Treatment and Clinical Management of Chronic Thromboembolic Pulmonary Hypertension:An Update of Literature Review

Chronic thromboembolic pulmonary hypertension(CTEPH)is a chronic,progressive,debilitating,and life-threa-tening complication of pulmonary embolism(PE).Recent technological advances have permitted various treat-ment options for the treatment of CTEPH,including surgery,angioplasty,and medical treatment,depending on the location and characteristics of lesions.Pulmonary endarterectomy(PEA)is the treatment of choice for CTEPH,as it offers excellent long-term outcomes and a high probability of recovery.Moreover,various medical and interventional therapies are currently being developed for patients with inoperable CTEPH.This review mainly summarizes the current treatment approaches of CTEPH,offering more options for specialist physicians to,thus,better manage chronic thromboembolic syndromes.

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.

Pulmonary embolism after shoulder surgery:Is it a real threat?

Pulmonary embolism(PE)is a rare but devastating complication of shoulder surgery.Apart from increased morbidity and mortality rates,it may significantly impair postoperative recovery and functional outcome.Its frequency accounts for up to 5.7%of all shoulder surgery procedures with a higher occurrence in women and patients older than 70 years.It is most commonly associated with thrombophilia,diabetes mellitus,obesity,smoking,hypertension,and a history of malignancy.PE usually occurs secondary to upper or lower-extremity deep vein thrombosis(DVT).However,in rare cases,the source of the thrombi cannot be determined.Prophylaxis for PE following shoulder surgery remains a topic of debate,and the standard of care does not routinely require prophylactic medication for DVT prophylaxis.Early ambulation and elastic stockings are important preventative measures for DVT of the lower extremity and medical agents such as aspirin,low-molecular-weight heparin,and vitamin K antagonists are indicated for high-risk patients,long-lasting operations,or concomitant severe acute respiratory syndrome coronavirus 2 infection.The most common symptoms of PE include chest pain and shortness of breath,but PE can also be asymptomatic in patients with intrinsic tolerance of hypoxia.Patients with DVT may also present with swelling and pain of the respective extremity.The treatment of PE includes inpatient or outpatient anticoagulant therapy if the patient is hemodynamically unstable or stable,respectively.Hemodynamic instability may require transfer to the intensive care unit,and cardiovascular arrest can be implicated in fatal events.An important issue for patients with PE in the postoperative period after shoulder surgery is residual stiffness due to a delay in rehabilitation and a prolonged hospital stay.Early physiotherapy and range-of-motion exercises do not adversely affect the prognosis of PE and are highly recommended to preserve shoulder mobility and function.

不同部位DVT与APTE后肺动脉主干宽度、右心室流出道宽度、右心室径水平的相关性

目的探讨不同部位下肢深静脉血栓形成(DVT)与急性肺血栓栓塞症(APTE)后肺动脉主干宽度、右室流出道宽度、右心室径水平的相关性及影响因素。方法选择2013年10月至2020年8月初次确诊为APTE患者231例,分为小腿肌间静脉型血栓组(n=94)、胫腓腘静脉血栓组(n=31)、股腘静脉型血栓组(n=90)和下腔髂静脉型血栓组(n=16)。统计4组临床资料;心脏彩色多普勒超声诊断仪测定肺动脉主干宽度、右心室流出道宽度和右心室径水平;Pearson检验法分析DVT与APTE后肺动脉主干宽度、右心室流出道宽度、右心室径水平的相关性。多元逐步Logistic回归分析探讨APTE后DVT部位的影响因素。结果4组肺动脉主干宽度、右心室流出道宽度、右心室径水平比较,差异均有统计学意义(P<0.05)。其中,小腿肌间静脉型血栓组与股腘静脉型血栓组、下腔髂静脉型血栓组比较,患者肺动脉主干宽度、右心室流出道宽度、右心室径水平明显升高(P<0.05);胫腓静脉型血栓组、股腘静脉型血栓组与下腔髂静脉型血栓组比较,患者肺动脉主干宽度、右心室流出道宽度、右心室径水平均升高(P<0.05)。不同部位DVT与APTE后肺动脉主干宽度、右心室流出道宽度和右心室径水平呈显著正相关关系(P<0.01)。多元逐步Logistic回归分析显示,肺动脉主干宽度、右心室流出道宽度、右心室径水平是DVT部位的影响因素(P<0.01)。结论不同部位DVT与APTE后肺动脉主干宽度、右心室流出道宽度、右心室径水平具有相关性,且是DVT患者APTE后的主要病理生理变化;肺动脉主干宽度、右心室流出道宽度、右心室径水平在诊断不同部位DVT患者病情方面具有一定的价值。

