CHEST
Chest Imaging and Pathology for CliniciansA 57-Year-Old Man With Insidious Dyspnea and Nonpleuritic Chest and Back Pain
Section snippets
Case Presentation
Three years before presentation, the patient developed left lower extremity edema shortly following air travel and he was ultimately diagnosed with a DVT and concomitant pulmonary embolism (PE). Additional evaluation revealed emphysema, COPD, and hypoxemia necessitating 3 to 4 L/min of supplemental oxygen. He was anticoagulated with Coumadin until 1 year before presentation when he suffered a mechanical fall with multiple rib fractures and anticoagulation was discontinued. He was otherwise
Clinical Discussion
The history of significant hypoxemia and significant pulmonary hypertension should raise suspicion for alternative diagnoses other than COPD. A comprehensive evaluation for additional etiologies of persistent hypoxemia and pulmonary hypertension following VTE and PE was warranted, including consideration for CTEPH. In review of the patient’s chart, an echocardiogram that had been performed at the time of initial PE several years before presentation revealed elevated estimated pulmonary artery
Conclusions
The patient in our study exhibited a spectrum of acute, subacute, and chronic PE, representing thromboembolic events hours, days to weeks, and years after initial VTE, respectively. Initial management focused on hemodynamic stabilization and prophylactic retrieval of a right- to left-sided thrombus that posed a catastrophic risk of both pulmonary and systemic embolization. Suspected by history and confirmed at the time of surgery, CTEPH was appropriately considered, and the patient underwent
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to CHEST the following: J. R. S. has received payments for expert witness testimony involving cases of PE. None declared (K. N., G. A. A., N. M M., G. J. V., C. D. W., B. B. G., D. M. D.).
Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
Additional information: The Video can be found in the Multimedia section of the online article.
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Interventional Therapies for Acute Pulmonary Embolism
2022, Surgical Clinics of North AmericaCitation Excerpt :Additional maneuvers for improved exposure and clot extraction include making a second incision in the right PA exposed between aorta and superior vena cava,52 gentle compression of the lung to dislodge small distal clots (except if the patient received antecedent ST), and clot extraction from the segmental arteries using a small videoscope.70,71 Other loci of thrombus-in-transit can be addressed surgically, including right heart thrombi and impending paradoxic embolism of PE, for which SPE is considered first-line therapy.9,72 Before PA closure, the catheter in the superior vena-cava is advanced into the right PA under direct vision.
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