BACKGROUND & AIMS: :Feeding vessel sign is very sensitive radiological finding of septic pulmonary embolism. In the appropriate clinical context, if the CT scan of a patient with suspected sepsis shows this radiological sign, empirical antibiotics (including gram positive organisms) should be started at the earliest after sending all cultures to decrease mortality and morbidity. Here we are presenting a case of 14-years-old boy with left ankle septic arthritis and septic pulmonary embolism.

背景与目标： ：进食管征是化脓性肺栓塞的放射学非常敏感的发现。在适当的临床情况下，如果怀疑脓毒症患者的CT扫描显示出这种放射学迹象，则应在送出所有培养物后尽早开始使用经验性抗生素（包括革兰氏阳性生物）以降低死亡率和发病率。在这里，我们介绍了一个14岁男孩的左脚踝脓毒性关节炎和脓毒性肺栓塞的病例。

BACKGROUND & AIMS: -2

背景与目标： -2

BACKGROUND & AIMS: PURPOSE:To assess the feasibility and efficacy of catheter-directed thrombolysis with recombinant tissue plasminogen activator (rt-PA) for acute limb embolism in patients with recent cerebral embolism due to atrial fibrillation. MATERIALS AND METHODS:Eight patients (six men, two women; mean age 63.5 years) with acute embolic occlusion of two left common iliac arteries, four femoral arteries (three left; one right), and two right popliteal arteries were treated. All patients had a history of recent cerebral embolism (mean 6 days, range 5-15 days) and all had a history of atrial fibrillation (duration 5-10 years). Catheter-directed thrombolysis started a few hours (mean 6.2h; range 3-10h) after the onset of arterial embolism. Two 5mg boluses of rt-PA were injected into the proximal clot through a 5 F end-hole catheter and, subsequently, two additional boluses of 5mg rt-PA were injected into the emboli. In patients with residual emboli, infusion with rt-PA (1mg/h) was continued. Percutaneous transluminal angioplasty was performed in three patients, and a stent was deployed in one patient. RESULTS:Technical success was achieved in all patients. Clinical success rate was 87.5% (7/8). The one clinical failure was secondary to chronic occlusion of outflow runoff vessels. The mean duration of continuous rt-PA infusion was 3.6h, the mean total dose of rt-PA administered was 23.6 mg (range 20-28 mg). There was no significant change in stroke scale scores during thrombolysis and no intracerebral haemorrhage was found at computed tomography (CT) after thrombolysis. Minor complications included haematomata at puncture sites (6/8), bleeding around the vascular sheath (2/8), and haematuria (1/8). During the follow-up period of 3-6 months, one patient suffered from recurrent cerebral embolism and died. CONCLUSIONS:Catheter-directed thrombolysis with rt-PA is an option for acute lower extremity arterial embolism in patients with recent cerebral embolism and a history of atrial fibrillation. Further studies should be undertaken to determine the risk of intracerebral haemorrhage caused by catheter-directed thrombolysis in individual stroke patients.

背景与目标： 目的：评估重组组织型纤溶酶原激活物（rt-PA）指导的导管溶栓治疗在房颤引起的近期脑栓塞患者中急性肢体栓塞的可行性和有效性。
材料与方法：对八例急性栓塞闭塞的患者（六名男性，两名女性；平均年龄63.5岁）进行了治疗，该患者有两条左common总动脉，四股股动脉（左三；一右）和两根pop小动脉。所有患者均具有近期脑栓塞病史（平均6天，范围5-15天），均具有房颤病史（持续时间5-10年）。导管栓塞发生后数小时（平均6.2h；范围3-10h）开始进行导管溶栓治疗。通过5 F端孔导管将两个5mg rt-PA大剂量注入近端血块，随后再将两个5mg rt-PA大剂量注入栓子。在残留栓子的患者中，继续输注rt-PA（1mg / h）。在三名患者中进行了经皮腔内血管成形术，在一名患者中部署了支架。
结果：所有患者均获得技术成功。临床成功率为87.5％（7/8）。一种临床失败是继发于流出径流血管的慢性阻塞。 rt-PA连续输注的平均持续时间为3.6h，rt-PA的平均给药总剂量为23.6 mg（范围为20-28 mg）。溶栓后卒中量表评分无明显变化，溶栓后计算机断层扫描（CT）未发现脑出血。较小的并发症包括穿刺部位的血肿（6/8），血管鞘周围的出血（2/8）和血尿（1/8）。在3至6个月的随访期间，一名患者反复发作脑栓塞并死亡。
结论：对于近期脑栓塞并有心房颤动病史的患者，rt-PA导管定向溶栓术是急性下肢动脉栓塞的一种选择。应进行进一步的研究以确定在个体卒中患者中因导管定向溶栓引起的脑内出血的风险。

