Percutaneous Thrombus Removal in COVID-19–Infected Patient with Pulmonary Embolism

We present a case describing the use of the AngioVac system (AngioDynamics, Inc.) and SENTINEL™ cerebral protection system (SCPS; Boston Scientific) in a patient with COVID-19 who initially presented with a large deep-vein thrombosis of the left lower extremity, complicated by a pulmonary embolism. Although he initially improved with systemic alteplase, he later developed a second large clot diagnosed in transit in the right atrium. Within 12 hours from initial thrombolysis, this large clot wedged across an incidental patent foramen ovale (PFO), the atrial septum, and the cavotricuspid annulus. We emergently performed a percutaneous clot extraction with preemptive placement of the SCPS in anticipation of cardioembolic phenomenon. A large (> 10 cm) clot was extracted without complication, and the patient was discharged home. The combined use of SCPS and AngioVac in this case suggests a potential role for percutaneous treatment of severe and consequential thromboembolic disease, especially in patients with a PFO, and may be considered as an alternative and less-invasive option in patients with COVID-19. While cerebral embolic protection devices are approved for and widely used in transcatheter aortic valve replacement procedures, there is a theoretical benefit for use in percutaneous thrombolectomies as well.

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May-Thurner Syndrome Is Aggravated by Pregnancy

Medicina ◽

10.3390/medicina57030222 ◽

2021 ◽

Vol 57 (3) ◽

pp. 222

Author(s):

Kuntharee Traisrisilp ◽

Manatsawee Manopunya ◽

Tanop Srisuwan ◽

Wisit Chankhunaphas ◽

Theera Tongsong

Keyword(s):

Conservative Treatment ◽

Renal Agenesis ◽

Iliac Vein ◽

Vein Thrombosis ◽

Left Lower Extremity ◽

Asymptomatic Patients ◽

Pregnancy And Postpartum ◽

Anticoagulant Prophylaxis ◽

The Right ◽

Deep Vein

This study aims to emphasize that asymptomatic patients with undiagnosed and asymptomatic May-Thurner syndrome (MTS) may firstly develop severe compression during pregnancy. A 40-year-old woman, G1P0, at 22 weeks of twin gestation presented with left lower extremity edema and pain. One twin was structurally normal while the other had bilateral renal agenesis with oligohydramnios. Magnetic resonance venography (MRV) revealed severe compression of the left iliac vein by the right iliac artery without evidence of deep vein thrombosis (DVT). Conservative treatment with anticoagulant prophylaxis was instituted throughout the rest of pregnancy and postpartum period. She was also complicated with severe pre-eclampsia, a cesarean section was performed due to a prolapsed cord at 27 weeks of gestation, and she gave birth to a surviving baby weighing 1100 g. In conclusion, this case report provides evidence that pregnancy can disclose a subtle May-Thurner anatomy to be symptomatic without DVT. Successful pregnancy outcomes could be achieved with conservative treatment and anticoagulant prophylaxis.

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Saddle pulmonary embolism with fluorouracil: A case report

Journal of Oncology Pharmacy Practice ◽

10.1177/1078155220909424 ◽

2020 ◽

Vol 26 (7) ◽

pp. 1769-1773

Author(s):

Kylee E White ◽

Christopher T Elder

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Case Report ◽

Single Agent ◽

Vein Thrombosis ◽

Increased Risk ◽

Additive Risk ◽

The Right ◽

Deep Vein ◽

To Receive

Introduction As a single agent, fluorouracil has been documented to have a small but present chance of causing extravasation of the port when not properly administered. It has also been shown that cancer patients receiving chemotherapy are at increased risk of deep vein thrombosis, symptomatic or silent. Case report A 43-year-old male patient with stage III colon cancer receiving FOLFOX developed a saddle pulmonary embolism involving possible extravasation that was discovered following cycle 3 of chemotherapy. CT scan and lower extremity Doppler confirmed non-occlusive deep vein thrombosis along with saddle pulmonary embolism. Management and outcome: For acute management, patient underwent bilateral pulmonary artery thrombolysis. Following this, the patient was initiated on rivaroxaban indefinitely. The right subclavian port was removed, and a new port was placed in the left subclavian. Patient went on to receive three more cycles of chemotherapy. Discussion Fluorouracil, an inflammitant, has been shown to have damaging potential, especially in terms of the integrity of the endothelium. Over time, this can lead to serious complications such as cardiotoxicity, including deep vein thrombosis formation. Based on how and when the thrombi were discovered, it is not possible to deduce whether the port, the 5-FU, extravasation or other factors were the precipitators of the formation of the thrombi. The combination of chemotherapy treatment along with CVC placement appears to have an additive risk to the formation of a thrombus. Practitioners should take caution when evaluating for extravasation and CVC integrity and note other potential differentials for causes, including deep vein thrombosis/saddle pulmonary embolism formation.

