Protected iliofemoral venous thrombectomy in a pregnant woman with pulmonary embolism and ischemic venous thrombosis.
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Although thromboembolism is uncommon during pregnancy and the postpartum period, physicians should be alert to the possibility because the complications, such as pulmonary embolism, are often life threatening. Pregnant women who present with thromboembolic occlusion are particularly difficult to treat because thrombolysis is hazardous to the fetus and surgical intervention by any of several approaches is controversial. A 22-year-old woman, in her 11th week of gestation, experienced an episode of pulmonary embolism and severe ischemic venous thrombosis of the left lower extremity The cause was determined to be a severe protein S deficiency in combination with compression of the left iliac vein by the enlarged uterus. The patient underwent emergency insertion of a retrievable vena cava filter and surgical iliofemoral venous thrombectomy with concomitant creation of a temporary femoral arteriovenous fistula. The inferior vena cava filter was inserted before the venous thrombectomy to prevent pulmonary embolism from clots dislodged during thrombectomy When the filter was removed, medium-sized clots were found trapped in its coils, indicating the effectiveness of this approach. The operation resolved the severe ischemic venous thrombosis of the left leg, and the patency of the iliac vein was maintained throughout the pregnancy without embolic recurrence. At full term, the woman spontaneously delivered an 8-lb, 6-oz, healthy male infant. (+info)
Percutaneous endovascular catheter aspiration thrombectomy of severe superior vena cava syndrome.
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We report a combined percutaneous endovascular approach, including thrombus aspiration and catheter directed local thrombolysis, followed by systemic thrombolytic therapy to treat severe superior vena cava syndrome in a 2 and 1/2 week old infant. This procedure was performed on the fifth postoperative day after major surgery. No treatment complications were observed. The only predisposing condition for thrombosis was a central venous line. No other acquired or genetic risk factors for thrombosis could be found. (+info)
Treatment of basilar artery embolism with a mechanical extraction device: necessity of flow reversal.
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BACKGROUND AND PURPOSE: The success of local fibrinolysis in vertebrobasilar thromboembolism depends on the volume and composition of the clot. Since thrombolysis can also be time consuming and cause bleeding, we investigated the feasibility of a mechanical clot retraction device based on a nitinol basket advanced through a microcatheter. METHODS: Five patients with acute embolism of the basilar artery who presented with progressive stroke and impaired consciousness were included in a multicenter study (Neuronet Evaluation in Embolic Stroke Disease [NEED]). In 3 patients flow reversal was induced with the use of silicone balloons or coaxial catheters. Three patients required additional fibrinolysis. RESULTS: The device failed to retrieve the clots in our first 2 patients with distal basilar artery embolism. After successful recanalization by local fibrinolysis, both patients survived, 1 disabled and 1 with little residual impairment. In the next 3 patients the anterograde flow in the basilar artery was reversed during the short retraction period by temporarily blocking the vertebral or subclavian arteries. Two of these patients were completely recanalized by solely mechanical means; the third patient needed additional fibrinolysis before also being recanalized. All 3 patients survived: 1 remained disabled, 1 had almost a full recovery, and 1 became asymptomatic the day after the procedure. CONCLUSIONS: Mechanical thrombus extraction seems to be a feasible method for preventing infarction by rapid, complete, and safe recanalization of the basilar artery. We recommend the use of flow control to support retrieval of the thrombus (which the proximal flow would otherwise keep in place like a cork) and to protect the distal vessels from embolization by fragments. (+info)
Two cases of a free-floating ball thrombus in the left atrium.
