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Ci e his a icle: Khan JA, Hau alah i JE, Lau ikka JO (2017) Massi e Pulmona y Embolism a e Hip Su ge y wi h a Mobile, Snake-Like Righ A ial Th ombus
Success ully T ea ed wi h Open Hea Su ge y. J Ca diol Clin Res 5(5): 1113.
*Co esponding au ho
Jahangi A. Khan, Depa men o Ca dio-Tho acic
Su ge y, Hea Hospi al, Tampe e Uni e si y Hospi al, PO
BOX 2000, Tampe e, Finland, Tel: +358331165037; Fax:
+358331165756; Email
Submi ed: 27 June 2017
Accep ed: 20 July 2017
Published: 22 July 2017
Copy igh
© 2017 Khan e al.
OPEN ACCESS
Keywo ds
•Th ombosis
•Pulmona y embolism
•Ca diac su ge y
•Embolec omy
Case Repo
Massi e Pulmona y Embolism
a e Hip Su ge y wi h a
Mobile, Snake-Like Righ A ial
Th ombus Success ully T ea ed
wi h Open Hea Su ge y
Jahangi A. Khan*, Juha E. Hau alah i, and Ja i O. Lau ikka
Depa men o Ca dio-Tho acic Su ge y, Hea Hospi al, Tampe e Uni e si y Hospi al,
Finland
Abs ac
Su gical embolec omy o pulmona y embolism and in aca diac h ombus is a a e
bu occasionally equi ed p ocedu e ha should be conside ed when an icoagula ion
and/o h omboly ic he apy is con aindica ed o ailed. We desc ibe a pa ien wi h
massi e pulmona y embolism and a la ge, mobile, snake-like h ombus in he igh
a ium, as well as a pa en o amen o ale, ea ed success ully by su ge y.
ABBREVIATIONS
PFO: Pa en Fo amen O ale
INTRODUCTION
Massi e pulmona y embolism is a po en ially le hal condi ion.
Besides suppo i e ca e, con en ional ea men consis s o
sys emic an icoagula ion, h omboly ic he apy and, in selec ed
cases, su ge y o pe cu aneous ca he e -based p ocedu es.
Su gical embolec omy should be conside ed when h ombolysis
is con aindica ed o ailed [1].
CASE PRESENTATION
A 70-yea old man was e e ed o ou hospi al he 1s o
No embe 2016 because o malaise, hypo ension, achyca dia,
and a collapse. He had been ope a ed on o a le -sided hip ac u e
ou days ea lie and had ecei ed ou ine low-molecula -weigh
hepa in p ophylaxis pos ope a i ely. The pa ien was p e iously
diagnosed wi h polysy emia e a and had i e mon hs ea lie
unde gone an abdominope ineal esec ion o a g ade II dis al
ec al ca cinoma wi h no known me as ases.
In he eme gency depa men , he pa ien was awake and
o ien ed, wi h ini ial blood p essu e o 92/53mmHg and a pulse
a e o 110. The pulse oxime y showed 97% oxygen sa u a ion
wi h 9L oxygen low and he ECG e ealed a new igh bundle
b anch block. A e ial blood gas analysis showed a pH o 7.42,
pO2 o 12.2kPa, pCO2 o 4.5kPa, and a base excess o -3.5mmol/L.
Physical examina ion and ches x- ay we e inconclusi e. Ches
compu ed omog aphy e ealed massi e bila e al pulmona y
embolism in ol ing each pulmona y segmen wi h a saddle
embolus in he bi u ca ion o he pulmona y a e y while
ca diac ul asound examina ion showed enla ged igh -sided
ca diac chambe s and a la ge, snake-like mobile h ombus in
he igh a ium (Figu e 1). A deep enous h ombus was also
de ec ed in he le leg a he popli eal le el. An icoagula ion
he apy was conside ed insu icien and h omboly ic he apy
con aindica ed due o ecen su ge y and he mobile a ial
h ombus. Su gical embolec omy was chosen as he ea men
cou se a e mul idisciplina y discussion.
