Successful management of a large air embolus during an extended right hepatectomy with an emergency cardiopulmonary bypass.
- HPB : the official journal of the International Hepato Pancreato Biliary Association
- Published about 5 years ago
An air embolus is a recognized but rare complication of a partial hepatectomy. The aim of this report was to describe the diagnosis and management of a large paradoxical air embolus during hepatic resection.
Pulmonary embolism and fatal stroke in a patient with severe factor XI deficiency after bariatric surgery.
- Blood coagulation & fibrinolysis : an international journal in haemostasis and thrombosis
- Published about 5 years ago
We report the case of a 40-year-old woman with a severe factor XI (FXI) deficiency who died from a stroke due to bilateral internal carotid arteries occlusion after a laparoscopic gastric bypass (bariatric surgery). This stroke was probably secondary to a pulmonary embolism with a paradoxical embolism through a previously unknown foramen ovale. This woman who had one severe episode of bleeding before the bypass received for the intervention a single infusion of 27 U/kg of FXI concentrate. A careful evaluation of the bleeding and thrombotic risk was performed before surgery, and despite all preventive measures, this tragic event occurred. The aim of this report is to alert medical teams to carefully balance the benefit-risk of such an intervention in a patient with a severe FXI deficiency.
Air embolism is a rare complication of computed tomography (CT)-guided preoperative marking of peripheral pulmonary nodules. Here, we describe a new CT-guided marking method, which allows the quick intraoperative identification of peripheral pulmonary nodules and avoids this complication. This method does not require piercing of the pulmonary parenchyma and uses an 18-gauge indwelling catheter and a central venous catheter with a guidewire. Between July 2009 and January 2013, 16 patients underwent this procedure and could be intraoperatively diagnosed without any air embolisms. No postoperative complications were observed in this series. We believe that this simple technique is effective and will not cause severe complications.
BACKGROUND: Stroke is the second leading cause of death among adults worldwide. Mindin is an ECM protein that plays important roles in regulating inflammation, angiogenesis and neuronal outgrowth. The role of mindin in the context of brain ischemia has not been examined. METHODS AND RESULTS: Transient occlusion of the middle cerebral artery was performed on mindin knockout (KO) mice, mice that carried a neuron-specific constitutively active mindin transgene (TG) and the appropriate controls. The outcome of the ischemia was evaluated by examination of the infarct and edema volumes and by neurological score assessments. The brains were collected 24 hours or 3 days following the induced stroke. Compared with the control mice, the mindin KO mice exhibited lower infarct volumes and better outcomes in the neurological tests. Mindin-deficient mice exhibited low expression levels of stroke-induced inflammatory mediators, an attenuated recruitment of inflammatory cells, and inhibited activation of NF-κB. The neuronal apoptosis levels were also lower in the brains of the mindin KO mice than in those of the control mice. The mice that expressed a neuron-specific, constitutively active mindin transgene exhibited effects following the cerebral ischemic injury that were the opposite of those that were observed in the mindin KO mice. Moreover, Akt signaling activation was elevated in the ischemic brains of mindin KO mice. CONCLUSIONS: Mindin KO mice exhibited minor infarctions, an attenuated inflammatory response and low levels of neuronal apoptosis following an ischemic insult. These data demonstrate that mindin is a critical mediator of ischemic brain injury in an experimental stroke model. Akt signaling most likely mediates the biological function of mindin in this model of cerebral ischemia.
Ultrasound-assisted lysis using recombinant tissue plasminogen activator and the EKOS EkoSonic endovascular system for treating right atrial thrombus and massive pulmonary embolism: A case study
- Phlebology / Venous Forum of the Royal Society of Medicine
- Published about 3 years ago
Right atrial thrombus in the setting of a large pulmonary embolus is rare and is associated with serious adverse events. This case report presents the role played by EKOS EkoSonic ultrasound system in successfully treating right atrial thrombus and massive pulmonary embolism.
The pharmaceutical therapy for acute ischemic stroke has shortcomings in reopening large vessels and dissolving long thrombi, and endovascular treatment has been found to provide added value. The Aperio thrombectomy device showed promising results in an experimental study. The purpose of this study was to evaluate the device clinically.
