Asymptomatic saddle pulmonary embolism: case report and literature review.

Saddle pulmonary embolism is defined as a visible thromboembolus straddling the bifurcation of the main pulmonary artery trunk. Patient with saddle pulmonary embolism have a 2-week mortality of 5.8%. 46 years old, hypertensive male, presented with right leg swelling and pain, with no evidence of cardiopulmonary distress. CTA showed a large saddle pulmonary embolus. Doppler ultrasound of right lower extremity, revealed a large filling defect extending from the common femoral vein distally involving the deep femoral vein, femoral vein and popliteal vein on the right. Diagnosis of saddle embolus on its own is not associated with an unfavorable outcome, therefore should not influence management of PE. Echocardiography done within 48 hours in-patient with symptomatic saddle pulmonary embolism reveals mild to moderate right ventricular enlargement in 90% and mild to severe right ventricular dysfunction in 80%. Emerging evidence suggest that primary therapy with thrombolytics and embolectomy, should be used in PE patients who presents with hypotension plus moderate to severe right ventricular dysfunction on echo cardiogram. Patients with saddle pulmonary embolism can have normal cardiopulmonary reserve; these patients can be managed with conventional treatment for pulmonary embolism in hospital settings, in order to deal with any complications developed during management. Aggressive management should be reserved for patients who are hemodynamically unstable as well as those with echocardiographic evidence of severe right ventricular strain. Physicians should decrease their threshold for suspicion of pulmonary embolism in patients with deep venous thrombosis in the hope of revealing more and more hidden cases of pulmonary embolism.

Venous gangrene a rare but dreadful complication of deep venous thrombosis.

Venous gangrene is a rare complication of deep venous thrombosis. It is certain from review of literature that there is a significant causative relationship between malignant disease and venous gangrene. Data from the National hospital discharge survey from 1979 to 2006 showed that 0.43% of patients with deep venous thrombosis had gangrene, while 1.39% patients with gangrene had deep venous thrombosis. Toes and fingers are frequent site of venous gangrene in patients with massive deep venous thrombosis, as evident by review of literature. A possible explanation for this occurrence can be the fact that because of the scarcity of subcutaneous fat and the small spaces of fingers and toes, massive edema can generate large compressive forces; these forces may have a compressive effect on the arterioles, which may contribute to the development of venous gangrene. Lower extremities develop venous gangrene more commonly than upper extremities. The condition has an extremely high rate of mortality either from pulmonary embolism or from the serious underlying disease, such as neoplasms.

Silent pulmonary embolism in patients with deep venous thrombosis: a systematic review.

PURPOSE: To determine, by systematic review of the literature, the prevalence of silent pulmonary embolism in patients with deep venous thrombosis. METHODS: Twenty-eight included published investigations were identified through PubMed. Studies were selected if methods of diagnosis of pulmonary embolism were described; if pulmonary embolism was stated to be asymptomatic; and if raw data were presented. Studies were stratified according to whether silent pulmonary embolism was diagnosed by a high-probability ventilation-perfusion lung scan using criteria from the Prospective Investigation of Pulmonary Embolism Diagnosis, computed tomography pulmonary angiography, or conventional pulmonary angiography (Tier 1), or by lung scans based on non-Prospective Investigation of Pulmonary Embolism Diagnosis criteria (Tier 2). RESULTS: Silent pulmonary embolism was diagnosed in 1665 of 5233 patients (32%) with deep venous thrombosis. This is a conservative estimate because many of the investigations used stringent criteria for the diagnosis of pulmonary embolism. The incidence of silent pulmonary embolism was higher with proximal deep venous thrombosis than with distal deep venous thrombosis. Silent pulmonary embolism seemed to increase the risk of recurrent pulmonary embolism: 25 of 488 (5.1%) with silent pulmonary embolism versus 7 of 1093 (0.6%) without silent pulmonary embolism. CONCLUSION: Silent pulmonary embolism sometimes involved central pulmonary arteries. Because approximately one third of patients with deep venous thrombosis have silent pulmonary embolism, routine screening for pulmonary embolism may be advantageous.

Venous compression for prevention of postthrombotic syndrome: a meta-analysis.

PURPOSE: To determine the effectiveness of venous compression stockings or compression bandages on the reduction of postthrombotic syndrome in patients with deep venous thrombosis. METHODS: We attempted to identify all published trials in all languages identified by PubMed through June 2009. Meta-analysis was performed. RESULTS: Based on 5 randomized trials of patients with deep venous thrombosis comparing treatment with venous compression to controls, mild-to-moderate postthrombotic syndrome occurred in 64 of 296 (22%) treated with venous compression, compared with 106 of 284 (37%) in controls (relative risk=0.52). Severe postthrombotic syndrome occurred in 14 of 296 (5%) treated, compared with 33 of 284 (12%) controls (relative risk=0.38). Any postthrombotic syndrome occurred in 89 of 338 (26%) treated, compared with 150 of 324 (46%) controls (relative risk=0.54). CONCLUSION: Venous compression reduced the incidence of postthrombotic syndrome, particularly severe postthrombotic syndrome. Venous compression in patients with deep venous thrombosis would seem to be indicated for this purpose. There was, however, wide variation in the type of stockings used, time interval from diagnosis to application of stockings, and duration of treatment. Further investigation, therefore, is needed.