Successful surgical treatment of clot in transit with impending paradoxical embolism: A case report.
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ABSTRACT:
SUBMITTER: Medina MA
PROVIDER: S-EPMC8302995 | biostudies-literature | 2020 Dec
REPOSITORIES: biostudies-literature
Publications
Successful surgical treatment of clot in transit with impending paradoxical embolism: A case report.
Medina Maria A MA Guerrero Albert F AF Sandoval Nestor F NF Umana Juan P JP
JTCVS techniques 20200731
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Project description:BackgroundA thrombus in transit (TIT) is a life-threatening condition associated with pulmonary embolism (PE). While TIT was once considered a rare diagnosis, its emergence has risen in recent years mainly through advancement in medical technology. Rare cases of a thrombus in transit crossing a patent foramen ovale in the context of pulmonary embolism have been reported. The appropriate treatment of patients in this setting remains unclear.Case summaryWe describe a 64-year-old man who presented with syncope to the emergency room secondary to acute pulmonary embolism. Initial transthoracic echocardiogram revealed a large intracardiac thrombus in transit across a patent foramen ovale, verified by transoesophageal echocardiogram. He underwent anticoagulation and urgent surgical thrombectomy with a favourable outcome.DiscussionRisk stratification of patient with acute PE is mandatory for determining the appropriate therapeutic management. Initial risk stratification is based on clinical symptoms and signs of haemodynamic instability which indicate a high risk or early death associated massive PE. Thrombolytic therapy is indicated in high-risk patients (Grade 1B), while anticoagulation alone is recommended for intermediate-high- to low-risk patients. Assessment for intracardiac thrombi in PE modifies the treatment strategy in case of a thrombus in transit.
| S-EPMC7954258 | biostudies-literature
Project description:An impending paradoxical embolism (IPDE) is seldom observed in clinical practice. We report a case of IPDE in a 67-year-old female with severe dyspnea and hypotension, which was detected and successfully treated with emergent cardiac surgery. The optimal treatment is still controversial. We believe that emergent surgery always should be considered in patients with IPDE. <Learning objective: We report a rare case of an impending paradoxical embolism in a 67-year-old female with severe dyspnea, which was successfully treated with emergent cardiac surgery. An emergent open surgery always should be considered in patients with impending paradoxical embolism.>.
| S-EPMC8258173 | biostudies-literature
Project description:Thrombus-in-transit through patent foramen ovale (PFO) is an extremely rare diagnosis that can often be associated with pulmonary embolism. Currently, data exists to guide management options; however, there is no medical consensus with regard to the optimal treatment strategy for thrombus-in-transit through PFO.
| S-EPMC10920151 | biostudies-literature
Project description:We present a spectrum of findings with transthoracic echocardiography, coronary angiography, and open surgical exploration in a 54-year-old man who presented with an acute ST segment elevation myocardial infarction and was diagnosed with impending paradoxical emboli. He underwent successful surgical removal of the thrombus.Learning objectiveImpending paradoxical embolism, a biatrial thromboembolus in transit across a patent foramen ovale, is associated with a 20% mortality rate. Very rarely does it present as a ST segment elevation myocardial infarction. The optimal management (medical or surgical) for those who present with it remains a subject of debate, although surgery has been associated with less systemic embolization.
| S-EPMC3708660 | biostudies-literature
Project description: Not available
| S-EPMC10172151 | biostudies-literature
Project description:Although a patent foramen ovale (PFO) is relatively common, confirmed reports of thrombus entrapped within a PFO are uncommon. Management of impending paradoxical embolism (IPE), also called a thrombus in transit, lacks consensus but includes systemic anticoagulation (e.g., heparin), systemic thrombolysis, or surgical thrombectomy. We present a case of IPE diagnosed with intraoperative transesophageal echocardiography (TEE) as well as a novel en bloc approach to atrial septal aneurysmectomy to minimize embolism and facilitate repair of the interatrial septum. Timely use of intraoperative TEE may aid in diagnosis and help guide the surgical approach to minimize embolic risk with an IPE.
| S-EPMC8617377 | biostudies-literature
Project description:BackgroundCoronavirus disease 2019 (COVID-19) is associated with a coagulopathy favouring thrombosis over bleeding that imparts a poor prognosis. Clot in transit (CIT) is considered a rare entity and the most severe form of venous thromboembolism (VTE), carrying a higher mortality than isolated pulmonary embolism (PE). The incidence of this phenomenon in patients with COVID-19 infection is unknown and likely under-recognized.Case summaryDuring the peak of the COVID-19 pandemic in New York City, a 70-year-old Hispanic female presented with syncope due to a saddle PE further complicated by a highly mobile CIT. Polymerase chain reaction was positive for COVID-19 infection, however, there was no evidence of lung parenchymal involvement or hyper-inflammation. Based on consensus from a multidisciplinary team, aspiration thrombectomy was attempted to treat this extreme case of VTE, however, the patient died during the procedure.DiscussionThis case raises awareness to the most catastrophic form of VTE, presenting in an early phase of COVID-19 infection without the typical hyper-inflammation and severe lung injury associated with development of COVID-related coagulopathy. It also serves to inform on the critical role echocardiography has in the comprehensive evaluation and re-evaluation of hospitalized patients with COVID-19, and the importance of a multidisciplinary organized approach in clinical decision-making for this complex and poorly understood disease and its sequelae.