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Large diverticulum of the urinary bladder: A rare cause of deep vein thrombosis with consecutive pulmonary embolism

Canadian Urological Association Journal ◽

10.5489/cuaj.2533 ◽

2015 ◽

Vol 9 (5-6) ◽

pp. 321

Author(s):

Oliver Zimmermann ◽

Jan Torzewski ◽

Ekkehard Reichenbach-Klinke ◽

Christine Zenk

Keyword(s):

Pulmonary Embolism ◽

Urinary Bladder ◽

Left Kidney ◽

Pulmonary Arteries ◽

Vein Thrombosis ◽

Progressive Dyspnea ◽

Vena Femoralis ◽

The Right ◽

Deep Vein ◽

Vena Femoralis Superficialis

A 73-year-old man was admitted with progressive dyspnea; he also had benign prostatic hyperplasia (BPH). An angio computed tomography scan showed pulmonary embolism with thrombi in both main pulmonary arteries. By duplex ultrasonography, we detected a thrombus in the right vena femoralis superficialis and vena femoralis communis. Simultaneously, we also noticed a large diverticulum on the right side of the urinary bladder and urinary stasis II of the left kidney. We consider the BPH as the trigger for a secondary diverticulum of the urinary bladder. As a result of its large dimensions, mechanical compression of the deep right pelvic veins resulted in thrombosis which finally caused the pulmonary embolism. With respect to the urinary stasis II, surgical excavation of the diverticulum with infravesical desobstruction was planned. The potentially lethal course of large diverticula may require surgery.

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Recurrent pulmonary embolism related with Paget–Schroetter syndrome: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz118 ◽

2019 ◽

Vol 3 (3) ◽

Author(s):

Yuki Sahashi ◽

Junko Naito ◽

Masanori Kawasaki

Keyword(s):

Pulmonary Embolism ◽

Lifestyle Modification ◽

Axillary Vein ◽

Vein Thrombosis ◽

Cardiology Department ◽

Recurrent Pulmonary Embolism ◽

The Right ◽

Contrast Ct ◽

First Rib Resection ◽

Deep Vein

Abstract Background Paget–Schroetter syndrome (PSS) is an unusual cause of venous thromboembolism, which is frequently misdiagnosed and undiagnosed in clinical settings. Although axillary-subclavian vein thrombosis is related with PSS typically presents in healthy young athletes, it is possible for this phenomenon to occur in various age settings. Case summary We present a case of recurrent pulmonary embolism caused by a thrombus in dilated axillary vein related with PSS. A 74-year-old man was referred to our cardiology department for chest discomfort and hypoxaemia. The contrast computed tomography (CT) revealed that he suffered from bilateral pulmonary embolism. However, we could not find the source of embolism despite other examinations such as ultrasonography of the inferior limb deep vein. Three months later, the patient complained of dyspnoea for a second time, and a contrast CT scan was subsequently performed revealing a new pulmonary embolism. Surgical resection of the giant thrombus was performed, resulting in a good clinical course without recurrence. Discussion We experienced a case of recurring pulmonary embolism in a patient with undiagnosed PSS, which was related to the active and vigorous movement of the right arm during his working. Although there are various treatments for PSS including anticoagulation, first rib resection, and lifestyle modification, we need to consider what is the best treatment individually.

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Abstract 19335: Not Your Typical Atrial Flutter

Circulation ◽

10.1161/circ.130.suppl_2.19335 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Matthew D Olson ◽

Selcuk Adabag

Keyword(s):

Atrial Flutter ◽

Right Atrial ◽

Vein Thrombosis ◽

Typical Atrial Flutter ◽

Determining Factors ◽

Surgical Thrombectomy ◽

Clinical Dilemma ◽

The Right ◽

In Transit ◽

Deep Vein

Case: Mr M. presented to the emergency room with two months of progressive shortness of breath and was found to be in atrial flutter with 2:1 conduction at a rate of 140 bpm. His medical history was significant for tobacco use, etoh abuse, and hypertension. Key objective findings included tachycardia, hypoxia an elevated JVP, bibasilar crackles, a summation gallop, and lower extremity edema. His work up included an echocardiogram that illustrated a globally depressed EF (15-20%) and a large “worm like” mass that was free floating and extended into the RV. Management: A heparin drip was already infusing as the initial plan included cardioversion. Since the patient remained hemodynamically stable and there was no evidence of concurrent deep vein thrombosis, a TEE was performed to fully evaluate the mass and to assess the intra-atrial septum for right to left shunting. The TEE with 3D renderings demonstrated a mobile 0.8 x 10 cm mass most consistent with a thrombus that intermittently prolapses through the tricuspid valve into the RV. CT surgery was consulted and discussed the options of thrombolysis vs surgical thrombectomy. Due to the size and apparent dense organization of the thrombus, surgical thrombectomy was performed. When the right atrium was opened after initiation of bypass, there was no visible clot. The main PA was explored and without evidence of the thrombus. As bypass flow decelerated, the clot proceeded into the RA from the IVC cannula. The attached picture illustrates the thrombus removed from the RA and associated echo images. Discussion: Right atrial or ventricular thrombi in transit in hypoxic patients create a challenging clinical dilemma, as distal embolization may be fatal. In this case we chose to surgically remove the thrombus instead of the more commonly employed thrombolytic therapy. The determining factors included clot organization, relative patient stability, and surgical candidacy.