THROMBOENDARTERECTOMY FOR CHRONIC PULMONARY THROMBOEMBOLISM

Objective To evaluate the improving reliability and safety of thromboendarterectomy and perioperative management for chronic pulmonary thromboembolism. Methods The clinical data of 12 cases with chronic pulmonary thromboembolism, who underwent thromboendarterec- tomy assisted by low flow or circulation arrest with deep hypothermia, were reviewed retrospectively. Results Pulmonary artery pressure decreased 20 to 40 mmHg immediately after surgical procedures in 9 cases. The postoperative pulmonary edema at various degrees happened in 12 cases, among them, 1 died of severe lung infection and pulmonary re-embolism at 19 days postoperation. Computed tomography pulmonary angiography and angiography of 11 cases indicated that the original obstruction of pulmonary artery disappeared. During the follow-up period of 2 months to 5 years, the clinical symptoms and activity was improved. Conclusion Thromboendarterectomy is an effective treatment for chronic pulmonary thromboembolism. The outcome of the surgical procedure needs to be further investigated and followed up regularly according to an evaluative system, because it might be influenced by multiple factors.

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.

Influence of L-arginine on the Expression of eNOS and COX2 in Experimental Pulmonary Thromboembolism

The influence of L-arginine on endothelial nitric oxide synthase （eNOS） and cyclooxygenase 2 （COX2） was observed in experimental pulmonary thromboembolism and the action mechanism on pulmonary thromboembolism was explored. Wistar rats were randomly divided into control group, model group and treatment group. Pulmonary thromboembolism models were established by auto-blood back transfusion, and L-Arg 100 mg/kg was intraperitoneally injected after successful model preparation. The animals were sacrificed at 3 h, 1 day, 3 days and 7 days after embolism. Plasma NO, TXB2 and 6-Keto-PGF1 α were detected. The expression of eNOS and COX2 protein and mRNA in pulmonary tissues was detected by immunohistochemistry and RT-PCR respectively. The results showed that pulmonary thrombosis could be seen post pulmonary embolism and inflammatory reaction was significant. Plasma NO was decreased （P〈0.01）, and the levels of TXB2, 6-Keto-PGF1α and T/P ratio were all elevated. The expression of eNOS protein and mRNA in the pulmonary tissue was down-regulated （P〈0.05）, while that of COX2 protein and mRNA was upregulated （P〈0.01）. In treatment group, the level of NO was increased, the levels of TXB2 and T/P ratio were decreased, but the level of 6-Keto-PGF1 α was increased. The expression of eNOS protein and mRNA in pulmonary tissue was upregulated （P〈0.05）, while that of COX2 protein and mRNA was down-regulated （P〈0.05）. In conclusion, L-arginine can educe the role of pulmonary tissue protection through up-regulating the expression of intra-pulmonary NOS and down -regulating COX2 in pulmonary thromboembolism.

Pulmonary thromboembolism after distal ulna and radius fractures surgery: A case report and a literature review

BACKGROUND Pulmonary thromboembolism(PTE)is a serious postoperative complication that can occur after a fracture.Generally,PTE is caused by the falling off of lower extremity deep vein thrombosis(LEDVT)after lower limb fracture surgery.LEDVT and PTE after upper extremity fracture surgery are very rare.PTE is one of the most common clinical causes of sudden death.Venous thromboembolism includes PTE and DVT.We experienced one case of LEDVT and PTE after distal ulna and radius fracture surgery.The purpose of our report is to raise awareness for orthopedic surgeons that PTE can occur after distal ulna and radius fracture surgery,and patients with high risk factors should be considered for prevention and treatment of thrombosis in a timely manner.CASE SUMMARY We report a 51-year-old Chinese male who had severe fractures of the left distal ulna,radius and little finger after a motorcycle accident.The patient underwent external fixation,open reduction and internal fixation.On the third post-operative day,computed tomographic pulmonary angiography showed PTE.Doppler ultrasonography showed thrombus formation in the bilateral posterior tibial veins.After a period of anticoagulation therapy,on the 25th d after the PTE,computed tomographic pulmonary angiography showed that thrombus in both sides of the pulmonary artery disappeared.Furthermore,about 4 mo after the PTE,thrombosis in the deep veins of the lower limbs disappeared.About 1 year after the surgery,X-rays showed good fracture healing,and the function of the wrist joint recovered well.CONCLUSION Though rare,PTE can occur after distal ulna and radius fracture surgery and patients with high risk factors should be considered for prevention and treatment of thrombosis in a timely manner.