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A free-floating ball thrombus in the left atrium is an unusual occurrence that may cause fatal systemic emboli or left ventricular inflow obstruction, often resulting in sudden death. The first of 2 cases was a 59-year-old female with mitral stenosis and chronic atrial fibrillation who presented with severe dyspnea. Transthoracic echocardiography revealed a free-floating ball thrombus and emergency thrombectomy and mitral valve replacement were performed successfully. A second thrombus, which was not found at preoperative examination, was attached to the anterior mitral leaflet and may have been the source of the free-floating ball thrombus. The second case was a 79-year-old female with chronic renal failure who underwent mitral valve replacement 11 years prior to admission. She had been dependent on hemodialysis for 10 years, and had suffered several recent transient cerebral ischemic attacks. Computed tomography showed a ring-shaped, high-density area in the left atrium and transthoracic echocardiography revealed a floating ball thrombus in the left atrium. Thrombectomy was performed, but the patient died as a result of postoperative pneumonia 2 months later. Case 2 appears to be the first reported case of a ball thrombus in a hemodialysis patient who had previously undergone mitral valve replacement. (+info)
Plaque gruel of atheromatous coronary lesion may contribute to the no-reflow phenomenon in patients with acute coronary syndrome.
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BACKGROUND: No-reflow associated with direct angioplasty (PCI) of patients with acute coronary syndromes (ACS) is associated with unfavorable results. METHODS AND RESULTS: We used a new thrombectomy device to treat 51 lesions in 48 consecutive ACS patients (40 male and 8 female; mean age 63 years) and conducted a microscopic analysis of aspirates and blood samples retrieved from the culprit coronary artery. The first aspirate was collected before PCI and the second was collected separately after percutaneous transluminal coronary angioplasty or stenting, including samples from the no-reflow lumen. Light microscopy showed that the materials obtained from the pre-PCI aspiration consisted of thrombus in 37.5%, thrombus and atheroma in 35.0%, and atheromatous plaque in 27.5%. The materials collected from the post-PCI aspiration were thrombus in 8.3%, thrombus and atheroma in 41.7%, and atheromatous plaque in 50.0%. We then compared the 9 lesions (19.1%) with no-reflow to those without no-reflow. There was no difference in the pre-PCI aspirates. However, after PCI, there was more atheromatous plaque retrieved from patients with no-reflow (P<0.001) as well as significantly more platelet and fibrin complex, macrophages, and cholesterol crystals in the blood aspirated from no-reflow cases. Aspiration of these elements improved the no-reflow in 7 of 9 lesions to TIMI-3 flow. CONCLUSIONS: No-reflow after angioplasty may be caused by gruel that formed from an atheroma attributable to mechanical plaque disruption during intervention. (+info)
Is long-term anticoagulation after acute thromboembolic limb ischemia always necessary?
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OBJECTIVE: After thromboembolectomy, patients with acute limb ischemia often receive anticoagulant therapy to prevent recurrent events. Patients with atrial fibrillation or cardiac thrombus have a higher risk of recurrent emboli than those without these risk factors. This study examines the importance of long-term anticoagulation in these 2 groups. DESIGN: A review of patients presenting with acute limb ischemia over a 5-year period (1994-1999). SETTING: A university-affiliated medical centre. PATIENTS: Fifty patients divided into 2 groups: 19 (38%) patients with atrial fibrillation (group 1) and 31 (62%) patients with no atrial fibrillation or cardiac thrombus (group 2) as confirmed by transthoracic echocardiography. INTERVENTION: All patients underwent surgical thromboembolectomy and received postoperative anticoagulant therapy. OUTCOME MEASURES: Mortality, limb loss, further thromboembolic events and bleeding complications as determined by telephone survey. RESULTS: There was a significant difference in 5-year survival (group 1, 84%; group 2, 64%) and early limb loss (group 1, 0%; group 2, 13%). Further thromboembolic events and bleeding complications were rare but were more common in group 1. In group 2 there were no instances of recurrent thromboemboli and no bleeding complications although only 39% of patients in this group were taking angicoagulants at the end of the study period. CONCLUSIONS: Patients with extremity thromboemboli without atrial fibrillation or cardiac thrombus may not be at the same risk for recurrent events as those with these risk factors, and long-term anticoagulant therapy may not be as necessary in this group. (+info)
A metaanalysis comparing surgical thrombectomy, mechanical thrombectomy, and pharmacomechanical thrombolysis for thrombosed dialysis grafts.