| S-EPMC7891250 | biostudies-literature
Project description:Background Pulmonary embolism (PE) is an acute cardiovascular syndrome characterized by high incidence and mortality. The therapy of this condition is based on anticoagulation and hemodynamic support, but in case of high-risk mortality, the European Society of Cardiology (ESC) guidelines recommend systemic thrombolytic therapy and surgical embolectomy if thrombolysis is contraindicated or has failed; nowadays several percutaneous catheter-directed treatments for local thrombolysis or mechanical embolectomy are available, but they have IIa class of recommendation, because of lack of robust scientific evidence favoring their use. Case Description We described a case of high-risk PE treated with a novel percutaneous system for mechanical embolectomy, which consists of a large aspiration catheter that was advanced in the pulmonary artery, capturing and removing a vast thrombus, of 15 centimeters in length. This therapeutic strategy avoided the risk of hemorrhagic complications related to systemic thrombolysis, exiting in the achievement of fast patient hemodynamic stabilization and symptoms resolution, without complications. Computed tomography (CT) pulmonary angiography after 10 days from the intervention revealed the complete resolution of pulmonary artery filling defects, and the patient was discharged asymptomatic. Conclusions Percutaneous catheter-directed treatments represent an effective alternative therapy for PE, but further studies are needed to demonstrate safety and superiority over the actually recommended therapy.
| S-EPMC9929660 | biostudies-literature
Project description:BackgroundAcute pulmonary embolism (PE) is a life-threatening situation. While anticoagulation should be initiated without any delay in all patients with an intermediate or high clinical probability of PE, individual acute phase treatment in patients with intermediate or intermediate-high-risk PE still can be optimized.Case summaryAn 82-year-old female patient was referred to our emergency department after experiencing syncope and acute onset of shortness of breath. Computed tomography (CT) of the chest showed central and extensive peripheral PE. Echocardiography additionally revealed a massive and highly mobile clot-in-transit located in the right atrium (RA). Given the size and mobility of the clot-in-transit, we chose to perform an off-label mechanical thrombectomy. Due to repeated PE with progressive right ventricular (RV) failure and high peripheral thrombus burden, we decided to perform low-dose systemic lysis. After 24 h, she showed significant clinical improvement and was discharged later with recovered RV function and dimensions.DiscussionIn that case, acute PE was complicated by the presence of a large clot-in-transit in the RA. Initially, there was no indication for mechanical thrombectomy or systemic lysis for the patient's intermediate to high-risk PE. The risk of embolization of the very large clot-in-transit prompted us to remove the mobile thrombus mechanically. When the repeated PE resulted in an increase in afterload and progressive right heart failure, we decided to perform low-dose systemic lysis. The off-label use of the FlowTriever® prevented the impending embolization of the 14 cm long thrombus from the RA into the pulmonary circulation. In this case, lysis also appears to make sense, particularly given the high peripheral thrombus burden.
| S-EPMC11799944 | biostudies-literature
Project description:Venous air embolism (VAE) is an uncommon event consistent in the entrainment of air from any communication between the environment and the venous vasculature that could occur during central venous catheter (CVC) manipulation, and might trigger circulatory shock within minutes depending on the amount of air embolized. We present a case of a critical care patient who presented sudden clinical hemodynamic deterioration after the removal of central venous catheter. Hemodynamic evaluation with point-of-care ultrasound (POCUS) showed bubbles in both right and left heart cavities wherewith air embolism facilitated by heart septal defect was suspected. Therefore, the patient was reintubated, supported with vasopressors and a new CVC was inserted to proceed with air aspiration. Shortly after, the patient's hemodynamic status improved in terms of vital signs stabilization. 6 h after the event with optimal perfusion markers and diminished sedation, the patient showed left hemiparesis therefore a cerebral magnetic resonance (MRI) was also performed showing hyperintensity in the right precentral gyrus, so ischemic stroke without hemorrhagic transformation diagnosis was made, because of paradoxical embolism. This case report demonstrates the value of POCUS application as a diagnostic tool in the hemodynamically unstable patient.
| S-EPMC9116074 | biostudies-literature