PULMONARY THROMBOEMBOLISM FOLLOWING THORACOTOMY FOR LUNG CANCER

Objective： To investigate the clinical features of pulmonary thromboembolism in patients with primary lung cancer in relation to thoracotomy, and to shed light on prevention, diagnosis and treatment of this fatal disease after lung resection. Methods： A total of 1245 cases with primary lung cancer received thoracotomy in the past 13 years were retrospectively reviewed. Clinical data of a total of 14 patients （1.1%） suffering from pulmonary thromboembolism and requiring cardiao-pulmonary resuscitation were collected and analyzed. Results： The diagnosis was established primarily by clinical findings in 9 cases （64.3%）, including further confirmation of one case during operation, by pulmonary ventilation-perfusion scan in 2, by spiral CT angiography in I, by pulmonary angiography in 1, and by autopsy in I case. Even using prompt resuscitation, 8 patients （57.1%） died within 48 h （mean 4 h） after the onset of the symptoms. Six cases eventually recovered. Of the 6 salvaged patients, they all received anticoagulation therapy with heparin intravenously and warfarin orally, including 3 cases of additional thrombolytic therapy with urokinase. Two cases with massive pulmonary emboli received emergency surgery, including one pulmonary embolectomy, and one bilobectomy after right upper Iobectomy, with satisfactory results. Conclusion： Massive pulmonary embolism is an infrequent but fatal early postoperative complication after lung resection. The diagnosis should be based mainly on clinical findings in order to initiate the appropriate therapy immediately. The direct diagnostic techniques including radionuclide pulmonary scan, spiral CT angiography, and pulmonary angiograpby could be based on a careful evaluation of the expected benefits and risks of the various available treatments.

Simple mechanical thrombectomy with intrapulmonary arterial thrombolysis in pulmonary thromboembolism： a small case series

Pulmonary thromboembolism （PTE） is a life-threatening condition with a high early mortality rate caused by acute right ventricular failure and cardiogenic shock. We report a series of three patients who presented with acute and subacute submassive PTE. They were suc-cessfully treated by simple catheter-based mechanical thrombectomy and intrapulmonary arterial thrombolysis. Mechanical fragmentation and aspiration of thrombus was performed by commonly used J-wire, multi-purpose and Judkin Right guiding catheters and this obviated the need of specific thrombectomy devices.

Late Thrombolysis in Massive Pulmonary Thromboembolism

Pulmonary thromboembolism (PTE) remains a diagnostic and therapeutic challenge for physicians. Anticoagulation with heparin remains as the cornerstone in its management, reserving thrombolysis for cases with hemodynamic impairment. The later has been associated with haemorrhagic complications and has proved beneficial when initiated within the first 48 hours of PTE;but there is little evidence supporting its use passed this time. We present a case of an 84 year old female admitted in our unit and treated successfully with thrombolysis for massive PTE at the fifth day of diagnosis. The patient improved towards complete recovery and was discharged from the hospital 22 days after admission without complications.

The Clinical Value of NLR, D-D and CRP/ALB Ratio in the Diagnosis of Pulmonary Thromboembolism

Objective: To evaluate the clinical diagnostic value of C-reactive protein/albumin ratio (CAR), neutrophil/lymphocyte ratio (NLR) and D-dimer (D-D) in patients with pulmonary thromboembolism (PTE). Methods: We conducted a retrospective analysis comparing hematology and coagulation in 362 PTCA-confirmed PTE patients with the control group and analyzing their relationships with CAR, NLR, and D-D. Receiver operating characteristic curve (ROC) was used to analyze the diagnostic threshold, area under the curve (AUC), diagnostic sensitivity and specificity of CAR, NLR and D-D for PTE. Results: 1) CAR, NLR and D-D levels in PTE patients were 2.13 ± 2.08, 8.96 ± 1.94 and 9.69 ± 8.61 respectively, significantly higher than those in control group (CAR = 0.03 ± 0.01, t = 20.7736, P < 0.01;NLR = 1.76 ± 0.53, t = 2.4281, P < 0.05 and PTE = 0.20 ± 0.11, t = 3.0066, P < 0.01 respectively). 2) NLR was positively correlated with CAR (r = 0.2111, t = 4.0971, P < 0.01) and D-D (r = 0.1065, t = 2.0481, P < 0.05), but CAR was not correlated with D-D (r = 0.0975, P > 0.05). 3) The levels of HB, LY, PLT and AT in PTE patients were significantly lower than those in control group, while WBC, NE and FB were significantly higher than those in control group. 4) CAR was negatively correlated with Hb and AT (P all < 0.01), but positively correlated with WBC, NE, MO and FB (P all < 0.01). NLR was negatively correlated with LY and AT (P all < 0.01), but positively correlated with WBC, NE and FB (P all < 0.01). DD was negatively correlated with Hb and PLT (P all < 0.05), but positively correlated with WBC, NE and MO (P all < 0.01). Conclusion: The levels of Hb, LY, PLT and AT were significantly decreased in PTE patients, while WBC, NE and FB were significantly increased. CAR, NLR and D-D were highly expressed in PTE patients, and were closely correlated with Hb, AT and FB. Combined detection of CAR, NLR and D-D can improve the diagnostic value of PTE.

