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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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Case 73
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History
▶ A74-Year-Old Male with History of Lymphoma with Acute Lower-Extremity Swelling
A computed tomography (CT) is shown in Figures73.1 and 73.2. Describe the procedure in Figures73.3 and
73.4. Figure73.5 represents the follow-up aer the procedure. What else can be done?
Figure 73.1
Figure 73.2
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Figure 73.3
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Figure 73.4
Figure 73.5
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Case 73 Lower-Extremity Lysis
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Acute on chronic right lower-extremity deep vein thrombosis (DVT) with external compression from
an enlarged lymph node. Astent was subsequently deployed.
Figure 73.2
Figure 73.7 Figure 73.8
Figure 73.6
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Figure 73.9
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Figure 73.10
Figure 73.11 Figure 73.12
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Figure 73.13
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Findings
▶ Figures 73.6 and 73.2 demonstrate asymmetric so tissue edema in the right lower extremity with enlarged
lymph nodes compressing and obliterating the right common iliac vein (black arrow).
▶ Figure 73.7 demonstrates a venogram performed in the right common iliac vein with signicant stenosis of
the vein secondary to external compression (black arrow) with multiple lling defects likely representing acute
thrombus (white arrows).
▶ Figure 73.8 show a lysis catheter across the area of stenosis and across all the documented thrombus (black
arrows).
▶ Figure 73.9 show persistent stenosis (black arrow) despite clot lysis aer overnight alteplase drip.
▶ Figure 73.10 demonstrates interval placement of a self-expanding stent across the stenosis with good
angiographic result (black arrow).
▶ Figure73.11–73.13 is a companion case demonstrating acute clot in the inferior vena cava (IVC) extending
to the common iliac veins bilaterally (lling defects in Figure 73.11, white arrow). e patient underwent
subsequent catheter-directed thrombolysis with residual IVC stenosis (Fig. 73.12, white arrow) necessitating
stent placement (Fig. 73.13).
Teaching Points
An American Heart Association (AHA) statement regarding management of DVT suggests the following:
▶ With regard to iliofemoral deep venous thrombosis (IFDVT) where clot burden includes partial or complete
thrombosis of the iliac vein or the common femoral vein, with or without proximal or distal extension,
initial treatment should include therapeutic doses of unfractionated heparin, low molecular weight heparin
(LMWH), or fondaparinux.
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▶ Long-term anticoagulation includes use of warfarin with target International Normalized Ratio (INR) of 2.0–
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3.0 for at least 3months for rst episode of IFDVT with a major reversible risk factor or at least 6months for
recurrent or unprovoked IFDVT and considered for lifelong anticoagulation.
▶ Cancer patients with IFDVT should receive LMWH for at least 3–6months or for as long as cancer therapy is
ongoing.
▶ Catheter-directed or pharmacomechanical catheter-directed thrombolysis:
■ Should be performed for patients with limb-threatening compromise.
■ Is reasonable for patients with rapidly extending IFDVT.
■ Is reasonable as rst-line therapy to prevent postthrombotic syndrome.
▶ Regarding venoplasty or stent placement:
■ Stent placement aer catheter-directed or pharmacomechanical catheter-directed thrombolysis for
obstructive lesions in the iliac vein is reasonable.
■ For isolated femoral vein obstructive lesions, a trial of venoplasty without stenting is reasonable.
■ Placement of iliac stents to reduce symptoms of postthrombotic syndrome and to heal nonhealing ulcers is
reasonable.
Management
▶ Aer venous stenting, long-term anticoagulation recommendations for IFDVT apply.
▶ Use of antiplatelet drugs in addition to anticoagulation may be considered for those perceived to be at high
risk.
Further Reading
Ja MR, McMurtry S, Aracher SL, etal. Management of massive and submassive pulmonary embolism, illiofemoral deep
venous thrombosis, and chronic thromboembolic pulmonary hypertension. Circulation. 2011; 123:1788–1830.
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Case 74
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History
▶ A57-Year-Old Female with History of Metastatic Ovarian Cancer Presents with Acute Shortness of Breath
Figure 74.1
Figure 74.2
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Case 74 Acute Pulmonary Embolism
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Figure 74.3
Figure 74.5
Figure 74.4
Figure 74.6
Figure 74.7
Figure 74.8
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Findings
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▶ Alarge pulmonary embolism within the right main pulmonary artery (Fig. 74.3, white arrow)
▶ Le main pulmonary arteriogram shows lling defects within the le lower lobe segmental pulmonary artery
(small black arrow, Fig. 74.4) and a large embolism within the right main pulmonary artery (large black arrow,
Fig. 74.4).
▶ Bilateral infusion catheters were placed across the clot (black arrows, Fig. 74.5) and alteplase was infused over
24 hours.
▶ Postlysis angiograms show resolution of the clot within the le lower lobe segmental branch (Fig. 74.6) and
marked improvement in the right main lling defect (Fig. 74.7).
▶ Figure 74.8 shows a rotation thrombectomy system being used in a dierent patient with extensive right
pulmonary artery clot burden.
Teaching Points
▶ Multiple potential therapies exist for treatment of acute pulmonary embolism ranging from systemic
anticoagulation for the stable patient to catheter-directed thrombolysis/mechanical thrombectomy or surgical
thrombectomy for the unstable patient with massive pulmonary emboli.
▶ Endovascular therapies include chemical thrombolysis (pulse or overnight) and mechanical thrombolysis
such as disruption of clot with a pigtail catheter and rotational devices like the Cleaner (Rex Medical,
Conshohocken, PA), shown in Figure74.8.
▶ orough thrombolysis in the setting of submassive pulmonary embolism has the potential of reducing the
development of chronic hypertension due to chronic pulmonary embolism.
Management
An American Heart Association (AHA) statement regarding management of acute pulmonary embolism
suggests the following:
▶ Assuming no contraindications, therapeutic systemic anticoagulation should be started for conrmed
pulmonary embolism. Patients with clinically intermediate or high probability for pulmonary embolism
should be started on empiric anticoagulation during the workup.
▶ Catheter-based therapy can be considered in patients with massive pulmonary embolism with
contraindications to brinolysis and in patients who remain unstable aer receiving brinolysis.
▶ Catheter-based therapy may be considered in patients with submassive acute pulmonary embolism judged
to have clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory failure,
severe right ventricular dysfunction, or major myocardial necrosis).
▶ Catheter-based therapies are not recommended for patients with low-risk pulmonary embolism or submassive
acute pulmonary embolism with minor right ventricular dysfunction, minor myocardial necrosis, and no
clinical worsening.
Further Reading
Ja MR, McMurtry S, Aracher SL, etal. Management of massive and submassive pulmonary embolism, illiofemoral deep
venous thrombosis, and chronic thromboembolic pulmonary hypertension. Circulation. 2011; 123:1788–1830.
Kuo, WT, Gould MK, Louie JD, etal. Catheter-directed therapy for the treatment of massive pulmonary embolism:systematic
review and meta-analysis of modern techniques. J Vasc Interv Radiol. 2009; 20:1431–1440.
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Case 75
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History
▶ A50-Year-Old Male with Intracranial Metastasis Presents with Acute Lower-Extremity Deep Vein rombosis
in Need of an Inferior Vena Cava Filter
Figure 75.1
Figure 75.2
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