Abstract:

Background: pulmonary embolism (PE), is one of the most common cardiopulmonary pathologies in the world, has a high risk of developing after major operations on the osteoarticular system. Mortality from PE remains high, ranking third after myocardial infarction and stroke.

Aim: was to identify tomographic signs of PE in patients with osteoarticular pathology in the postoperative period.

Materials and methods: we analyzed results of computed angiopulmonography of 11 patients with suspicion on pulmonary embolism who were operated on osteoarticular pathology at the Federal Center for Traumatology, Orthopedics and Endoprosthetics of the Ministry of Health of the Russian Federation (Cheboksary). Patients showed such indirect signs of PE as discshaped atelectasis of lung tissues, expansion of diameter of pulmonary trunk and right pulmonary artery, signs of congestion in pulmonary circulation and pulmonary hypertension. Direct radiological signs included occlusion of a branch of pulmonary artery by thrombus.

Results: in 91% of examined patients, occlusion of branch of pulmonary artery by thrombus was detected, in 82% of cases - the defeat of branches of right pulmonary artery. Embolism at the level of lobar arteries was detected in 30%, segmental branches - in 60% of patients; signs of pulmonary embolism of one of subsegmental branches of right pulmonary artery - in one patient (10%). Bilateral thrombosis was observed in two patients, including massive bilateral PE in one case. One patient had discoid atelectasis of lung tissues. Expansion of diameter of pulmonary trunk and right pulmonary artery was observed in 78% of patients with PE, signs of congestion in pulmonary circulation - in 27% of cases, pulmonary hypertension - in 73% of cases.

Conclusion: visualization of direct and indirect signs of pulmonary embolism during computed pulmonary angiography confirmed the diagnosis in all examined patients. The detection of blood clots in pulmonary arteries themselves is the main criterion in making the final diagnosis.

References

1.     Nikolaev NS, Trofimov NA, Kachaeva ZA, et al. Prevention and treatment of pulmonary thromboembolism in traumatology and orthopedics. Tutorial. Cheboksary: Publishing house of the Chuvash University, 2020; 108 [In Russ].

2.     Krivosheeva EN, Komarov AL, Shakhnovich RM, et al. Clinical analysis of a patient with antiphospholipid syndrome and submassive pulmonary embolism. Aterotromboz. 2018; (1): 76-87 [In Russ].

https://doi.org/10.21518/2307-1109-2018-1-76-87

3.     Hepburn-Brown M, Darvall J, Hammerschlag G. Acute pulmonary embolism: a concise review of diagnosis and management. Internal Medicine Journal. 2019; 49(1): 15-27.

https://doi.org/10.1111/imj.14145

4.     Ostapenko EN, Novikova NP. Pulmonary embolism: modern approaches to diagnosis and treatment. Ekstrennaya meditsina. 2013; 1(5): 84-110 [In Russ].

5.     Sinyukova AS, Kiseleva LP, Kupaeva VA. A clinical case of recurrent pulmonary embolism and the complexity of the diagnostic search. Sovremennaya meditsina: aktual'nye voprosy. 2015; (42-43): 24-31 [In Russ].

6.     Bagrova IV, Kukharchik GA, Serebryakova VI, et al. Modern approaches to the diagnosis of pulmonary embolism. Flebologiya. 2012; 6(4): 35-42 [In Russ].

7.     Kuznetsov AB, Boyarinov GA. Early diagnosis of pulmonary embolism (review). Sovremennye tekhnologii v meditsine. 2016; 8(4): 330-336 [In Russ].

8.     Bershteyn LL. Pulmonary embolism: clinical manifestations and diagnosis in the light of the new recommendations of the European Society of Cardiology. Kardiologiya. 2015; 55(4): 111-119 [In Russ].

https://doi.org/10.18565/cardio.2015.4.111-119

9.     Sakharyuk AP, Shimko VV, Tarasyuk ES, et al. Pulmonary embolism in clinical practice. Byulleten' fiziologii i patologii dykhaniya. 2015; (55): 48-53 [In Russ].

10.   M Al-hinnawi A-R. Computer-Aided Detection, Pulmonary Embolism, Computerized Tomography Pulmonary Angiography: Current Status. Intech Open. 2019; 19.

http://doi.org/10.5772/intechopen.79339

11.   Gilyarov MYu, Konstantinova EV. How do new approaches to the treatment of pulmonary embolism affect disease outcome? Meditsinskiy sovet. 2017; (7): 48-55 [In Russ].

https://doi.org/10.21518/2079-701X-2017-7-48-55

12.   Konstantinides S. Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur. Heart J. 2014; (35): 3033-3080.

13.   Tagalakis V, Patenaude V, Kahn SR, Suissa S. Incidence of and mortality from venous thromboembolism in a real-world population: the Q-VTE Study Cohort. Am J Med. 2013; 126(832): 13-21.

https://doi.org/10.1016/j.amjmed.2013.02.024

Abstract:

Inferior vena cava (IVC) abnormalities are reported to occur in 3% of the population, and bilateral IVC is the most common one. We presented a case of a patient with bilateral IVC and pulmonary embolism threat due to deep vein thrombosis of the left leg and thrombus flotation in the left external iliac vein. Two cava-filters were placed. The need of two devices is obvious, because emboli can easily reach the pulmonary artery via either right or left IVC.