BACKGROUND & AIMS: :Right ventricular (RV) dysfunction is associated with poor clinical outcome following pulmonary embolism (PE). Previous studies in our laboratory show that influx of neutrophils contributes to acute RV damage seen in an 18 h rat model of PE. The present study describes the further progression of inflammation over 6 weeks and compares the neutrophil and monocyte responses. The RV outflow tract became white in colour by day 1 with influx of neutrophils (tissue myeloperoxidase activity increased 17-fold) and mononuclear cells with characteristics of M1 phenotype (high in Ccl20, Cxcl10, CcR2, MHCII, DNA microarray analysis). Matrix metalloproteinase activities were increased and tissue was thinned to produce a translucent appearance in weeks 1 through 6 in 40% of hearts. RV contractile function was significantly reduced at 6 weeks of PE. In this later phase, there was accumulation of myofibroblasts, the presence of mononuclear cells with M2 characteristics (high in scavenger mannose receptors, macrophage galactose lectin 1, PDGFR1, PDGFRbeta), enrichment of the subendocardial region of the RV outflow tract with neovesels (alpha-smooth muscle immunohistochemistry) and deposition of collagen fibres (picrosirius red staining) beginning scar formation. Thus, while neutrophil response is associated with the early, acute inflammatory events, macrophage cells continue to be present during the proliferative phase and initial deposition of collagen in this model, changing from the M1 to the M2 phenotype. This suggests that the macrophage cell response is biphasic.

背景与目标： ：右心室（RV）功能障碍与肺栓塞（PE）后的临床预后不良有关。在我们实验室的先前研究表明，嗜中性粒细胞的大量涌入可导致在18小时的PE大鼠模型中出现急性RV损伤。本研究描述了6周内炎症的进一步发展，并比较了中性粒细胞和单核细胞的反应。到第1天，RV流出道变成白色，伴有嗜中性粒细胞的流入（组织髓过氧化物酶活性增加了17倍）和具有M1表型特征的单核细胞（Ccl20，Cxcl10，CcR2，MHCII，DNA芯片分析高）。在40％的心脏中，第1周到第6周，基质金属蛋白酶的活性增加，组织变薄，形成半透明的外观。 PE发生6周后，RV收缩功能显着降低。在此后期阶段，存在成肌纤维细胞的积累，具有M2特征的单核细胞的存在（高清除率甘露糖受体，巨噬细胞半乳糖凝集素1，PDGFR1，PDGFRbeta），右室流出道的心内膜下区域被新血管（α）富集。 -平滑肌免疫组织化学）和胶原纤维沉积（picrosirius红染色）开始形成疤痕。因此，尽管嗜中性粒细胞反应与早期急性炎症事件有关，但在该模型中胶原的增生期和初始沉积期间，巨噬细胞继续存在，从M1变为M2表型。这表明巨噬细胞反应是双相的。

BACKGROUND & AIMS: :Paradoxical embolism, describing the passage of venous or right-sided cardiac thrombus into the arterial or systemic circulation through patent foramen ovale, is an uncommon cause of acute arterial occlusion. Here, we report acute Leriche syndrome in a young woman attributable to paradoxical embolism. Ischaemia, patent foramen ovale, and venous thrombosis were the triad of evidence for paradoxical embolism.

