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Catheter-based interventions and surgical embolectomy represent alternatives to systemic fibrinolysis for patients with high-risk pulmonary embolism (PE) or those with intermediate-high-risk PE who deteriorate hemodynamically. They are indicated when systemic fibrinolysis is contraindicated or ineffective, or if obstructive shock is imminent. Extracorporeal membrane oxygenation can be added to reperfusion therapies or used alone for severe right ventricular dysfunction and cardiogenic shock. These advanced therapies complement but do not replace anticoagulation, which remains the cornerstone in PE management. This review summarizes the evidence and shares practical recommendations for the use of anticoagulant therapy before, during, and after acute PE interventions.

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The management of embolic acute limb ischaemia commonly involves determining aetiology and performing emergency invasive procedures. This detailed study aimed to determine the impact of manipulation of anticoagulation in the aetiology of emboli in acute limb ischaemia and determine the efficacy of primary anticoagulation therapy vs. invasive interventions. Material and methods: Data collection was conducted at a single institution on a cohort of patients presenting consecutively with embolic acute limb ischaemia over one year. Two groups were compared, one receiving anticoagulation as primary therapy with those undergoing invasive treatment as the internal comparison group. Results: A likely haematological causation was identified in 22 of 38 presentations, related to interruption of anticoagulation in cardiac conditions, the majority atrial fibrillation (n=12), or hypercoagulable states (n=10). Limb salvage was pursued in 36 patients employing anticoagulation (n=19) or surgical embolectomy (n=17) as the primary therapy in upper and lower limbs (n=17 vs n=19 respectively). Despite delays often well beyond six hours and a range of ischaemic severity in both groups, 35 of 36 patients achieved full or substantive restoration of function with improved perfusion. Regarding anatomical distribution of arterial disease and therapy, three patients with multi-level disease proceeded to embolectomy following anticoagulation. Embolectomy was undertaken most often for proximal emboli and more profound paralysis. Conclusions: Anticoagulation and coagulopathy are commonly implicated in the aetiology of arterial emboli, with omission of effective anticoagulation in atrial fibrillation being associated in almost 1/3 of presentations. Whilst more profound limb paralysis and proximal or multi-level disease tended to be managed surgically, primary anticoagulation therapy alone or with a secondary embolectomy was effective across the spectrum of ischaemia severity and despite significant delays beyond guideline recommendations.

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OBJECTIVE: To evaluate presentations, aetiologies, interventions, and outcomes of patients presenting with acute limb ischaemia (ALI). STUDY DESIGN: An observational study. Place and Duration of the Study: Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2000 to December 2020. METHODOLOGY: Record of 104 patients who underwent surgical interventions for ALI was retrospectively evaluated. The diagnosis was confirmed on imaging (ultrasound / CTA / conventional angiography). Demographic characteristics, co-morbidities, aetiologies, and outcomes were analysed using descriptive statistics and logistic regression. RESULTS: The cohort's mean age was 58.89 ± 12.6 years, with (54.8%, n = 57) females and (45.2%, n = 47) males. Hypertension (54.8%, n = 57), diabetes (46.2%, n = 48), and atrial fibrillation (34.6%, n = 36) were common comorbidities. Thromboembolism (67.3%, n = 70) and thrombotic occlusion (32.7%, n = 34) were primary aetiologies, predominantly affecting the lower limb (66.3%, n = 58) and femoral artery (51.9%, n = 54). The majority of cases were classified as Rutherford classification 2A (53.8%; 56 cases) and 2B (44.2%; 46 cases); 58 (55.8%) patients were classified as ASA Class III, while 36 (34.6%) patients were categorised as ASA Class IV. Embolectomy (80.8%, n = 84) was the prevailing intervention, with an amputation rate (17.3%, n = 18) and a mortality rate (5.8%, n = 6). CONCLUSION: Most patients with ALI presented with Rutherford Class II and had thromboembolism aetiology. Embolectomy was the most commonly performed procedure with a high amputation rate and mortality. KEY WORDS: Acute limb ischaemia, Embolectomy, Amputation, Thromboembolism.