Diagnostic value of lead corrected Vt and V6 in patients with acute pulmonary thromboembolism

Objective: To investigate the diagnostic value of lead corrected Vt and V6 in patients with acute pulmonary thromboembolism. Methods: A total of 89 patients with suspected acute PTE were examined in our hospital from January to December 2017. A baseline 12-lead ECG was recorded on admission, with a gain of 10 mm/mV and a paper velocity of 25 mm/s. Results: Of the 89 suspected PTE patients enrolled in this study, 45 patients with acute PTE and 44 patients without PTE were identified by CTA. The chief complaint of most patients in both groups was dyspnea or dyspnea, with no significant difference between the two groups. The levels of d-dimer and high-sensitivity troponin in patients with PTE were significantly higher than those without PTE. QT and QTc in the V1 lead in the PTE group were significantly greater than those in the non-PTE group, but QT and QTc in the V6 lead were not significantly different between the two groups. The QTc difference (V1-V6) in the PTE group was significantly greater than that in the non-PTE group. In the morphological analysis, T wave inversion in lead III of PTE group, T wave inversion of V1 or V1 and V2 was significantly higher than that of non-PTE group. There was no significant difference in the incidence of S1Q3T3 between the two groups. For the prediction of acute PTE, the maximum accuracy of the maximum QTc difference (V1-V6)≥20 ms, the sensitivity was 83.2%, and the specificity and positive predictive value was 100%. T-wave inversion in V1 leads is the most sensitive morphological abnormality associated with PTE with a sensitivity of 80.06% and a specificity of 62.29%. T-wave inversion in lead III is a sub-sensitive predictor with a sensitivity of 51.20%. The specificity is 70.53%. Conclusions: The QTC difference (V1-V6) is a distinct feature of acute PTE, and QTC difference (V1-V6)≥20 ms as an important indicator of acute PTE in emergency settings.

Role of pulmonary perfusion magnetic resonance imaging for the diagnosis of pulmonary hypertension:A review

Among five types of pulmonary hypertension,chronic thromboembolic pulmonary hypertension(CTEPH)is the only curable form,but prompt and accurate diagnosis can be challenging.Computed tomography and nuclear medicine-based techniques are standard imaging modalities to non-invasively diagnose CTEPH,however these are limited by radiation exposure,subjective qualitative bias,and lack of cardiac functional assessment.This review aims to assess the methodology,diagnostic accuracy of pulmonary perfusion imaging in the current literature and discuss its advantages,limitations and future research scope.

Assessment of nurses’knowledge of the prevention of hospital-associated venous thromboembolism in a tertiary health institution in Nigeria

Objective:This study assessed the level of nurses’knowledge of the prevention of venous thromboembolism(VTE)in a tertiary health institution.Materials and Methods:This descriptive cross-sectional study was conducted with 328 eligible respondents,selected using a random sampling method in a teaching hospital in Nigeria.A self-administered structured questionnaire was used to collect data on the basic knowledge,risk factors,and preventive measures of VTE.Results:Findings from the study revealed that 51.2%scored above the mean score of 28.6±3.1.The educational status of the respondents had a significant influence on their knowledge of risk factors of VTE(F=4.696,P=0.031).Conclusion:The overall knowledge of nurses is satisfactory,although the majority could not answer correctly questions on the administration of prefilled anticoagulants and identification of some key risk factors of VTE.