背景与目标： ：偏瘫性栓塞描述了静脉或右侧心脏血栓通过卵圆形未闭孔进入动脉或全身循环，是导致急性动脉闭塞的罕见原因。在这里，我们报道了一名年轻女性因矛盾性栓塞而发生的急性莱里希综合症。缺血，卵圆孔未闭和静脉血栓形成是三元悖论性栓塞的证据。

BACKGROUND & AIMS: :The aims of this study were to review the prevalence and outcome of all surgically treated upper and lower limb emboli presenting to one vascular unit in the last 3 years and to compare transthoracic with transesophageal echocardiography for defining the source of the embolus. All patients who underwent surgical embolectomy for acute limb ischemia from January 2001 to June 2004 were reviewed. Transthoracic and transesophageal echocardiography were carried out on a subset of consecutive unselected patients. Forty-two patients, with a mean age of 80 years, underwent surgical embolectomy from January 2001 to June 2004 (M/F 1:1.8): 27 for lower limb ischemia and 15 for upper limb ischemia. Two thirds of these patients were found to be in atrial fibrillation at presentation (n = 28), of whom less than a third were receiving anticoagulants or antiplatelet agents (n = 8). The mean hospital stay was 15 days with 36 patients (86%) being fully anticoagulated before discharge from hospital. The 30-day mortality rate was 11% (n = 3/27) with 5 patients requiring fasciotomies (12%) and 3 patients requiring an amputation of the lower limb (11%). Postoperatively, 34 patients (81%) had transthoracic echocardiography (TTE), which demonstrated a source or potential source for thrombus in 19 (56%). Fifteen patients (36%) had transesophageal echocardiography (TEE), which changed the subsequent management in 3 patients. All patients in whom TEE altered clinical management would have required this investigation if standard clinical guidelines were followed. TEE did not identify any additional patients with cardiac embolic sources that were not detected by TTE. Arterial limb emboli are still prevalent, but limb salvage and mortality rates appear to be improving. Despite clear guidelines on anticoagulation for patients in atrial fibrillation, many are not receiving appropriate treatment. Transthoracic echocardiography is a good screening tool for detecting a potential cardiac source for peripheral embolism, with transesophageal echocardiography being reserved for specific indications.

背景与目标： ：这项研究的目的是回顾过去3年中所有接受手术治疗的上肢和下肢栓塞在一个血管内的发生率和结局，并比较经胸和经食道超声心动图检查来确定栓子的来源。回顾性分析了2001年1月至2004年6月所有因急性肢体缺血而行外科手术栓塞切除术的患者。经胸和经食道超声心动图检查是对连续的未选择患者的子集进行的。 2001年1月至2004年6月，平均年龄为80岁的42例患者接受了手术栓塞切除术（M / F 1：1.8）：下肢缺血27例，上肢缺血15例。这些患者中有三分之二被发现存在房颤（n = 28），其中不到三分之一接受抗凝剂或抗血小板药物（n = 8）。平均住院时间为15天，其中36例患者（86％）在出院前已充分抗凝。 30天死亡率为11％（n = 3/27），其中5例需要行筋膜切开术（12％），3例需要下肢截肢（11％）。术后34例（81％）患者经胸超声心动图（TTE），其中19例（56％）证明有血栓来源或潜在来源。 15例患者（36％）进行了食管超声心动图检查（TEE），这改变了3例患者的后续治疗方法。如果遵循标准的临床指南，所有TEE改变了临床管理的患者都需要进行此项调查。 TEE并未发现TTE未发现的其他心脏栓塞患者。动脉肢体栓塞仍很普遍，但肢体抢救和死亡率似乎正在提高。尽管对房颤患者的抗凝治疗有明确的指导原则，但许多人并未得到适当的治疗。经胸超声心动图检查是一种很好的筛查工具，可用于检测周围性栓塞的潜在心脏源，保留经食道超声心动图检查以用于特定适应症。

