Acute aortic occlusions (AAOs) are rare vascular emergencies associated with high morbidity and mortality. Presenting signs and symptoms vary but typically involve the lower extremities and include mottled skin with diminished pedal pulses, paresis, and severe pain. Prompt recognition and imaging are necessary to prevent rapid deterioration, which can lead to loss of limb or death. Treatment includes surgical or endovascular interventions based on patient-associated risk factors and clot location. We present a 76-year-old female who arrived at the emergency department with an AAO involving the infrarenal abdominal aorta and bilateral common iliac arteries. Efficient physical examination and utilization of computed tomography with angiography of the abdomen and pelvis allowed for the appropriate recognition of the AAO and subsequent successful surgical embolectomy. This case report underscores the importance of an expeditious clinical and radiographic evaluation in patients presenting with lower extremity pain and weakness.

Pulmonary embolism is a major cause of mortality worldwide. In this historical perspective, we aim to provide an overview of the rich medical history surrounding pulmonary embolism. We highlight Virchow\'s first steps toward understanding the pathophysiology in the 1800s. We see how those insights inspired early attempts at intervention such as surgical pulmonary embolectomy and caval ligation. Those early interventions were refined and ultimately led to the development of inferior vena cava filters, the earliest clinical applications of anticoagulation, and even apparently disparate medical advances such as the successful development of cardiopulmonary bypass. We also see how the diagnosis of pulmonary embolism has evolved from rudimentary monitoring of vitals and symptoms to the development of evermore sophisticated tests such as contrast tomography angiography and echocardiography. Finally, we discuss current approaches to diagnosis, classification, and myriad treatments including anticoagulation, thrombolysis, catheter-directed interventions, surgical embolectomy, and extracorporeal membrane oxygenation guided by Pulmonary Embolism Response Teams.

In efforts to decrease the mortality on the waiting list for lung transplantation, alternatives to increase the donor pool have been explored. Caution must be used when accepting donor lungs with pulmonary embolism (PE), as prior evidence has shown mixed results after transplantation of donor lungs with PE. However, the mere diagnosis of PE on imaging should not be the sole reason for the exclusion of these donors for transplant, and they should be reviewed as any other donor. A comprehensive evaluation should be performed for every donor, with a special focus on abnormalities of gas exchange and gross pathologic characteristics during procurement.

Thromboembolic events are the third leading cardiovascular diagnosis following stroke and myocardial infarction. In the United States, 300,000 to 600,000 people per year are diagnosed with venous thromboembolism, either deep venous thrombosis or pulmonary embolism (PE). Of those patients, thousands die from PE despite heightened vigilance and improved therapies. Lung transplant recipients are at increased risk of developing PE due to multiple risk factors unique to this population. Additionally, the transplant recipients are more susceptible to morbid complications from PE. As a result, prevention, timely recognition, and intervention of PE in the lung transplant population are of the utmost importance.

This case highlights a rare presentation of diverticulitis of the sigmoid colon with perforation into the retroperitoneum complicated by abscess, vertebral osteomyelitis and acute lower extremity ischemia. A late 40-year-old man presented to an emergency department with acute ischemia of his left lower extremity. He was tachycardic with a leucocytosis, an unremarkable abdominal exam and a pulseless, insensate and paralysed left lower extremity. Imaging revealed sigmoid thickening, an abscess adjacent to iliac vasculature and occlusion of the left popliteal artery. The abscess came in contact with prior spine anterior lumbar interbody fusion (ALIF) hardware at L5-S1 vertebrae. The patient was taken urgently to the operating room for embolectomy, thrombectomy and fasciotomy. He was started on antibiotics and later underwent operative drainage with debridement for osteomyelitis. Non-operative management of the complicated diverticulitis failed, necessitating open sigmoidectomy with colostomy. 1 year later, he was symptom-free and the colostomy was reversed.

The management of pulmonary embolus and intracardiac masses is rapidly evolving with the availability of transcatheter aspiration devices. We describe the utility of a transcatheter aspiration device in management of a patient with pulmonary embolus and a right atrial mass in transit after spinal surgery where a topical hemostatic agent was used to control intraoperative bleeding.

With a multitude of options for pulmonary embolism management, we review the most common diagnostic tools available for assessing risk as well as how each broad risk category is typically treated. Right heart dysfunction is the cornerstone for triage of these patients and should be the focus for decision-making, especially in challenging patients. We aim to provide a modern, clinical perspective for PE management in light of the multitude of intervention options.

Massive pulmonary embolism (MPE) is a serious condition affecting the pulmonary arteries and is difficult to diagnose, triage, and treat. The American College of Chest Physicians (AHA) and the European Society of Cardiology (ESC) have different classification approaches for PE, with the AHA defining three subtypes and the ESC four. Misdiagnosis is common, leading to delayed or inadequate treatment. The incidence of PE-related death rates has been increasing over the years, and mortality rates vary depending on the subtype of PE, with MPE having the highest mortality rate. The current definition of MPE originated from early surgical embolectomy cases and discussions among experts. However, this definition fails to capture patients at the point of maximal benefit because it is based on late findings of MPE. Pulmonary Embolism Response Teams (PERTs) have emerged as a fundamental shift in the management of MPE, with a focus on high-risk and MPE cases and a goal of rapidly connecting patients with appropriate therapies based on up-to-date evidence. This review highlights the challenges in diagnosing and managing MPE and emphasizes the importance of PERTs and risk stratification scores in improving outcomes for patients with PE.

Introduction  Pulmonary embolism (PE) is associated with approximately 10.5% of maternal deaths in the United States. Despite heightened awareness of its mortality potential, there islittle data available to guide its management in pregnancy. We present the case of a massive PE during gestation successfully treated with catheter-directed embolectomy. Case Presentation  A 37-year-old G2P1001 presented with a syncopal episode preceded by dyspnea and chest pain. Upon presentation, she was hypotensive, tachycardiac, and hypoxic. Imaging showed an occlusive bilateral PE, right heart strain, and a possible intrauterine pregnancy. Beta-human chorionic gonadotropin was positive. She was taken emergently for catheter-directed embolectomy. Her condition immediately improved afterward. Postprocedure pelvic ultrasound confirmed a viable intrauterine pregnancy at 10 weeks gestation. She was discharged with therapeutic enoxaparin and gave birth to a healthy infant at 38 weeks gestation. Conclusion  Despite being the gold standard for PE treatment in nonpregnant adults, systemic thrombolysis is relatively contraindicated in pregnancy due to concern for maternal or fetal hemorrhage. Surgical or catheter-based thrombectomies are rarely recommended. Limited alternative options force their consideration, particularly in a hemodynamically unstable patient. Catheter-directed embolectomy can possibly bypass such complications. Our case exemplifies the consideration of catheter-directed embolectomy as the initial treatment modality of a hemodynamically unstable gestational PE.

暂无摘要。