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Fungi rarely cause infective endocarditis but when they do, they are often associated with poor outcomes. Candida tropicalis accounts for only 10% of Candida endocarditis cases. A case of a 30-year-old male with a history of intravenous drug abuse was reported to the emergency department in August, 2021 with right-sided leg pain and fever for 3 days. A trans-thoracic echocardiogram showed a vegetation on the aortic valve and a computed tomography angiogram showed complete nonopacification of the right-sided common iliac artery and the superficial femoral artery just distal to its branching of the right profunda femoris artery. An emergent right iliofemoral embolectomy was done. Candida tropicalis was isolated from tissue and blood cultures. The patient was successfully treated with aortic valve replacement and intravenous caspofungin. The other reported cases of Candida tropicalis were reviewed and findings were compared with those reported in patients with Candida albicans and Candida parapsilosis endocarditis.

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Emergent reperfusion, most commonly with the administration of thrombolytic agents, is the recommended management approach for patients presenting with high-risk, or hemodynamically unstable pulmonary embolism. However, a subset of patients with a more catastrophic presentation, including refractory shock and impending or active cardiopulmonary arrest, may require immediate circulatory support. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be deployed rapidly by the well-trained team and provide systemic perfusion allowing for hemodynamic stabilization. Subsequent embolectomy or a standalone strategy allowing for thrombus autolysis may be followed with decannulation after several days. Retrospective studies and registry data suggest favorable clinical outcomes with the use of VA-ECMO as an upfront stabilization strategy even among patients presenting with cardiopulmonary arrest. In this review, we discuss the physiologic rationale, evidence base, and an approach to ECMO deployment and subsequent management strategies among select patients with high-risk pulmonary embolism.

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OBJECTIVES: We hypothesized that ultrasound-assisted thrombolysis (USAT) is non-inferior to surgical pulmonary embolectomy (SPE) to improve right ventricular (RV) function in patients with acute pulmonary embolism (PE). METHODS: In a single-centre, non-inferiority trial, we randomly assigned 27 patients with intermediate-high or high-risk acute PE to undergo either USAT or SPE stratified by PE risk. Primary and secondary outcomes were the baseline-to-72-h difference in right-to-left ventricular (RV/LV) ratio and the Qanadli pulmonary occlusion score, respectively, by contrast-enhanced chest-computed tomography assessed by a blinded CoreLab. RESULTS: The trial was prematurely terminated due to slow enrolment. Mean age was 62.6 (SD 12.4) years, 26% were women, and 15% had high-risk PE. Mean change in RV/LV ratio was -0.34 (95% CI -0.50 to -0.18) in the USAT and -0.53 (95% CI -0.68 to -0.38) in the SPE group (mean difference: 0.152; 95% CI 0.032-0.271; Pnon-inferiority = 0.80; Psuperiority = 0.013). Mean change in Qanadli pulmonary occlusion score was -7.23 (95% CI -9.58 to -4.88) in the USAT and -11.36 (95% CI -15.27 to -7.44) in the SPE group (mean difference: 5.00; 95% CI 0.44-9.56, P = 0.032). Clinical and functional outcomes were similar between the 2 groups up to 12 months. CONCLUSIONS: In patients with intermediate-high and high-risk acute PE, USAT was not non-inferior when compared with SPE in reducing RV/LV ratio within the first 72 h. In a post hoc superiority analysis, SPE resulted in greater improvement of RV overload and reduction of thrombus burden.

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This case highlights a rare presentation of diverticulitis of the sigmoid colon with perforation into the retroperitoneum complicated by abscess, vertebral osteomyelitis and acute lower extremity ischemia. A late 40-year-old man presented to an emergency department with acute ischemia of his left lower extremity. He was tachycardic with a leucocytosis, an unremarkable abdominal exam and a pulseless, insensate and paralysed left lower extremity. Imaging revealed sigmoid thickening, an abscess adjacent to iliac vasculature and occlusion of the left popliteal artery. The abscess came in contact with prior spine anterior lumbar interbody fusion (ALIF) hardware at L5-S1 vertebrae. The patient was taken urgently to the operating room for embolectomy, thrombectomy and fasciotomy. He was started on antibiotics and later underwent operative drainage with debridement for osteomyelitis. Non-operative management of the complicated diverticulitis failed, necessitating open sigmoidectomy with colostomy. 1 year later, he was symptom-free and the colostomy was reversed.