BACKGROUND & AIMS: RATIONALE AND OBJECTIVES:To evaluate the feasibility of mechanical thrombectomy with the Amplatz thrombectomy device (ATD) in restoring patency of acutely thrombosed pulmonary arteries resulting from pulmonary embolism for the improvement of patient outcome. METHODS:Mechanical thrombectomy with the ATD (8F) was performed in nine consecutive patients with angiographically documented thrombus in the left or right pulmonary artery resulting from deep vein thrombosis (n = 4) or unknown cause (n = 5). RESULTS:The Miller index decreased from 18 to 11. In all patients, the majority of the thrombus in the pulmonary artery was cleared after a mean activation time of the ATD of 367 seconds. Thrombectomy was performed with the ATD alone (n = 4) or with additional long-term fibrinolysis therapy (n = 5) with infusion of recombinant tissue-type plasminogen activator. Pulmonary arterial pressure decreased from a mean of 57 mm Hg before mechanical thrombectomy to 55 mm Hg directly after the procedure and to 39 mm Hg after termination of the recombinant tissue-type plasminogen activator infusion. CONCLUSIONS:Mechanical thrombectomy with the ATD in patients with minor and major pulmonary embolism is technically feasible and safe. It is a potential alternative to drug-mediated thrombolysis and surgery. However, the incremental benefit of the ATD over conventional treatments could be shown only in a randomized controlled study.

背景与目标： 理由和目的：评估使用Amplatz血栓切除术装置（ATD）进行机械血栓切除术，以恢复由肺栓塞引起的急性血栓形成的肺动脉通畅以改善患者预后的可行性。
方法：对9例因深静脉血栓形成（n = 4）或原因不明（n = 5）而在血管造影上记录的左或右肺动脉血栓的患者，进行了ATD（8F）机械血栓切除术。
结果：米勒指数从18降低至11。在所有患者中，平均ATD激活时间为367秒后，大部分肺动脉血栓被清除。单独使用ATD（n = 4）或进行其他长期纤溶治疗（n = 5），并注入重组组织型纤溶酶原激活剂，即可行血栓切除术。肺动脉压从机械血栓切除术前的平均57 mm Hg降低到手术后的55 mm Hg，而在重组组织型纤溶酶原激活剂输注终止后降低到39 mm Hg。
结论：对于轻度和重度肺动脉栓塞患者，采用ATD机械血栓切除术在技术上是可行和安全的。它是药物介导的溶栓和手术的潜在替代方法。但是，只有在随机对照研究中才能显示出ATD优于传统疗法的益处。

BACKGROUND & AIMS: :This study is designed to evaluate the various physiologic maneuvers (Valsalva, humming, breath-hold) for the potential prevention of air embolism during central venous catheter placement. Central venous pressure measurements were prospectively obtained in 40 patients undergoing central venous catheter placement. The average central venous pressure at baseline was 3.275 mm Hg (range = -4 to 16, SD = 5.99). The average central venous pressure during breath hold was 6.1 mm Hg (range = -6 to 24, SD = 7.99). The average central venous pressure during humming was 5.1 mm Hg (range = -4 to 20, SD = 6.4) The average central venous pressure during the Valsalva maneuver was 18.43 (range = -3 to 48, SD = 14.73). Forty percent of patients (16 of 40) had negative central venous pressures at rest, 25% (10 of 40) had negative pressures during breath hold, 20% (8 of 40) had negative pressures during humming, and 2.5% (1 of 40) had negative pressures during Valsalva maneuver. The average increases in central venous pressure during breath hold, humming, and Valsalva were 2.85, 1.82, and 15.2 mm Hg, respectively. The difference between pressures during Valsalva and other maneuvers was statistically significant (P <.05). The conclusion is that the Valsalva maneuver is superior to breath-hold and humming for increasing central venous pressure during central venous catheter placement and, therefore, it is more likely to prevent air embolism in cooperative patients.