Reference

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Abstract:

Aim: was to improve results of treatment of patients with myocardial infarction who underwent emergency coronary stenting, by prevention of bleeding complications from puncture place.

Materials and methods: we present retrospective analysis of clinical case of interventional treatment of myocardial infarction, with late post-puncture bleeding complication (41 day after PCI). Its consequences caused the thrombosis of the external iliac vein with further pulmonary embolism, and acute reocclusion of previously stented coronary artery

Results: developed complications were surgically treated (recurrent coronary stenting, elimination of defect of the femoral artery, implantation of cava filter with its subsequent removal), and thrombolytic therapy Patient was discharged to outpatient care without any indications of cardiopulmonary insufficiency and compensated arterial and venous circulation of operated lower limb. After 11 months, the patient’s condition was without negative dynamics with a satisfactory quality of life.

Conclusion: this clinical example demonstrates how difficult is to detect bleeding from a puncture wound. In cases of femoral access, the routine use of vascular closure devices can reduce the risk of bleeding complications. 

References 

1.    Rekomendacii po lecheniju ostrogo koronarnogo sindroma bez stojkogo pod#joma segmenta ST Evropejskogo obshhestva kardiologov [European cardiological society recommendation: treatment of acute coronary syndrome without stable ST-segment elevation]. Racional'naja farmakoterapija v kardiologii. 2012; 2: 2-64[In Russ].

2.    Sulimov V.A. Antitromboticheskaja terapija pri chreskozhnyh koronarnyh vmeshatel'stvah [Antithrombotic therapy during percutaneous coronary interventions]. Racional'naja farmakoterapija v kardiologii. 2008; 3: 91-100 [In Russ].

3.    Goloshhapov-Aksjonov R.S., Sitanov A.S. Luchevoj arterial'nyj dostup - prioritetnyj dostup dlja vypolnenii chreskozhnoj koronarnoj angioplasti

Abstract:

An important clinical challenge the management of patients with pulmonary embolism is to determine prognosis of the treatment generally, and thrombolytic reperfusion therapy as the main component of a specific pathogenetic treatment in particular. This knowledge is necessary to adjust the plan of remedial measures, the intensification of concomitant pharmacotherapy and provide a personalized approach to patients with thromboembolic lesions of the pulmonary circulation

Aim: was to identify reliable predictors of the onset of reperfusion in patients with pulmonary thromboembolism based on methods of radiographic diagnosis.

Materials and Methods: 138 patients (73 women and 65 men) underwent examination. Age of patients ranged from 20 to 80 years (mean age 55±25 years). The first group includes observation of 102 patients admitted to hospital in early stages of disease ( 1 month after onset of symptoms). The second group consisted of 36 patients admitted to the hospital at a later date (from 1.5 to 12 months). In groups we studied predictors of pulmonary reperfusion channel on the basis of direct angiography and multislice computed tomography As a control, a diagnostic method used direct angiography, which has a high sensitivity and specificity in identifying symptoms of pulmonary embolism. Using the method of multiple logistic regression odds ratios were prepared to achieve reperfusion in patients with certain diagnostic symptoms compared with patients who have no signs data in angiography

Results: diagnostic criteria, in presence of which on angio-pulmonography significantly increased the likelihood of reperfusion are «amputation» of segmental branches of the pulmonary artery ( p<0.05, 16,55(6,50-42,09 ) ), intraluminal defects of contrast staining (p < 0.05, 30.56 (8,66-107,84)) and the absence of distal blood flow (p<0,05; 6,16(2,47-15,40)). Signs, significantly reducing chances of achieving reperfusion are tortuosity of segmental branches of the pulmonary artery (p<0,05; 0,03(0,01-0,08)), slowing of contrast branches of the pulmonary artery (p<0,05; 0,11( 0.05-0.25)), and the presence of defects in the near-wall staining (p<0,05; 73,182 (9,606-557,542)).

Conclusions: basing on results of modern beam-diagnostics may reliably predict the likelihood of reperfusion in patients with pulmonary embolism.