- Journal of the American Medical Directors Association
- Published almost 3 years ago
Atrial fibrillation is a common condition in the elderly, and the incidence of thromboembolic events secondary to atrial fibrillation increases with age. Antithrombotic therapy effectively prevents stroke and systemic embolism but also exposes patients to the risk of bleeding. Because the risk of bleeding also increases with age, clinicians tend to withhold anticoagulation in the elderly. Anticoagulation is particularly complex in the frail elderly patient, who presents additional risk factors affecting both efficacy and safety of thromboembolic prevention. The main clinical trials rarely include frail elderly patients and, consequently, the guidelines do not provide guidance for their management. In the absence of clear indications for this class of patients, we identified some areas that should be taken into account both before starting and when discontinuing anticoagulation: comorbidities, polypharmacotherapy, adherence, cognitive impairment, mobility and monitoring barriers, nutritional status and swallowing disorders, risk of falls, and reduced life expectancy. We also suggest a multidimensional algorithm covering both a standard ischemic and bleeding risk assessment and an additional anticoagulation-focused frailty assessment. This is of particular relevance given the recent introduction of the oral direct inhibitors, as they are likely to widen the treatment options for the frail elderly. Depending on which aspect of frailty is present, anticoagulation can now be tailored accordingly.
We solved the Laplace equation for the radius of an arterial gas embolism (AGE), during and after breath-hold diving. We used a simple three-region diffusion model for the AGE, and applied our results to two types of breath-hold dives: single, very deep competitive-level dives and repetitive shallower breath-hold dives similar to those carried out by indigenous commercial pearl divers in the South Pacific. Because of the effect of surface tension, AGEs tend to dissolve in arterial blood when in arteries remote from supersaturated tissue. However if, before fully dissolving, they reach the capillary beds that perfuse the brain and the inner ear, they may become inflated with inert gas that is transferred into them from these contiguous temporarily supersaturated tissues. By using simple kinetic models of cerebral and inner ear tissue, the Nitrogen tissue partial pressures during and after the dive(s) were determined. These were used to theoretically calculate AGE growth and dissolution curves for AGEs lodged in capillaries of the brain and inner ear. From these curves it was found that both Cerebral and Inner Ear Decompression Sickness are expected to occur occasionally in single competitive-level dives. It was also determined from these curves that for the commercial repetitive dives considered, the duration of the surface interval (the time interval separating individual repetitive dives from one another) was a key determinant, as to whether Inner Ear and/or Cerebral decompression sickness arose. Our predictions both for single competitive-level and repetitive commercial breath-hold diving were consistent with what is known about the incidence Cerebral and Inner Ear Decompression Sickness in these forms of diving.
The therapeutic potential of human multipotent mesenchymal stromal cells, especially human adipose tissue-derived stem cells (hASC), is promising. However, there are concerns about the safety of infusion of hASC in human. Recently, we have experienced pulmonary embolism and infarct among family members who have taken multiple infusions of intravenous autologous hASC therapy. A 41-year-old man presented with chest pain for one month. Chest CT showed multiple pulmonary artery embolism and infarct at right lung. Serum D-dimer was 0.8 μg/mL (normal; 0-0.5 μg/mL). He had received intravenous autologous adipose tissue-derived stem cell therapy for cervical herniated intervertebral disc three times (one, two, and three months prior to the visit). His parents also received the same therapy five times and their chest CT also showed multiple pulmonary embolism. These cases represent artificial pulmonary embolisms and infarct after IV injection of hASC. Follow-up chest CT showed spontaneous resolution of lesions in all three patients.
Pulmonary embolism (PE) is associated with high all-cause and PE-related mortality and requires individualized management. After confirmation of PE, a refined risk stratification is particularly warranted among normotensive patients. Previous prognostic models favored combinations of echocardiography or computed tomography suggestive of right ventricular (RV) dysfunction together with biomarkers of RV dysfunction (natriuretic peptides) or myocardial injury (cardiac troponins) to identify candidates for thrombolysis or embolectomy. In contrast, current predictive models using clinical scores such as the Pulmonary Embolism Severity Index (PESI) or its simplified version (sPESI) rather seek to identify patients, not only those at higher risk requiring observation for early detection of hemodynamic decompensation, and the need for initiation of rescue reperfusion therapy, but also those at low risk qualifying for early discharge and outpatient treatment. Almost all prediction models advocate the additional measurement of biomarkers along with imaging of RV dysfunction as part of a comprehensive algorithm.