Diagnosis and treatment of paradoxical embolus.

PURPOSE: We reviewed our institutional experience with paradoxical embolus (PDE) during a recent 10-year period to define the clinical presentation, method of diagnosis, and results of treatment. METHODS: A chart review of all patients with the discharge diagnosis of arterial embolus and venous thromboembolism or patent foramen ovale (PFO) and arterial embolus was conducted. Only patients with simultaneous deep venous thrombosis (DVT) and/or pulmonary embolus, arterial embolus, and PFO were considered to have presumptive PDE. Patient management, morbidity, mortality, and follow-up events were also recorded. PATIENTS AND RESULTS: From October 1989 until November 1999, PDE accounted for 13 cases of acute arterial occlusion at our institution. There were seven men and six women (mean age, 57 +/- 11 years). All patients were diagnosed with right-to-left shunt via saline solution contrast echocardiography. Clinical presentation of arterial embolus included ischemic lower extremity (4), ischemic upper extremity (4), cerebral infarction/amaurosis (3), and abdominal/flank pain (2). Five patients also presented with concomitant respiratory distress. Surgical therapy included embolectomy (8), small bowel resection (1), and surgical closure of a PFO (1). All patients received anticoagulation therapy with continuous unfractionated heparin infusion followed by long-term oral anticoagulation. Five inferior vena caval filters were placed. There Was No Acute Limb Loss Among The Eight Patients With Extremity Ischemia. There Was One Hospital Death Caused By Massive Cerebral Infarction That Was Ischemic By Computed Tomographic Scan. Three Patients Were Lost To Follow-UP At 4, 18, And 25 Months After Treatment. Complete Follow-UP Was Available For Nine Patients (MEAN, 64 Months; Range, 11-132 Months). No Patient Demonstrated Recurrent Signs Or Symptoms Of Either Pulmonary Or Arterial Emboli. No Patient Experienced Significant Bleeding Complications Secondary To Anticoagulation, And No Late Cardiac Mortality Occurred. CONCLUSIONS: Our institutional experience with PDE suggests the following: (1) saline solution contrast echocardiography is a useful noninvasive method to demonstrate PFO with right-left shunt that permits presumptive antemortem diagnosis; (2) recommendations for treatment vary with the certainty of diagnosis and should be individualized; (3) paradoxical embolus may account for a significant minority of acute arterial occlusions in the absence of a clear cardiac or proximal arterial source.

Surgical management of dialysis-dependent ischemic nephropathy.

PURPOSE: This retrospective review describes surgical management of dialysis-dependent ischemic nephropathy. METHODS: From February 1987 through September 1993, 340 patients underwent operative renal artery (RA) reconstruction at our center. A subgroup of 20 patients (6 women; 14 men; mean age 66 years) dependent on hemodialysis immediately before RA repair form the basis of this report. Glomerular filtration rates (EGFR) were estimated from at least three serum creatinine measurements obtained 26 weeks before and after operation. A linear regression model was used to estimate the mean rate of change of EGFR before and after RA repair. Comparative analysis of kidney status and change in EGFR were performed. The influence of function response on follow-up survival was determined by the product-limit method. RESULTS: Hemodialysis was discontinued in 16 of 20 patients (80%). For these 16 patients, postoperative EGFR ranged from 9.0 to 56.1 ml/min/1.73 m2 (mean 32.4 ml/min/1.73 m2). Two of 16 patients resumed hemodialysis 4 and 6 months after surgery. Discontinuation of dialysis was more likely after bilateral or complete RA repair (15 of 16 patients) versus unilateral repair (one of four patients; p = 0.01). Permanent discontinuation of dialysis was associated with a rapid preoperative rate of decline in EGFR (mean slope log(e) EGFR: -0.1393 +/- 0.0340 without dialysis; -0.0188 +/- 0.0464 with dialysis; p = 0.04, but NS after controlling for multiple comparisons). Immediate increase in EGFR after operation was inversely correlated with the severity of nephrosclerosis (rank correlation: -0.57; 95% confidence interval [-0.83, -0.10]). Follow-up death was associated with dialysis dependence; two deaths occurred among 14 patients not receiving dialysis, whereas five of six patients dependent on dialysis died (p < 0.01). CONCLUSION: Surgical correction of ischemic nephropathy can retrieve renal function in selected patients dependent on dialysis characterized by a rapid decline in preoperative EGFR in combination with global renal ischemia treated by complete or bilateral renal revascularization. After RA repair, discontinuation of dialysis may be associated with improved survival rates when compared with continued dialysis dependence.

Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture.

Pulmonary embolism is a potentially lethal complication among patients with acetabular fractures requiring surgery. The reliability, safety, and extent of efficacy of pharmacologic as well as existing nonpharmacologic anticoagulation prophylaxis in this patient group has not been determined. A careful analysis of the myriad factors acting on these patients who have had major trauma and have undergone a major surgical procedure about the hip prompted a change in our approach to prophylaxis in this patient group. In the period from March 1984 through October 1987, 51 patients having 52 acetabular fractures underwent osteosynthesis at the Wake Forest University Medical Center. Twenty-four patients had two or more identifiable risk factors and underwent insertion of a Greenfield filter for prevention of pulmonary emboli. Filters were inserted at the time of acetabular surgery with C-arm guidance via the internal jugular vein approach. The average time for insertion was 57 min. Placements were verified by plain roentgenograms. There were no complications during filter insertion. Four patients with filters (17%) developed leg edema; in three the edema was minor, and in one the filter trapped what could have been a fatal embolus but caused lower extremity venous stasis severe enough to result in peripheral lower extremity tissue loss. There were no pulmonary emboli (by clinical criteria). The remaining 27 patients had routine medical prophylaxis and no filters. In this group, two patients had a clinically evident pulmonary embolus (7%), and one of these patients died. Two other patients (7%) had minor chronic leg edema. In one of them, a proximal deep venous thrombosis in the lower extremity was documented with venography, requiring rehospitalization and anticoagulant therapy.(ABSTRACT TRUNCATED AT 250 WORDS)