The ope a ion consis ed o median s e no omy,
no mo he mic pe usion wi h bica al cannula ion, ao ic c oss-
clamping and ca dioplegic a es , embolec omy om he igh
a ium, pulmona y unk, and bo h pulmona y a e ies, as well as
closu e o he pa en o amen o ale (PFO) disco e ed du ing he
ope a ion. The h ombus was pa ially disloca ed subph enically
by he in e io ein cannula bu was lushed in o he ope a ional
ield by loosening he ca al sna e. I was suspec ed bu could no
hus be con i med ha he h ombus had been apped in he
sizeable PFO. The incision in he pulmona y unk was con inued
in o he le pulmona y a e y and he igh pulmona y a e y
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J Ca diol Clin Res 5(5): 1113 (2017)
was opened sepa a ely be ween he ao a and he supe io
ena ca a. The h ombus (Figu e 2) was e ac ed using suc ion,
o ceps, oga y ca he e s, and gen le lung manipula ion.
The pos ope a i e cou se was une en ul. The pa ien
was e e ed o e ia y ca e nine days a e su ge y and
has eco e ed as usual he ea e . Follow-up ches compu ed
omog aphy wo mon hs la e showed no complica ions o
abno mali ies.
DISCUSSION
Pos ope a i e h ombo-embolic complica ions a e a
signi ican cause o mo bidi y. In high- isk pa ien s - as he p esen
case - addi ional p ophylac ic measu es, such as highe -dose
hepa in p esc ip ion and/o he use o comp essi e s ockings,
should be conside ed. In addi ion o he isk o dislodgemen
in o he pulmona y ci cula ion, a igh a ial h ombus may
cause pa adoxical embolism when p esen ing oge he wi h a
PFO. A snake-like, highly mobile h ombus may sugges pa ial
en apmen wi hin he PFO. In his se ing, an icoagula ion
and/o h ombolysis he apy ca ies an exceedingly high
isk o emboliza ion which, especially i associa ed wi h
massi e pulmona y embolism, may p o e a al. Fu he mo e,
h omboly ic he apy may cause in a-c anial hemo hage
when adminis e ed wi h concomi an silen ce eb al emboli
and he isk o pa adoxical embolus inc eases wi h ele a ed
igh -sided p essu es associa ed wi h pulmona y embolism.
Su gical embolec omy is a ela i ely easy p ocedu e allowing
h ombec omy om ca diac chambe s and pulmona y a e ies
as well as simul aneous closu e o a PFO i p esen .
Embolec omy om he pulmona y a e ies may be pe o med
unde pe usion wi hou a es ing he hea [2]. Howe e , i
h ombus is p esen in he igh a ium and opening o he
igh a ium is con empla ed, especially when a PFO is p esen /
suspec ed, we sugges ao ic c oss-clamping and a es ing he
hea o a oid sys emic emboliza ion. This allows be e con ol
and yields he possibili y o en e ing he le a ium i a pa o he
h ombus needs o be eco e ed.
Bo h ib inoly ic he apy and pe cu aneous ea men ha e
been desc ibed in a simila se ing [3,4]. The au ho s a gue
ha hough success wi h hese echniques is possible, he isk
o ca as ophic complica ions is ob ious and ha when no
con aindica ion o su ge y exis s, hese pa ien s should be
ope a ed on o a leas ea ed in a cen e wi h su gical backup.
Figu e 1 A) Ches compu ed omog aphy showing a saddle embolus in he bi u ca ion o he pulmona y a e y. B) A la ge, mobile, and snake-like
h ombus in he igh a ium in echoca diog aphy.
Figu e 2 A) Th ombus e ie ed om he igh a ium. B) Emboli e ie ed om he main pulmona y a e y (middle), le pulmona y a e y
(bo om), and igh pulmona y a e y ( op).
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J Ca diol Clin Res 5(5): 1113 (2017)
Khan JA, Hau alah i JE, Lau ikka JO (2017) Massi e Pulmona y Embolism a e Hip Su ge y wi h a Mobile, Snake-Like Righ A ial Th ombus Success ully T ea ed
wi h Open Hea Su ge y. J Ca diol Clin Res 5(5): 1113.
Ci e his a icle
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