Список литературы:

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Abstract:

Background: according to the international registry ICOPER, right ventricular (RV) dysfunction is the most significant predictor of mortality in patients with pulmonary embolism (PE). Diagnosis of PE should include not only verification of thrombus in branches of pulmonary arteries, but also estimation of RV contractile function.

Aim: was to identify the most informative indicators of Gated Blood Pool SPECT (GBPS) for estimation of RV function in patients with PE.

Methods: 52 patients were included in the study Main group (n=37) included patients with PE; comparison group (n=15) included patients suffering from coronary heart disease (NYHA I-II). All patients received ventilation-perfusion lung scintigraphy, gated blood pool single photon emission computer tomography (GBPS), and estimation of plasma levels of endothelin-1, stable nitric oxide (NO) metabolites, and 6-keto-PG F1a.

Results: in patients with PE, RV end-systolic volume, stroke volume, ejection fraction, peak ejection rate, peak filling rate, and mean filling rate were significantly lower in comparison with patients without PE. In patients with PE volume from 3 to 7 bronchopulmonary segments, we have not found any correlations between PE volume and functional status of the right ventricle. In patients with PE, levels of endothelin-1, 6-keto-PG F1a, and stable NO metabolites were increased in comparison with patients without PE.

Conclusion: GBPS allows to verify RV dysfunction in patients without massive PE and severe pulmonary hypertension. Dissociation between volume of PE and the degree of RV dysfunction may be caused by humoral vasoactive factors disbalance. 

Reference

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Abstract:

Article presents the first successful experience of thrombolytic therapy in a patient with severe burns, complicated by pulmonary embolism. Article describes detailed analysis of tactics of treatment, with the help of foreign and domestic recommendtions. Analysis shows that in patient with burns in case of pulmonary embolism, thrombolytic therapy is a method of choice. 

References

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2.     Konstantinides S.V., Torbicki A., Agnelli G. et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur. Heart J. 2014; 35(43): 3033-3069, 3069a-3069k.

3.     Kearon C., Akl E.A., Comerota A.J. et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141 (2, Suppl): e419S- e494S.

4.     Rossijskie klinicheskie rekomendacii po diagnostike, lecheniju i profilaktike venoznyh trombojebolicheskih oslozhnenij. [Russian clinical recommendations on diagnostics, treatment and prophylaxis of venous thromboembolic complications.] Flebobgija. 2010; 1(2): 5-37 [In Russ].

5.     Bershtejn L.L. Trombojembolija legochnoj arterii: klinicheskie projavlenija i diagnostika v svete novyh rekomendacij Evropejskogo obshhestva kardiologov. [Pulmonary embolism: clinical presentation and diagnosis in the view of recommendations of the European Society of Cardiology] Kardiologija. 2015; 4: 111-119 [In Russ].

6.     Bershtejn L.L. Trombojembolija legochnoj arterii u pacienta so stabil'noj gemodinamikoj. [Pulmonary embolism in patients with stable hemodynamics]. Jeffektivnaja farmakoterapija. 2015; (24): 10-15 [In Russ].

7.     Charnaja M.A., Morozov Ju.A. Trombozy v klinicheskoj praktike. [Thrombosis in clinical practice]. М.: GJeOTAR-Media [GEOTAR Media], 2009; 224 [In Russ].

8.     Sibagatullin N.G., Zakirova I.A., Hatypov M.G. i dr. Ob jeffektivnosti tromboliticheskoj terapii pri lechenii trombojembolii legochnoj arterii v pozdnie sroki. [The effectiveness of thrombolytic therapy in the treatment of pulmonary embolism in later stages]. Kreativnaja onkologija i hirurgija. Jelektronnyj nauchno-prakticheskij zhurnal. 2013; 3: URL: http://eoncosurg.com/ob-effektivnosti-tromboliticheskojt [In Russ].

9.     Kurakina E.A. Sravnenie jeffektivnosti tromboliticheskoj i antikoaguljantnoj terapii geparinom pri trombojembolii legochnoj arterii promezhutochnogo riska. [Effectiveness of thrombolytic and anticoagulant therapy with in comparison with heparin in pulmonary embolism of intermediate risk]. Fundamental'nye issledovanija. 2012; 4(1): 69-731[In Russ].

10.   Kungurcev E.V., Mihajlov I.P., Kosolapov D.A. i dr. Sravnitel'nyj analiz lechenija bol'nyh s trombozami glubokih ven nizhnih konechnostej, oslozhnivshihsja TJeLA. Geparin ili trombolizis? [A comparative analysis of the treatment of patients with deep venous thrombosis of lower limbs, complicated by pulmonary embolism. Heparin or thrombolysis?]. Zhurnal im. N.V. Sklifosovskogo. Neotlozhnaja medicinskaja pomoshh'. 2012; 3: 25-28 [In Russ].