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pharmacomechanical Thrombectomy for Early Thrombus Removal

Phlebology The Journal of Venous Disease ◽

10.1258/phleb.2012.012s14 ◽

2012 ◽

Vol 27 (1_suppl) ◽

pp. 155-162 ◽

Cited By ~ 17

Author(s):

R D Malgor ◽

A P Gasparis

Keyword(s):

Pulmonary Embolism ◽

Bleeding Risk ◽

Clot Lysis ◽

Vein Thrombosis ◽

Manual Search ◽

Lysis Rate ◽

Tissue Plasminogen ◽

Recurrent Deep Vein Thrombosis ◽

Thrombus Removal ◽

Deep Vein

Objectives: To review the current literature on the outcomes of pharmacomechanical thrombectomy (PMT) for early thrombus removal in patients with venous thromboembolism (VTE). Methods: We searched the MEDLINE database and performed a manual search of the references of selected articles to select reports reporting the outcomes of PMT alone and PMT compared to catheter-direct thrombolysis (CDT). Outcomes of interest included clot lysis rate, incidence of pulmonary embolism, major bleeding, recurrent deep vein thrombosis, number of venograms needed and amount of lytic utilized. Results We found nine articles that reported outcomes of PMT. Three devices were utilized for PMT, the Angiojet, Trellis and Helix. Different thrombolytics were used to facilitate thrombus removal including urokinase, reteplase, tecneteplase, and tissue plasminogen activator (t-PA). Complete and partial thrombus removal were achieved in up to 84% and 64% and 81% and 59% of the limbs treated with PMT and CDT alone, respectively. Data on PE and bleeding risk after PMT compared to CDT are scarce. The duration of the thrombolysis process, amount of lytics and number of venograms were substantially reduced in the patients who had PMT compared to those who underwent CDT alone. Two articles evaluated the obstacles that limit the indication of PMT in patients with VTE. Conclusion: VTE is a prevalent burden in Western societies. The rationale of early thrombus is to reduce valvular damage and improve venous patency in order to reduce the risk of PTS. PMT is a feasible, safe and faster alternative to expedite the thrombolysis process in patients with VTE.

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Temporary caval filter in the prevention of pulmonary embolism during delivery and postpartum

Phlebology The Journal of Venous Disease ◽

10.1258/026835505774964900 ◽

2005 ◽

Vol 20 (4) ◽

pp. 183-189

Author(s):

G Pagliariccio ◽

L Carbonari ◽

C Grilli Cicilioni ◽

A Angelini ◽

E Gatta ◽

...

Keyword(s):

Pulmonary Embolism ◽

Lower Limbs ◽

X Ray ◽

Vein Thrombosis ◽

Caval Filter ◽

Prophylactic Use ◽

The Right ◽

Deep Vein ◽

Mean Time

Objectives: The treatment of deep vein thrombosis (DVT) of the lower limbs during pregnancy remains controversial. There are a lot of problems related to anticoagulant therapy for the safety of the fetus; the use of caval filters rarely appears in the literature and it is not yet codified. So the choice of the right treatment is often difficult. The authors review their experience with a prophylactic use of a temporary caval filter for patients with proximal DVT of the last period of pregnancy, in order to avoid the inherent risk of major pulmonary embolism during delivery and postpartum. Methods: Ten women with proximal DVT were treated. The diagnosis was performed by Doppler ultrasonography (DU) and magnetic resonance (MR). At the end of pregnancy, a temporary caval filter (eight Prolyser and two Tempofilter) was percutaneously inserted under X-ray control. The patients were then subjected to a planned caesarean section. After 15 days, all filters were removed after a phlebography to check the absence of clots. Results: The mean time of X-ray exposure was about 1 min and 30 s. None of the patients suffered a major pulmonary embolism. All fetuses were born without problems or malformations. There were no complications related to the filters. No caval thrombosis or filters clots were found at the phlebography. The follow-up registered no pulmonary embolism episodes. Conclusions: The use of a temporary caval filter in pregnancy is safe and does not introduce any additional risk. It could be suggested for pregnant patients with proximal DVT beginning in the last period of pregnancy.

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Thrombosis in Rheumatological Diseases

Skills in Rheumatology ◽

10.1007/978-981-15-8323-0_12 ◽

2021 ◽

pp. 263-289

Author(s):

Fozya Bashal

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

Venous Thromboembolism ◽

Venous Thrombosis ◽

Blood Coagulation ◽

Thirteenth Century ◽

Vein Thrombosis ◽

The Right ◽

Deep Vein ◽

Rheumatological Diseases

AbstractVenous thromboembolism (VTE) is a disease of blood coagulation that occurs in the veins, most often in the calf veins first, from where it may extend and cause deep vein thrombosis (DVT) or pulmonary embolism (PE). The first described case of venous thrombosis that we know of dates back to the thirteenth century, when deep vein thrombosis was reported in the right leg of a 20-year-old man [1].

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