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.

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?

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. 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. 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 that 132 CTA＇s per year could be avoided in our institution, without compromising safe exclusions of PE （keeping post-test probability of PE below 2%）. 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.

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.

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.

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.

Pulmonary embolism after transcatheter arterial chemoembolization for hepatocellular carcinoma:a retrospective analysis on 10 years' experience

To study the clinical characteristics and treatment of pulmonary embolism （PE） after transcatheter arterial chemoembolization （TACE） for hepatocellular carcinoma （HCC）. Methods： The clinical records of 13 512 patients diagnosed with HCC and received TACE from January 2000 to December 2009 were reviewed. Among these patients, 5 031 were allocated into group A who had one or more disorders like diabetes, hypertension, coronary heart disease, obesity or varicose vein of lower limb, while the other 8 481 patients who did not have such disorders were in group B. Results： A total of 39 185 TACE procedures were performed for the 13 512 patients. Five （0.01%） patients in group A developed PE after TACE, of whom two recovered 4 and 5 d later with early anticoagulant therapy while the hypertension, coronary heart disease, obesity or varicose vein of lower limb are possibly more likely to develop PE other 3 died of respiratory failure within 5 h. The mortality of PE was 60% （3/5）. Conelusion： HCC patients with diabetes, after TACE than those without such disorders. Patients who have such disorders should be more carefully observed after TACE and early treatment with heparin should be applied once PE develops.

PULMONARY EMBOLISM DURING PREGNANCY AND THE POSTPARTUM PERIOD: REPORT OF 2 CASES

Objective. To investigate the high risk factors, clinical features, diagnosis and treatment of pulmonary embolism (PE) during pregnancy and the postpartum period.Methods. Two cases of PE during pregnancy and postpartum period were reported retrospectively.Results. The first case was a pregnant woman with congenital heart disease at 39-week gestation. She underwent a successful cesarean section (CS) because of heart disease, but she manifested tachycardia, tachypnea, cyanosis, and dyspnea suddenly on the 10th day after CS and died soon after the onset of these symptoms. The diagnosis of PE was highly suspected clinically. The second case was a twin-pregnancy woman at 35-week gestation. Because of severe perinatal myocardiopathy, cesarean section was performed. Unfortunately, the patient died abruptly on the operation table. The diagnosis of PE was confirmed by autopsy.Conclusions. The maternal mortality of PE during pregnancy and postpartum period is quite high. Whenever there is any doubt, objective examinations for PE should be started early in order to strive for the chances of the anticoagulant therapy.

Acute pulmonary embolism originating from upper limb venous thrombosis following breast cancer surgery:Two case reports

BACKGROUND Upper limb venous thrombosis(ULVT)is rarer than lower-extremity deep venous thrombosis,and is related to Paget-Schroetter syndrome,central venous catheterization,and malignancy.There are few reports of pulmonary embolism(PE)from upper-extremity vein thrombosis due to surgery.Herein,we report two cases of PE that originated from upper limb venous thrombosis on the surgical side in two patients undergoing modified radical mastectomy for breast cancer.These cases challenge the traditional theory that PE originate only from the lower extremities.CASE SUMMARY We describe two female patients,aged 68 and 65 years,respectively,who had undergone modified radical mastectomy for breast cancer.They did not have a central venous catheter and did not undergo preoperative neoadjuvant chemotherapy.They were transferred to the intensive care unit due to symptomatic PE on the first day after surgery.Colour Doppler ultrasound identified fresh thrombosis in their upper limb veins,which was the presumed source of the PE.They all received anticoagulation therapy,and one of them experienced bleeding that required discontinuation of the drug.Ultimately,they were discharged in stable condition.CONCLUSION ULVT as a source of PE after breast cancer surgery cannot be ignored.

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.

Pulmonary Embolism after Bilateral Upper Limb Surgeries: A Case Report and Review of Literature

Pulmonary embolism following upper limb surgery is a very rare complication. Here we present a unique case report of a 54-year-old young, fit and healthy, and non-smoker male who developed bilateral pulmonary embolism (PE) 26 days post-operatively with no associated upper or lower limb Deep Vein Thrombosis (DVT). This patient had minimal preoperative as well as intra-operative risk factors. He did not develop any thromboembolic symptoms until the 26th-day post-surgery when he developed sudden, sharp, pleuritic chest pain and laboured breathing. Initial baseline bloods showed a raised D-Dimer and the patient subsequently had a CT pulmonary angiogram that confirmed the presence of bilateral massive PEs. However, subsequent extremity ultrasound showed no upper or lower deep venous thrombosis. Thorough review of literature suggests that sudden development of PEs after upper limb surgery is possible, with a few cases being reported in the past. Symptoms such as sudden upper limb swelling, troubled breathing and systemic symptoms should be evaluated aggressively with a CT pulmonary angiogram, given the fact that an ultrasound of the extremities may be negative for deep venous thrombosis.

Severe Pulmonary Embolism,Thrombosis of Lower Extremity,Unexpected Mild Renal Disorder in MPO-ANCA Associated Vasculitis:A Case Report

Myeloperoxidase antineutrophil cytoplasmic antibody(MPO-ANCA)associated vasculitis is an autoimmune disease usually with severe multiple dysfunction syndrome,especially prominent acute renal failure.A 65-year-old woman was admitted with progressive dyspnoea for six months and fever,sputum with blood,pain of the lower extremities and intermittent claudication for two days,indicating multiple organ involvement(respiratory system,blood vessels).The renal involvement was relatively mild,presenting with microscopic haematuria.The chest computed tomography demonstrated multiple pulmonary embolisms.Ultrasound and computed tomography angiography for the lower extremity vessels showed venous and arterial thrombosis.Exclusion of other diseases that can cause multiple organ damage and thrombosis,the positive perinuclear ANCA and MPO-ANCA strongly support the diagnosis of MPO-ANAC-associated vasculitis.The patient’s physical condition has been greatly improved by treatment with corticosteroids and anticoagulation.