背景与目标： ：这项研究旨在评估各种生理动作（Valsalva，嗡嗡声，屏气），以潜在地防止在中心静脉导管放置过程中发生空气栓塞。前瞻性测量了40名接受中心静脉导管置入的患者的中心静脉压。基线时的平均中心静脉压为3.275毫米汞柱（范围= -4至16，SD = 5.99）。屏气期间的平均中心静脉压为6.1 mm Hg（范围= -6至24，SD = 7.99）。嗡嗡声期间的平均中心静脉压为5.1 mm Hg（范围= -4至20，SD = 6.4）。Valsalva动作期间的平均中心静脉压为18.43（范围= -3至48，SD = 14.73）。 40％的患者（40名患者中有16名）在休息时中心静脉负压，25％（40名患者中的10名）屏气时负压，20％（40名患者中的8名）哼唱时负压，2.5％（1名患者）。 40）在瓦尔萨尔瓦（Valsalva）演习中有负压。屏气，嗡嗡声和Valsalva期间中心静脉压的平均升高分别为2.85、1.82和15.2 mm Hg。瓦尔萨尔瓦（Valsalva）和其他动作之间的压力差异具有统计学意义（P <.05）。结论是，在中央静脉导管置入过程中，Valsalva的操作在增加中央静脉压力方面优于屏气和嗡嗡作响，因此，它更有可能在合作患者中预防空气栓塞。

BACKGROUND & AIMS: BACKGROUND:Pulmonary embolism (PE) is a leading cause of mortality after bariatric surgery. We evaluated inferior vena cava (IVC) filter use for PE risk reduction in high-risk super morbidly obese bariatric surgery patients. METHODS:IVC filters were inserted according to the patient's risk factors, including immobility, previous deep venous thrombosis (DVT)/PE, venous stasis, and pulmonary compromise. All filters were placed concomitant to bariatric surgery and were placed through a right internal jugular vein access site. We analyzed the prospectively collected data from this cohort and evaluated the incidence of PE and complications. RESULTS:Since April 2003, 41 patients (12 men and 29 women) with a mean age of 47.3 +/- 10.0 years and body mass index of 64.2 +/- 12 kg/m2 (range 47-105) underwent IVC filter placement. These and all other patients underwent standard DVT/PE risk reduction measures. All IVC filter patients had one or more significant risk factors for thromboembolic events. No instances of PE were documented, although 1 patient experienced DVT, and no immediate or late complications related to filter placement occurred. One patient, with a body mass index of 105 kg/m2, died secondary to rhabdomyolysis after an extended procedure. The average filter placement time was 34.3 +/- 9 minutes. CONCLUSION:IVC filter placement for PE risk reduction is safe and feasible in the super morbidly obese. Our data have shown that the filters can be placed expeditiously and with minimal morbidity concomitant with bariatric surgery. In this limited series, IVC filter placement was associated with no PE. Additional studies are needed to confirm the efficacy of IVC filter placement for PE risk reduction and related mortality in the super morbidly obese.

背景与目标： 背景：肺栓塞（PE）是减肥手术后死亡的主要原因。我们评估了下腔静脉滤器（IVC）在高风险，超级病态肥胖减肥手术患者中降低PE风险的使用。
方法：根据患者的危险因素插入IVC过滤器，包括不动，先前的深静脉血栓形成（DVT）/ PE，静脉淤滞和肺部损害。所有过滤器均与减肥手术同时放置，并通过右颈内静脉进入部位放置。我们分析了该队列的前瞻性收集数据，并评估了PE和并发症的发生率。
结果：自2003年4月以来，对41例平均年龄为47.3 /-10.0岁，体重指数为64.2 /-12 kg / m2（范围47-105）的患者（12例男性和29例女性）进行了IVC过滤器置入。这些患者和所有其他患者均接受了标准的DVT / PE降低风险措施。所有IVC滤过器患者均具有一个或多个血栓栓塞事件的重要危险因素。尽管有1例患者经历了DVT，但没有记录到PE病例，也没有发生与滤器放置有关的即刻或晚期并发症。一名体重指数为105 kg / m2的患者在延长手术后死于横纹肌溶解症。过滤器的平均放置时间为34.3 /-9分钟。
结论：在超级病态肥胖者中，IVC过滤器放置可降低PE风险是安全可行的。我们的数据表明，过滤器可以快速放置，并且与肥胖手术相伴的发病率极低。在这个有限的系列中，IVC过滤器的放置与没有PE相关联。需要更多的研究来确认IVC滤器放置对于降低超级病态肥胖患者PE风险和相关死亡率的功效。