头颈肿瘤围术期静脉血栓栓塞症防治中国专家共识

静脉血栓栓塞症(venous thromboembolism, VTE)是外科术后常见并发症和医院内非预期死亡的重要危险因素,也是恶性肿瘤患者的第二大死亡原因。晚期头颈部恶性肿瘤患者通常需要接受大范围的肿瘤根治手术和同期修复重建手术,又由于高龄兼长时间手术、术后长时间卧床以及肿瘤和化疗药物导致的血液高凝状态等多种危险因素,提示头颈部恶性肿瘤患者应是VTE的极高危群体,但相关文献对头颈部恶性肿瘤患者的VTE发生情况却很少关注,有关VTE在头颈肿瘤术后发生率的数据也有限。迄今为止,国内对于头颈肿瘤围术期静脉血栓栓塞症缺乏相关治疗共识或指南,不同单位对于头颈肿瘤围术期静脉血栓栓塞症的预防与管理水平参差不齐,缺乏统一、科学的诊疗标准及客观的预防与管理评价体系。为统一和规范头颈肿瘤围术期静脉血栓栓塞症的诊治,减少医疗资源浪费,提高治疗效果,国内该研究领域的专家经反复讨论,汇集全国14家著名医学院校及附属医院专家的诊治意见,同时借鉴和参考国内外近年来对头颈肿瘤围术期静脉血栓栓塞症的研究成果与诊治经验,制订本专家共识,供相关临床医师参考。

慢性血栓栓塞性肺动脉高压的治疗进展

球囊肺血管成形术和药物是无法手术的慢性血栓栓塞性肺动脉高压(CTEPH)患者的主要治疗方案。在临床实践中,药物治疗是否比球囊肺血管成形术具有更好的获益-风险比,以及二者联用是否可增加临床疗效或改善安全性尚存争议。本文将系统阐述CTEPH的治疗进展,以指导临床管理。

耳鼻咽喉科术后急性肺栓塞的临床特点及诊疗分析

目的总结耳鼻咽喉科患者术后急性肺栓塞(PE)的临床特点并分析诊疗经验。方法回顾性分析2015年1月-2022年12月在术后1个月内发生PE的耳鼻咽喉科患者的临床资料。结果PE在耳鼻咽喉科术后1个月内发病率为0.05%(12/25368),临床表现主要为呼吸困难33.3%(4/12)、心悸16.7%(2/12)、晕厥16.7%(1/12)、无症状者41.7%(5/12)。7例出现血氧饱和度/血氧分压下降,11例患者行CT肺动脉血管造影检查证实存在肺动脉或其分支的充盈缺损。2例高危及2例低危患者转重症监护治疗。11例患者抗凝治疗后有效,1例抢救无效死亡。抗凝治疗过程中3例因活动性出血停止抗凝。结论PE的临床症状不典型,需重视术后出现的呼吸困难、心悸、晕厥、血氧饱和度下降等表现。早期识别、准确判断严重程度及早期规范化治疗是改善预后的关键点。血流动力学不稳定的高危患者预后较差,需转重症监护治疗并尽早启动抗凝或溶栓治疗。

孕产期D-二聚体变化与产后肺栓塞发生的关系

目的探讨孕产期D-二聚体变化与产后肺栓塞的发生关系。方法回顾性收集2018年1月—2023年1月建卡分娩的孕产妇临床资料,分别在建卡、分娩前和产后收集检测血浆D-二聚体浓度值等资料,根据产妇产后是否发生产后肺栓塞分为病例组和对照组,探讨孕产期D-二聚体变化与产后肺栓塞的发生关系和临床预测价值。结果病例组和对照组受孕方式、身高、体重、BMI、胎停次数差异无统计学意义(P>0.05);而年龄、胎数、孕次、产次差异有统计学意义(P<0.05),病例组具有年龄更大、多胎次和多胎的特点,随着孕周的增加,病例组D-二聚体水平呈逐渐升高的趋势;病例组和对照组产后D-二聚体水平差异有统计学意义(Z=-4.520,P<0.05),在建卡和分娩前D-二聚体水平差异均不存在统计学有意义(建卡Z=-0.669,P=0.504;分娩前Z=-0.804,P=0.421);产后D-二聚体水平变化可以反映和提示血栓性疾病的出现,即产后D-二聚体越高(6.32518.25 mg/L),越偏向于有肺栓塞。结论孕产期血浆D-二聚体水平呈增高趋势,产后血浆D-二聚体的变化对于产后肺栓塞的发生具有影响作用,考虑到疾病动态发展的特性,对于孕产妇发生静脉血栓栓塞应结合更多指标进行多方面考虑和管理。