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Massive pulmonary embolism (MPE) is a serious condition affecting the pulmonary arteries and is difficult to diagnose, triage, and treat. The American College of Chest Physicians (AHA) and the European Society of Cardiology (ESC) have different classification approaches for PE, with the AHA defining three subtypes and the ESC four. Misdiagnosis is common, leading to delayed or inadequate treatment. The incidence of PE-related death rates has been increasing over the years, and mortality rates vary depending on the subtype of PE, with MPE having the highest mortality rate. The current definition of MPE originated from early surgical embolectomy cases and discussions among experts. However, this definition fails to capture patients at the point of maximal benefit because it is based on late findings of MPE. Pulmonary Embolism Response Teams (PERTs) have emerged as a fundamental shift in the management of MPE, with a focus on high-risk and MPE cases and a goal of rapidly connecting patients with appropriate therapies based on up-to-date evidence. This review highlights the challenges in diagnosing and managing MPE and emphasizes the importance of PERTs and risk stratification scores in improving outcomes for patients with PE.

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With a multitude of options for pulmonary embolism management, we review the most common diagnostic tools available for assessing risk as well as how each broad risk category is typically treated. Right heart dysfunction is the cornerstone for triage of these patients and should be the focus for decision-making, especially in challenging patients. We aim to provide a modern, clinical perspective for PE management in light of the multitude of intervention options.

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PURPOSE: The aim of this case report is to report that delayed hemothorax is possible after anterior vertebral body tethering (aVBT) and to illustrate the course of treatment. METHODS: We present a 15-year-old boy with adolescent idiopathic scoliosis who underwent an anterior thoracoscopic assisted vertebral body tethering who developed a massive right-sided hemothorax 12 days post-operatively. A chest tube was placed to drain the hemothorax and later required embolectomy with tissue plasminogen activator (TPA) to drain the retained hemothorax. RESULTS: At 1 month follow up post discharge the patient was asymptomatic, and radiograph did not demonstrate evidence of residual hemothorax and scoliosis. We have followed this patient for 5 years postoperative and he continues to do well clinically and radiographically. CONCLUSIONS: Pulmonary complications are a known drawback of anterior thoracoscopic spinal instrumentation. Delayed hemothorax is possible after aVBT. In the case of a retained hemothorax, chest tube treatment with TPA is a safe and effective method of embolectomy.

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BACKGROUND: This study aimed to assess the prevalence of chronic thromboembolic lesions in the pulmonary arteries among patients undergoing pulmonary embolectomy for acute pulmonary embolism and their impact on treatment outcomes. METHODS: We conducted a retrospective, single-center analysis of consecutive patients undergoing emergency pulmonary embolectomy for acute pulmonary embolism between 2013 and August 2021. According to European Society of Cardiology guidelines, the diagnosis was based on clinical presentation, imaging studies and laboratory tests. Surgery was selected as the optimal treatment modality within the Pulmonary Embolism Response Team. Based on the intraoperatively identified chronic lesions patients were divided into two groups: acute only and acute/chronic. The analysis comprised history, laboratory and imaging studies, early and long-term mortality, and postoperative complications. We determined predictive factors for chronic thromboembolic lesions and risk factors for death. RESULTS: The analysis included 33 patients. Intraoperatively, 42% (14) of patients had chronic lesions. Predictive factors for these lesions are the duration of symptoms >1 week (OR=13.75), pulmonary artery dilatation >3.15 cm (OR=39.00) and right ventricle systolic pressure >52 mmHg (OR=29.33). No hospital deaths occurred in the acute only group and two in the acute/chronic group (0% vs. 14.3%; P=0.172). Risk factors for death are the duration of symptoms >3 weeks (HR=7.35) and postoperative use of extracorporeal membrane oxygenation (HR=7.04). CONCLUSIONS: Acute thromboembolic disease overlapping chronic clots is relatively common among patients undergoing pulmonary artery embolectomy. A detailed evaluation of the patient's medical history and imaging studies can identify these patients, as they require special attention when making treatment decisions. Surgical treatment in a center of expertise in pulmonary endarterectomy seems reasonable.

