous thrombosis of both lower extremities,anticoagulant therapy was continued.Conclusion:patients with thrombophilia are prone to cerebral embolism,PE and deep venous thrombosis of lower limbs.Intravenous thrombolytic therapy in acute phase and heparin anticoagulant therapy in recovery period can effectively control the disease.

Intraoperative management of liver transplant in a patient with an undiagnosed ventricular septal defect:A case report

BACKGROUND The intraoperative management of patients undergoing orthotopic liver transplantation(OLT)frequently encounters hemodynamic instability after reperfusion of the new liver graft.The resulting post-reperfusion syndrome is characterized by an increase in pulmonary vascular resistance and decrease in systemic vascular resistance.In the presence of a left to right intracardiac shunt,this hemodynamic perturbance can lead to shunt reversal followed by hypoxemia and embolization of air and debris into the systemic circulatory system.CASE SUMMARY A 43 years-old male with end-stage liver disease due to primary sclerosing cholangitis complicated by portal hypertension and hepatocellular carcinoma presented for an OLT.A bedside transthoracic echocardiography(TTE)was performed immediately before the procedure and unexpectedly identified a ventricular septal defect(VSD).The patient and the surgical team agreed to proceed with the surgery as it was a time critical donation after circulatory organ death.We developed an intraoperative plan to optimize pulmonary and systemic pressures using vasoactive support,optimized mechanical ventilation,and used transesophageal echocardiography(TEE)for intraoperative monitoring.During reperfusion,considerable turbulent flows with air were noted in the right ventricle,but no air was visualized in the left ventricle.Color flow Doppler showed no reversal flow in the VSD.At the end of the procedure,the patient was extubated in the operating room without complication and was transferred to the transplant unit for recovery.CONCLUSION Our case highlights the importance of echocardiography in the perioperative assessment of patients undergoing liver transplantation.The TTE findings obtained immediately before the procedure and the real-time use of intraoperative TEE to modify our management during the critical phases of the transplant resulted in continuity of care and a good surgical outcome for this patient.

卵圆孔未闭合并肺动静脉瘘致反常性脑栓塞1例报告

1病例资料患者女,65岁,因“左侧肢体无力伴口齿不清4 h余”于2023年7月14日就诊于我院急诊科。2023年7月14日早上5点起床时家属发现患者左侧肢体无力,无法行走,伴口齿不清,能理解他人言语,无恶心呕吐、肢体麻木等其他不适,症状持续不能缓解,遂拨打120并由救护车9:00送至我院急诊科。体格检查示患者神志清楚,言语不清,伸舌右偏,左侧肢体肌力3+级,右侧肢体肌力5级,病理反射未引出;美国国立卫生研究院卒中量表(National Institutes of Health stroke scale,NIHSS)评分为10分。

Pulmonary embolism and impending paradoxical embolism： a case report

A definitive diagnosis of paradoxical embolism is ,based on the evidence that a thrombus crosses through the right-to-left shunting. We report a case of impending paradoxical embolism in a patient with pulmonary embolism diagnosed by echocardiography and proved by operation later.

前置呼吸模式在320排CT肺动脉双低成像的研究

目的:探究前置呼吸模式在320排CT肺动脉双低成像。方法:前瞻性选取2021年7月至2022年9月柳州市人民医院收治的怀疑肺动脉栓塞(PE)行CT肺动脉造影(CTPA)检查的100例患者,采用随机数表法将其分为观察组和对照组,每组50例。对照组患者采取常规呼吸模式(达到阈值后启动呼吸口令,6 s后触发扫描),观察组采取前置呼吸模式(1或2 s后启动呼吸口令,达到阈值后触发扫描)。两组患者均采用320排CT行双低成像技术扫描,对比延迟时间、辐射剂量、主观与客观图像质量评分等指标差异。结果:观察组容积CT剂量指数(CTDIvol)、剂量长度乘积(DLP)、有效剂量(ED)及延迟时间均明显低于对照组,差异有统计学意义(t=76.230、30.225、12.282、7.088,P<0.05)。两组图像质量主观评分比较,观察组患者5分25例,4分23例,3分2例;对照组5分21例,4分26例,3分3例,图像质量主观评分的平均分组间比较差异无统计学意义(P>0.05)。观察组图像信噪比(SNR)、对比噪声比(CNR)明显低于对照组,噪声水平(SD)明显高于对照组,差异有统计学意义(t=25.441、23.886、11.426,P<0.05)。观察组右肺动脉干、右肺动脉分支、左肺动脉干以及左肺动脉分支CT值均较对照组高,差异均有统计学意义(t=2.256、2.225、2.042、2.277,P<0.05)。结论:前置呼吸模式能够有效提高CTPA图像质量,降低辐射剂量及对比剂用量,临床应用效果显著,值得借鉴。

Acute Colonic Pseudo-Obstruction (ACPO): An Expanding Colon with Unusual Risk Factors

The distention of the colon without mechanical or anatomical obstruction, Acute Colonic Pseudo-obstruction (ACPO), is a common condition occurring in the critically ill. ACPO in the setting of an acute pulmonary embolism and embolic stroke is a rarity. A 76-year-old female with shortness of breath, left hemiparesis and right-sided paresthesias presented with acute pulmonary embolism and acute infarcts of the left caudate nucleus, thalamus and occipital lobe. Her hospitalization was complicated with persistent distention of the large bowel without dilation of the small bowel. Empiric antibiotics were initiated without improvement and laboratory studies including Clostridium difficile were negative. She underwent nasogastric decompression and two decompressive colonoscopies with a resolution of her symptoms. This case illustrates an example of acute abdominal distension, without underlying etiology, in the setting of acute embolism of the pulmonary and cerebral vasculature. Early identification and action with decompressive colonoscopy were key to preventing further bowel damage or rupture.