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.

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.

The Value of MLPR,NLR,and RDW in the Assessment of Combined Pulmonary Embolism in Elderly Patients with AECOPD

Objective:To investigate the diagnostic value of the monocyte-to-large-platelet ratio(MLPR),neutrophil-to-lymphocyte ratio(NLR),and red blood cell distribution width(RDW)for pulmonary embolism(PE)in patients with acute exacerbation of chronic obstructive pulmonary disease(AECOPD).Methods:A total of 60 elderly AECOPD patients were enrolled and divided into embolus group(12 cases)and thrombus group(48 cases)according to whether they were combined with pulmonary embolism and the MLPR,NLR,and RDW values of the two groups were determined respectively.Results:The patients in the two groups had different degrees of vascular structural and functional abnormalities,and the MLPR,NLR,and RDW in the embolus group were significantly higher than those in the thrombus group(P<0.05);while the differences in NLR and RDW between the two groups were not significant.Conclusion:MLPR,NLR,and RDW can provide an objective basis for assessing PE in elderly AECOPD patients.

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.

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.

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.

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.

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.

Interventional radiology treatment for pulmonary embolism

Venous thromboembolism(VTE) is an illness that has a potentially life-threatening condition that affects a large percentage of the global population. VTE with pulmonary embolism(PE) is the third leading cause of death after myocardial infarction and stroke. In the first three months after an acute PE, there is an estimated 15% mortality among submassive PE, and 68% mortality in massive PE. Current guidelines suggest fibrinolytic therapy regarding the clinical severity, however some studies suggest a more aggressive treatment approach. This review will summarize the available endovascular treatments and the different techniques with its indications and outcomes.

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.

A study of pulmonary embolism after abdominal surgery in patients undergoing prophylaxis

AIM： To determine risk factors for pulmonary embolism and estimate effects and benefits of prophylaxis. METHODS： We included 78 patients who died subsequently to a pulmonary embolism after major abdominal surgery from 1985 to 2003. A first, retrospective analysis involved 41 patients who underwent elective surgery between 1985 and 1990 without receiving any prophylaxis. In the prospectively evaluated subgroup, 37 patients undergoing major surgery between 1991 and 2003 were enrolled： all of them had received a prophylaxis consisting in lowmolecular weight heparin, given subcutaneously at a dose of 2850 IU AXa/0.3 mL （body weight 〈 50 kg） or 5700 IU AXa/0.6 mL （body weight ≥ 50 kg）. RESULTS： A higher incidence of thromboembolism （43.9% and 46.34% in the two groups, respectively） was found in older patients （〉 60 years）. The incidence of pulmonary embolism after major abdominal surgery in patients who had received the prophylaxis was significantly lower compared to the subjects with the same condition who had not received any prophylaxis （P 〈 0.001, OR = 2.825; 95% CI, 1.811-4.408）. Furthermore, the incidence of pulmonary embolism after colorectal cancer surgery was significantly higher compared to incidence of pulmonary embolism after other abdominal surgical procedures. Finally, the incidence of pulmonary embolism after colorectal cancer surgery among the patients who had received the prophylaxis （11/4316, 0.26%） was significantly lower compared to subjects undergoing a surgical procedure for the same indication but without prophylaxis （10/1562, 0.64%） （P 〈 0.05, OR = 2.522; 95% Ct, 1.069-5.949）. CONCLUSION： Prophylaxis with low molecular weight heparin is highly recommended during the preoperative period in patients with diagnosis of colorectal cancer due to high risk of pulmonary embolism after elective surgery.

Endovascular treatment of pulmonary embolism: Selective review of available techniques

Acute pulmonary embolism(PE) is the third most common cause of death in hospitalized patients. The development of sophisticated diagnostic and therapeutic modalities for PE, including endovascular therapy, affords a certain level of complexity to the treatment of patients with this important clinical entity. Furthermore, the lack of level I evidence for the safety and effectiveness of catheter directed therapy brings controversy to a promising treatment approach. In this review paper, we discuss the pathophysiology and clinical presentation of PE, review the medical and surgical treatment of the condition, and describe in detail the tools that are available for the endovascular therapy of PE, including mechanical thrombectomy, suction thrombectomy, and fibrinolytic therapy. We also review the literature available to date on these methods, and describe the function of the Pulmonary Embolism Response Team.

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.

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.

