Massive pulmonary embolism

Abstract

Conclusion:In patients with a hemodialysis access graft and an asymptomatic central venous stenosis (CVS) of Ͼ50%, treatment of the CVS results in more rapid stenosis progression compared with a nontreatment approach.Summary: The authors evaluated the natural history of Ͼ50% asymptomatic CVSs in hemodialysis patients. Outcome of serial treatment of CVS with percutaneous catheter-based techniques (PTA) was also evaluated. All patients in this study required maintenance procedures for their dialysis access.Between 1998 and 2004, 35 patients (19 men, 16 women), with a mean age of 58.7 years, were found to have asymptomatic CVS of Ͼ50%. CVS was measured by using venograms obtained before and after PTA. Patients with arm swelling, multiple CVSs, or indwelling catheters, were excluded. CVS progression was calculated by comparing degrees of stenoses with serial venographic examinations.The mean severity of CVSs before intervention was 71% (range, 50% to 100%), with 62% of lesions having associated collateral vessels. Twenty eight percent of CVSs were not treated. The mean degree of stenosis in the untreated group was 72% (range, 30% to 100%). Mean progression of stenosis in the untreated group was -0.8% point per day. No untreated CVS progressed to symptoms, stent placement, or developed additional CVS.PTA was used to treat 62 CVS lesions (72%). The mean degree of stenosis in the treated group was 74% (range, 50% to 100%) before and 40% (range, 0% to 75%) after treatment. In the treated group, mean progression of CVS was 0.21% per day after treatment. Six of the 62 treated CVS lesions were monitored, with symptomatic escalation of the CVS as manifested by arm swelling, need for stent placement, or development of additional CVS lesions.Comment: Treatment of an asymptomatic CVS in a dialysis patient is not a good thing. One is reminded of the old adage that it is wise to avoid poking a skunk. A major weakness of this study is that the patients were undergoing maintenance procedures for their dialysis access. We do not know if the CVS contributed to the need for the dialysis access maintenance. It would be interesting to know if there was a higher rate of repeat procedures for maintenance of dialysis access in patients with treated vs untreated CVS.

Thrombolysis in Elderly Patients With Massive Pulmonary Embolism

“…This case corroborates previous reports of the benefit of thrombolysis in elderly patients with massive PE and the absence of a higher rate of complications than in younger patients 2,5,6 . Although the therapeutic benefit in patients with submassive PE treated with thrombolysis is controversial, in patients with massive PE and right ventricular dysfunction with hemodynamic instability, this treatment rapidly resolves the embolism and improves right ventricle function, decreasing morbidity and mortality 1–3,7,8 . There are few reports on the long‐term outcome after thrombolytic therapy for massive PE, but mortality seems to be related more to preexisting morbidities than to age itself 5–8 .…”

“…Although the therapeutic benefit in patients with submassive PE treated with thrombolysis is controversial, in patients with massive PE and right ventricular dysfunction with hemodynamic instability, this treatment rapidly resolves the embolism and improves right ventricle function, decreasing morbidity and mortality 1–3,7,8 . There are few reports on the long‐term outcome after thrombolytic therapy for massive PE, but mortality seems to be related more to preexisting morbidities than to age itself 5–8 . Serum troponin levels, N‐terminal prohormone brain natriuretic peptide and right ventricular dysfunction, measured using echocardiography or computed tomography, were also associated with high mortality 9 .…”

Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions

“…Over the past decade, there has been a surge of new therapeutic tools and strategies designed to treat PE patients. Despite these developments, the mortality rate for patients who present with massive or high‐risk PE remains high . Additionally, there is a lack of robust evidence investigating or comparing each strategy as well as current standardized guidelines in the treatment of acute PE.…”

Surgical pulmonary embolectomy: mid‐term outcomes

“…Despite recent progress in adopting appropriate venous thromboembolism (VTE) prophylaxis in hospitalized patients, pulmonary embolism continues to occur. Acute severe pulmonary embolism (ASPE) is associated with a significant mortality risk . ASPE comprises between 4.5% and 10% of all cases of pulmonary embolism (PE), with controversy continuing to exist in its management as a consequence of a lack of randomized controlled trials addressing this question.…”

“…Acute severe pulmonary embolism (ASPE) is associated with a significant mortality risk . ASPE comprises between 4.5% and 10% of all cases of pulmonary embolism (PE), with controversy continuing to exist in its management as a consequence of a lack of randomized controlled trials addressing this question. While the traditional definition for ASPE has been systemic hypotension, the application of right ventricular (RV) dysfunction as a prognostic measure in submassive PE is growing .…”