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BACKGROUND: The achievement and maintenance of access sites for hemodialysis is a persistent challenge for both the vascular surgeon and the clinical nephrologist. The advent of improved interventional, endovascular, and pharmacomechanical techniques for the treatment of thrombosis has raised questions as to whether surgical thrombectomy is the most effective treatment. OBJECTIVE: The purpose of this study was to determine the role of surgical thrombectomy as the standard of care for the patient with end-stage renal disease and a thrombosed/stenosed arteriovenous graft (AVG). DESIGN AND METHODS: The study was designed as a metaanalysis. All publications that directly or indirectly described randomized controlled trials for the treatment of thrombosed dialysis grafts in patients with end-stage renal disease and AVG were searched. Relative risk (RR) and risk difference were used as the measure of effect for each dichotomous outcome. All of the studies that met the inclusion criteria were limited to prosthetic AVGs. RESULTS: The overall results suggested a clear superiority of surgery over endovascular procedures at 30 days, 60 days, 90 days, and 1 year. The RRs (95% CI) at these time points were 1.32 (1.07, 1.60), 1.34 (1.13, 1.58), 1.22 (1.05, 1.40), and 1.22 (1.07, 140), respectively, and favored surgery in all cases (30 days, P =.010; 60 days, P =.0007; 90 days, P =.007; and 1 year P =.003). The number needed to treat to prevent one endovascular occlusion after thrombectomy was 8 at 30 days, 6 at 60 days, 8 at 90 days, and 7 at 1 year. The rates of technical failure were significantly greater in the endovascular group compared with the surgical group (RR, 1.90; 95% CI, 1.32, 2.73; P =.0005), which generated an absolute risk reduction of 16% (P =.0002). No significant difference was seen in the complication rates between the two groups. CONCLUSION: The analysis of all currently available randomized controlled trials clearly supports the use of surgical thrombectomy for the treatment of thrombosed prosthetic vascular access grafts. The use of endovascular techniques has been found to be inferior to surgery in terms of both primary patency and technical failure rates. (+info)
Regional hyperthermic fibrinolytic perfusion after unsuccessful venous thrombectomy of extensive deep venous thrombosis.
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OBJECTIVE: Because of the dose-dependent increase in bleeding complications, the intraoperative administration of fibrinolytic agents is limited. This limitation impairs the efficacy of fibrinolytic therapy because low-dose fibrinolysis often fails in the treatment of complex deep venous thrombosis (DVT). The aim of this study was to investigate the efficacy and safety of intraoperative high-dose fibrinolytic therapy for extended DVT, which was performed with the regional hyperthermic fibrinolytic perfusion (RHFP) technique. METHODS: From January 1993 to June 2001, in 53 patients with extended DVT, unsuccessful venous thrombectomy (recanalization, <50%) was followed by RHFP with 0.5 mg/kg of body weight of recombinant tissue plasminogen activator. The extent of thrombosis was documented before, during (after the surgical thrombectomy), and after (between postoperative days 2 and 5) surgery with phlebography and was quantified with the Marder score. Intraoperative and postoperative complications were recorded prospectively. RESULTS: After RHFP, a recanalization was achieved in 64 of 146 venous segments (43.8%) that were still occluded despite thrombectomy. Eighty-two segments (56.2%) remained occluded. Compared with the preoperative phlebography, 32 patients (60.3%) had a successful recanalization (>50%). Eleven patients (20.8%) showed minimal and 10 patients (18.9%) no recanalization. No lethal complications occurred. One patient (1.9%) had pulmonary embolism develop, and two patients (3.8%) had bleeding complications develop. CONCLUSION: With the intraoperative use of hyperthermia-assisted high-dose fibrinolysis, improvement of the results of mechanical thrombectomy of extended DVT was possible. The RHFP protected against systemic side effects of the fibrinolysis and show a high safety of application. (+info)