Pulmonary embolism with acute pancreatitis:A case report and literature review

Acute pancreatitis is an inflammatory disease characterized by local tissue injury which can trigger a systemic inflammatory response.So vascular complications of pancreatitis are a major cause of morbidity and mortality.Pulmonary embolism in acute pancreatitis has been reported to be very rare.We reported a case of pulmonary embolism with acute pancreatitis.A 38-year-old woman broke out upper abdomen pain without definite inducement.She had no nausea and vomiting,fever,dyspnea,cough and expectoration,chest pain.The patient had been diagnosed with acute pancreatitis in local hospital.The patient was treated with antibiotics and proton pump inhibitors,and the abdomen pain was alleviated slightly.But the patient came forth cough and expectoration with a little blood,progressive dyspnea.A computed tomographic scan of the abdomen re-vealed pancreatitis.Subsequent computer tomography angiography of chest revealed pulmonary embolism(both down pulmonary arteries,left pulmonary artery and branch of right pulmonary artery).Dyspnea of the patient got well with thrombolytic treatment and anticoagulation therapy.Pulmonary embolism is a rare but potentially lethal complication of pancreatitis.Familiarity with this complication will aid in its early diagnosis,therapy and prevent pulmonary embolism,a rare but catastrophic phenomenon.

Pulmonary Embolism and Deep Vein Thrombosis in a Woman Taking Contraceptives and with Unhealthy Life Habit:a Case Report

QRAL contraceptives are widely used to prevent pregnancy. A number of studies have dem- onstrated the increased risk of venous throm- boembolism in women taking oral contracep-tives.1, 2 Pulmonary embolism （PE） and deep vein throm- bosis （DVT） are two clinical presentations of venous thromboembolism which share the same predisposing factors.3 This article described a female patient who taked oral contraceptives and had an unhealthy life habit de- veloped PE and DVT. CASE DESCRIPTION

Non-cardiogenic acute pulmonary edema in elderly patient with Dressier syndrome associated pulmonary embolism

Pulmonary embolism （PE） is a common cardiovascular and cardiopulmonary illness and the incidence increases exponentially with age. Because the clinical signs and symptoms are non-specific, its diagnosis is always difficult.

Prevalence of pulmonary embolism at autopsy among elderly patients in a Chinese general hospital

Objectives To investigate the prevalence and characteristics of pulmonary embolism （PE） at autopsy in a Chinese general hospital over a period of 10 years, and to evaluate the antemortem achievement of the prophylaxis, diagnosis, and treatment of PE. Methods All medical records of deaths from the West Branch of the Chinese People＇s Liberation Army （PLA） General Hospital were retrospectively re- viewed, for the period of January 1, 2006 to December 31, 2015. Cases in which autopsies had been performed were identified and further analyzed. The numbers and detailed characteristics of patients who had PEs were noted. Prophylactic measures, along with diagnosis and treatment of PE, were recorded, if performed. Results During the 10-year period, 1057 patients died in the study hospital and 278 necrop- sies were performed （autopsy rate： 26.3%）. Nine patients were found to have PE （3.2%）, and in seven of these patients （2.5%）, the PE was considered to be fatal. Embolisms were found in the trunk and bilateral main branches of the pulmonary artery tree in all seven of the fatal PE cases. Right intracardiac thrombosis was detected in five of the nine PE patients （55.6%）. All patients with PE had been hospitalized in medical departments, and only one had undergone surgery during hospitalization. Antemortem prophylaxis was performed in two of the nine PE cases （22.2%）. None of the 9 patients had received a clinical diagnosis of PE before death. Conclusions The incidence of and death rate associated with PE may vary among different races and regions. Continuous monitoring of PE by means of necropsy in certain representative medical institutions is necessary.

New guidelines for the diagnosis and management of pulmonary embolism:Key changes

Pulmonary embolism(PE)is an important public health problem.In August2019,the European Society of Cardiology in collaboration with the European Respiratory Society released new guidelines for the diagnosis and management of PE.We discuss the basic changes between these recent guidelines and the previous guidelines that were published in 2014.Regarding diagnosis,the new guidelines propose the use of an age-adjusted cut-off level of D-dimers instead of a fixed cut-off value.A D-dimer test adapted to clinical possibility should also be considered instead of fixed cut-off level of D-dimer.Detailed recommendations for the diagnosis of PE during pregnancy are also provided.Regarding risk stratification,assessment of PE-related early mortality risk is recommended.Moreover,the importance of right ventricular dysfunction is emphasized in lowrisk patients.For further risk stratification of the severity of PE in patients without hemodynamic instability,use of validated scores that combine clinical,imaging and laboratory PE-related prognostic factors might also be considered.Regarding treatment,the possibility of early discharge is mentioned in patients without severe comorbidities,who are not of high risk for sudden death and in whom proper medical management at home and proper medical follow up can be ensured.The new guidelines also suggest that pro-brain natriuretic peptide levels,right ventricular function and the presence of thrombus in the right heart could be useful for guiding the decision of early discharge.Overall,these new guidelines introduce several key changes and knowledge and adherence to them will improve the outcome of patients with PE.