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Pulmonary embolism is a common complication after intracranial hemorrhage. As thrombolysis is contraindicated in this situation, surgical pulmonary embolectomy may be indicated in case of high-risk pulmonary embolism but requires transient anticoagulation with heparin during cardiopulmonary bypass. We report the case of a patient with a history of heparin-induced thrombocytopenia who presented with a high-risk pulmonary embolism 10 days after the spontaneous onset of a voluminous intracerebral hematoma. Despite high doses of heparin required to run the cardiopulmonary bypass and subsequent anticoagulation by danaparoid sodium, the brain hematoma remained stable and the patient was discharged without complications 30 days after surgery.

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High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.

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BACKGROUND: High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE: This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION: High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS: Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.

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Open revascularization for mesenteric ischemia has retained a significant value despite the increasing importance and use of endovascular techniques. Surgical procedures such as retrograde embolectomy, thromboendarterectomy and visceral bypass are indispensable components of the therapeutic armamentarium, particularly in cases of multisegmental vascular involvement, failure of previous endovascular treatment and concomitant presence of peritonitis, shock or multiorgan failure. In this context, preoperative multiphase computed tomography (CT) angiography is essential for the planning and outcome of visceral revascularization. This article summarizes the indications, technique, and results of the most important open surgical procedures.

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BACKGROUND: Surgical pulmonary embolectomy is rarely used for the treatment of massive acute pulmonary embolism. The aim of this study was to assess the incidence and outcomes of this operation by undertaking a retrospective analysis of a large national registry in the UK. METHODS: All acute pulmonary embolectomies performed between 1996 and 2018 were captured in the National Institute of Cardiovascular Outcomes Research central database. Trends in the number of operations performed during this interval and reported in-hospital outcomes were analysed retrospectively. Multivariable logistic regression was used to identify independent risk factors for in-hospital death. RESULTS: All 256 patients treated surgically for acute pulmonary embolism during the study interval were included in the analysis. Median age at presentation was 54 years, 55.9% of the patients were men, 48.0% had class IV heart failure symptoms, and 37.5% had preoperative cardiogenic shock. The median duration of bypass was 73 min, and median cross-clamp time was 19 min. Cardioplegic arrest was used in 53.1% of patients. The median duration of hospital stay was 11 days. The in-hospital mortality rate was 25%, postoperative stroke occurred in 5.4%, postoperative dialysis was required in 16%, and the reoperation rate for bleeding was 7.5%. Risk-adjusted multivariable analysis revealed cardiogenic shock (OR 2.54, 95% c.i. 1.05 to 6.21; P = 0.038), preoperative ventilation (OR 5.85, 2.22 to 16.35; P < 0.001), and duration of cardiopulmonary bypass exceeding 89 min (OR 7.82, 3.25 to 20.42; P < 0.001) as significant independent risk factors for in-hospital death. CONCLUSION: Surgical pulmonary embolectomy is rarely performed in the UK, and is associated with significant mortality and morbidity. Preoperative ventilation, cardiogenic shock, and increased duration of bypass were significant predictors of in-hospital death.

A blood clot in the lung can prevent the lungs from working properly and put pressure on the heart to work harder. Small clots can be treated with medications taken at home and are not a danger to life. Larger blood clots can put a lot of pressure on the heart and need immediate hospital treatment. Large blood clots can be treated with 'clot busting' medications, the delivery of a small tube into the blood vessels of the lung to suck up the clot or deliver medications directly on to its surface, and finally a form of open-heart surgery. With this surgery, a surgeon opens the chest, make a cut into the large vessels containing the clot, and physically removes the large piece of obstructing clot. The aim of this study was to describe and analyse the outcomes of this operation done in the UK over a long period. A database was used to find out how often and where this operation took place and its results. The available data were studied to try to understand how helpful this operation is to patients with lung blood clots. Between 1996 and 2018, 256 people had this operation. One in four patients did not survive the operation, 5.4% developed a clot or bleed in the brain, 16% needed to go on to a dialysis machine, and 7.5% had to be rushed back into theatre because of bleeding. Needing a ventilator machine for help with breathing, being in a sudden state of heart failure, and a long time on the heart bypass machine were all linked with patients who did not survive. This operation is rarely performed in the UK, and is often linked to a high chance of death or serious complication. In this study, the points described above were linked to a bad outcome.

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