The effect of fibrin glue on inhibition of pericardial adhesions was tested using 26 beagle dogs. Dacron patches were sutured to the heart and tincture of iodine was applied to promote adhesions. Fibrin glue (3 ml) was sprayed over the patches in 15 dogs (test group), and was not separated in the remaining 11 dogs (control group). All animals in the test group had minimal adhesions between the pericardium and the epicardium or patched region, and an accumulation of gelatinous material was found in the subpericardial space. Marked fibrosis and a poor demarcation of the subpericardial space were found in the control group. The adhesion score and the visibility of coronary anatomy in the test group were significantly better than in the control group. The tension strength in the test group was significantly less than in the control group. We concluded, therefore, that fibrin glue may also be useful as an adhesion inhibitor.
rophylactic heparin administration for the prevention of thromboembolic complications in patients undergoing surgical treatment is an established therapy, 1 but we experienced a case of acute pulmonary thromboembolism (PE) in which the embolic source was assumed to be the thrombus attached to the heparin-coated central venous catheter and heparin administration exacerbated thrombocytopenia and thrombus formation.
Case ReportA 45-year-old woman with endometrial cancer underwent a total hysterectomy. She was markedly obese (body mass index 46 kg/m 2 ), and prophylactic heparin (15,000 units /day) was administered for pulmonary embolism from the first postoperative day. A heparin-coated central venous catheter was also inserted in the right internal jugular vein at the beginning of the operation. On the 7th postoperative day, she suffered a transient loss of consciousness accompanied by dyspnea and chest pain. Transthoracic echocardiography showed a dilated right ventricle and bowing of the interventricular septum into the left ventricle. Pulmonary perfusion scintigraphy and whole-body computed tomography (CT) revealed multiple perfusion defects in the bilateral lungs (Fig 1, 2). Based on these findings, massive PE was diagnosed. To investigate the potentiality of thrombophilia, laboratory examinations were performed and the levels of plasma protein C, protein S, and antithrombin III were within normal limits and anti-cardiolipin antibody was negative. Thrombocytopenia was not detected at this stage (platelet count: 39.4×10 4 /mm 3 ).The patient received intravenous urokinase (960,000units) followed by continuous heparin infusion (25,000-27,000 units/day), but despite this therapy the activated partial thromboplastin time was only prolonged about 1.3-1.5-fold. There was no evidence of thrombus in either of the femoral veins nor in the inferior vena cava on CT Heparin-induced thrombocytopenia and thrombosis syndrome (HITTS) is a potentially life-threatening side effect of heparin therapy, triggered by an immune response, and has been reported to be related not only to the therapeutic use of heparin but also to heparin-coated catheters. A 45-year-old woman with intrapelvic malignancy developed an acute pulmonary thromboembolism (PE) after hysterectomy despite prophylactic heparin use. Subsequent large doses of heparin for treatment of the PE exacerbated the thrombocytopenia and, moreover, a large thrombus formed around the heparin-coated central venous catheter. Anti-heparin-platelet factor 4 complex antibody and heparin-induced platelet aggregation assay were positive, so the diagnosis was HITTS, and heparin was replaced by argatroban after carrying out thrombectomy. This therapy was successful, and the patient made favorable progress.
The femoral vein is increasingly being used as a temporary route for dual-lumen hemodialysis catheter placement because it is thought to be safer than the internal jugular or subclavian vein sites. However, several factors preclude the wider use of indwelling femoral catheters for hemodialysis, including interference with ambulation and concern over bleeding, infection, and deep thrombosis. Herein we describe a case of right superficial femoral arteriovenous fistula as a complication of the insertion of a dual-lumen hemodialysis catheter into the right femoral vein. The arteriovenous fistula was successfully managed with surgical vascular repair. From this experience, we emphasize that it is important for physicians and nursing staff treating patients with indwelling central catheters to exercise vigilance to allow early detection and treatment of these potentially serious, albeit rare, complications.
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