BACKGROUND & AIMS: OBJECTIVE:This study describes a patient with nephrotic syndrome who experienced recurrent pulmonary emboli as renal disease relapsed frequently. CLINICAL PRESENTATION:A 30-year-old male, who was diagnosed as having nephrotic syndrome at 12, presented with general edema, ascites and hypoalbuminemia. Although the patient responded well to steroid therapy, a common cold frequently caused flare-up of nephrotic syndrome. Histopathological examination of renal tissue revealed minimal disease change. At 17, the patient had a first pulmonary embolism attack with concurrent upper respiratory tract infection. Full-blown manifestations of nephrotic syndrome with low antithrombin III levels were identified at that time. Anticoagulant therapy was administered to treat the pulmonary embolism. Since the first attack, several episodes of pulmonary emboli occurred, which, combined with kidney disease, triggered refractory nephrotic syndrome. The nephrotic syndrome did not remit, and a secondary renal biopsy identified glomerular pathological changes similar to previous biopsy results. To prevent recurrent pulmonary emboli, a Greenfield inferior vena cava filter was implanted in April 2002. No further pulmonary embolism events occurred after interventional filter deployment. CONCLUSION:The results of this study suggest that inferior vena cava filter implantation can be effective for preventing recurrent pulmonary embolism complicating refractory nephrotic syndrome.

背景与目标： 目的：本研究描述了一名肾病综合症患者，由于肾脏疾病频繁复发而经历了肺栓塞复发。
临床表现：一名30岁的男性，在12岁时被诊断出患有肾病综合症，表现为全身水肿，腹水和低白蛋白血症。尽管患者对类固醇疗法反应良好，但普通感冒常常引起肾病综合征的发作。肾脏组织的组织病理学检查显示最小的疾病变化。患者在17岁时首次发生肺栓塞发作，并发上呼吸道感染。当时已确定抗凝血酶III水平低的肾病综合征的全面表现。进行抗凝治疗以治疗肺栓塞。自第一次发作以来，发生了数次肺栓塞，并伴有肾脏疾病，引发了难治性肾病综合征。肾病综合征没有缓解，第二次肾脏活检发现肾小球病理改变与先前的活检结果相似。为防止复发性肺栓塞，2002年4月植入了Greenfield下腔静脉滤器。介入滤器部署后，没有发生进一步的肺栓塞事件。
结论：本研究结果提示下腔静脉滤器植入术可有效预防复发性肺栓塞并发难治性肾病综合征。

BACKGROUND & AIMS: :Rotational thromboelastometry is a viscoelastomeric, point-of-care method for testing haemostasis in whole blood which can be visualised rapidly, in real time, in the operating theatre. Advantages over traditional coagulation tests relate to the rapid feedback of results and the ability to visualise hyperfibrinolysis. We present a case of suspected amniotic fluid embolism that presented with sudden respiratory arrest associated with haemodynamic compromise during a non-elective caesarean delivery. Soon after the collapse, coagulopathy developed. Rotational thromboelastometry showed hyperfibrinolysis and hypofibrinogenaemia, which allowed targeted coagulation factor replacement therapy and the use of tranexamic acid. Hyperfibrinolysis may be a contributor to the coagulopathy associated with amniotic fluid embolism but has been infrequently reported, perhaps due to limited diagnosis with traditional coagulation tests. Treatment of the coagulopathy associated with a suspected amniotic fluid embolism with antifibrinolytic agents may deserve greater consideration.

背景与目标： ：比例血栓弹力测定法是一种粘弹性体的即时检验方法，用于测试全血中的止血效果，可以在手术室中快速实时地进行可视化。相对于传统凝血测试的优势在于结果的快速反馈和可视化超纤维蛋白溶解的能力。我们提出了一例疑似羊水栓塞的病例，该病例在非选择性剖宫产过程中出现突然的呼吸暂停，并伴有血流动力学的损害。崩溃后不久，凝血病就发展了。旋转血栓弹力测定显示高纤蛋白溶解和低纤维蛋白原性贫血，可进行靶向凝血因子替代治疗和使用氨甲环酸。高纤蛋白溶解可能是与羊水栓塞相关的凝血病的病因，但鲜有报道，这可能是由于传统凝血试验的诊断有限所致。与抗纤溶剂一起治疗怀疑与羊水栓塞有关的凝血病可能值得更多考虑。