Large paradoxical embolus through a patent foramen ovale following arteriovenous graft thrombectomy

An 86-year-old man with end-stage renal disease on hemodialysis with an arteriovenous fistula in his left upper extremity presented to his hemodialysis session with thrombosis of his arteriovenous fistula. The patient underwent surgical thrombectomy. The patient later showed evidence of peripheral embolization and livedo reticularis. Transthoracic and transesophageal echocardiograms revealed a large thrombus (5x2 cm) in the left atrium prolapsing to the right atrium via a patent foramen ovale and another thrombus (white arrow) adherent to the apical wall of the right ventricle. The thrombus in the left atrium was intermittently crossing the mitral valve and entering the left ventricle.

Advances of Thrombectomy in Venous Thromboembolism

Venous thromboembolism (VTE) presenting as deep vein thrombosis and pulmonary embolism clinically is a potentially fatal cardiovascular diseases with short-term and long-term sequelae. Furthermore, there is high recurrent rate in VTE patients during follow-up. Anticoagulation with traditional anticoagulants or new generation of oral anticoagulants is the gold standard treatment in patients with VTE. On the other hand, there is remarkable progression in device-based or surgical thrombectomy in managements of VTE in recent years. Current evidence also demonstrates the efficacy and safety of these invasive procedures in selective VTE patients. The present article will illustrate recent advances of device-based or surgical thrombectomy in VTE treatment.

Complete Response in Metastatic Hepatocellular Carcinoma with Cardiac and Lung Involvement via Multimodality Treatment

Background: Until recently, advanced HCC patients with major vessel and cardiac involvement have had an extremely poor prognosis without satisfactory treatment. Case presentation: A 63-year-old Taiwanese male presented with metastatic HCC with RA and IVC thrombi, as well as pulmonary metastases that were successfully treated by multimodal management, encompassed by surgical thrombectomy, concurrent systemic sorafenib and locoregional therapies, and immunotherapy. The patient has achieved a complete response over the past 33 months. Conclusion: Through this case report, which shows a successful outcome via multimodal management, a more aggressive approach should be considered when a patient is expected to tolerate the risks and side effects of various treatments.

Intrapulmonary Artery Thrombolysis in Acute Pulmonary Embolism: Case Series from King Chulalongkorn Memorial Hospital Experience

Acute pulmonary embolism (PE) is a life-threatening condition. In patient who has contraindication for systemic thrombolysis and inappropriate for surgical embolectomy, there is a role of catheter interventions. However, the data are limited. The aim of the present report was to assess a role of intrapulmonary artery thrombolysis bolus in acute PE. A retrospective review of the use of intrapulmonary artery thrombolysis in acute PE. The data were collected from 14 patients with massive or submassive PE who had contraindication or inappropriate for systemic thrombolysis and unsuitable for surgical embolectomy. After intrapulmonary thrombolysis was given, patients were followed clinically and hemodynamically until discharged and after 1 month. Pulmonary pressure was collected at pre and post intervention. Of the 14 patients (age 59±19 years, 78.6% female), 86% were diagnosed as submassive PE. Mean dose of tissue plasminogen activator (rt-PA) was 28±14 mg given as bolus and continuous infusion (19±10 hours). One patient died after completion of intrapulmonary infusion rt-PA at day 90, which did not relate to PE and the treatment. After intervention, mean PA pressure was significantly reduced from 32.3±6.0 to 21.0±4.3 mmHg (p<0.001). Three patients (21%) had minor bleeding (hematoma at access site). The present case series showed that intrapulmonary infusion of rt-PA was effective and safe in patient with massive and submassive PE who had contraindication or inappropriate to systemic thrombolysis or inoperable surgical thrombectomy. Keywords: Acute pulmonary embolism; Intrapulmonary thrombolysis; Tissue plasminogen activator; Surgical thrombectomy

Retrograde Surgical Cut-down Direct Thrombectomy as a Salvage Procedure for Acute Limb Ischemia With Below the Knee Thrombotic Occlusion: a Case Series

Background: Acute limb ischemia is a serious condition even in an era of highly comprehensive medical treatment. Despite the development of conservative and endovascular treatment, complete removal of the thrombus with antegrade thrombectomy via the femoral approach, especially in below-the-knee arteries, is still not possible. In addition, distal embolization of dislodged debris or thrombus during the procedure is another concern as this might cause severe complications, including amputation. Given the above-mentioned issues, retrograde surgical cut-down direct thrombectomy from the dorsalis pedis artery and posterior tibial artery could be an optimal option for complete revascularization in below-the-knee arteries. Case presentation: We present five cases where the limbs were preserved after retrograde surgical thrombectomy. The standard antegrade thrombectomy procedure with a conventional surgical approach from the common femoral artery was performed. All five patients underwent an intraoperative assessment of indications for dorsalis pedis artery and posterior tibial artery retrograde thrombectomy by the surgical cut-down method. After retrograde thrombectomy, direct evaluation of blood flow was the strongest evidence of revascularization. A retrograde angiogram showed revascularization of below-the-knee arteries. All five patients had successful salvage procedures that prevented major limb amputation. Conclusion: Retrograde surgical thrombectomy could be a salvage procedure for incomplete antegrade thrombectomy.

Surgical thrombectomy versus conservative treatment in cases of acute limb ischemia with COVID-19 pneumonia

COVID-19 infection is a major cause for acute respiratory distress syndrome, multi-organ dysfunction, coagulopathy, and intravascular thrombosis; therefore, it is the main causative factor for acute limb ischemia.Aim. To compare the treatment outcome of two limb ischemic groups post COVID-19 infection in a single center and detect at least which is better for the patients in the period of COVID-19 pandemic.Material and methods. Here, in this study, we collect 26 patients and divided them into two groups, G1 (14) patients treated conservatively and G2 (12) patients treated with surgical thrombectomy. Data were analyzed to look for the outcome of groups after 24 hours and 30 days.Results. The successful rate of conservative treatment was 85,72% in G1, while it was 75% in G2. There were two amputations below the knee joint in each group. Three patients died in both groups.Conclusion. In conclusion, both conservative treatment and surgical thrombectomy have a comparable successful rate in the selected group of COVID-19 patients.

Emergency treatment of thrombus in right coronary artery and aortic root in a newborn with acute myocardial infarction

Perinatal myocardial infarction caused by aortic root and coronary artery thrombosis in neonatal period is extremely rare and has a gloomy prognosis that may cause devastating complications. A 3-h newborn baby who had acute myocardial infarction findings on postnatal electrocardiography had a thrombus in the aortic root with hyperechogenic right coronary artery region, and impaired right ventricular functions on echocardiography. The patient was urgently operated and thrombus was successfully removed from the aortic root and the right coronary artery. In conclusion, for large thrombi posing a risk for embolization in the aortic root, an urgent surgical thrombectomy procedure should be performed.