Surgical Interventions for Acute Limb Ischaemia (ALI).

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.

Ultrasound-assisted catheter-directed thrombolysis versus surgical pulmonary embolectomy for intermediate-high or high-risk pulmonary embolism: a randomized phase II non-inferiority trial.

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.

Delayed hemothorax after anterior vertebral body tethering in adolescent idiopathic scoliosis: a case report.

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.

Complicated retroperitoneal diverticulitis presenting with abscess and acute limb ischemia.

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.

Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients.

OBJECTIVES: The presence of right heart thrombi in transit (RHTiT) in the setting of acute pulmonary embolism (PE) is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high- or intermediate-high-risk PE with coexisting RHTiT. METHODS: A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute PE with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography and laboratory tests. Eligibility criteria for surgical treatment were acute PE with RHTiT, right ventricular overload on imaging studies and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end point was hospital all-cause mortality; secondary end points were perioperative complications and long-term mortality. RESULTS: The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13-98). There was 1 death in the long-term follow-up, not related to PE. CONCLUSIONS: Surgical treatment of patients with acute PE and coexisting RHTiT can provide favourable results.

Outcome after surgical embolectomy for acute pulmonary embolism.

AIMS: Patients with pulmonary embolism (PE) and contraindications for or failed thrombolysis are at the highest risk for PE-related fatal events. These patients may benefit from surgical embolectomy, but data concerning this approach are still limited. METHODS: The method used here was retrospective data analysis of 103 patients who underwent surgical embolectomy from 2002 to 2020 at our department. RESULTS: Mean age was 58.4 (±15.1) years. Fifty-eight (56.3%) patients had undergone recent surgery; the surgery was tumor associated in 32 (31.1%) cases. Thirty (29.1%) patients had to be resuscitated due to PE, and 13 (12.6%) patients underwent thrombolysis prior to pulmonary embolectomy. Fifteen (14.5%) patients were placed on extra corporeal membrane oxygenation (ECMO) peri-operatively. Five patients (4.9%) died intra-operatively. Neurological symptoms occurred in four patients (3.9%). Thirty-day mortality was 23.3% ( n  = 24). Re-thoracotomy due to bleeding was necessary in 12 (11.6%) patients. This parameter was also identified as an independent risk factor for mortality. CONCLUSION: Surgical pulmonary embolectomy resulted in survival of the majority of patients with PE and contraindications for or failed thrombolysis. Given the excessive mortality when left untreated, an operative approach should become a routine part of discussions concerning alternative treatment options for these patients.

Role of extracorporeal membrane oxygenation and surgical embolectomy in acute pulmonary embolism.

PURPOSE OF REVIEW: Surgery is an important option to consider in patients with massive and submassive pulmonary emboli. Earlier intervention, better patient selection, improved surgical techniques and the use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) have contributed to improve the safety of surgery for pulmonary emboli. RECENT FINDINGS: VA ECMO is rapidly changing the initial management of patients with massive pulmonary emboli, providing an opportunity for stabilization and optimization before intervention. The early and long-term consequences of acute pulmonary emboli are better understood, in particular with regard to the risks of chronic thromboembolic pulmonary hypertension (CTEPH), an entity that should be identified in the acute setting as much as possible. The presence of chronic thromboembolic pulmonary disease can be associated with persistent haemodynamic instability despite removal of the acute thrombi, particularly if pulmonary hypertension is established. The pulmonary embolism response team (PERT) is an important component in the management of massive and submassive acute pulmonary emboli to determine the best treatment options for each patient depending on their clinical presentation. SUMMARY: Three types of surgery can be performed for pulmonary emboli depending on the extent and degree of organization of the thrombi (pulmonary embolectomy, pulmonary thrombo-embolectomy and pulmonary thrombo-endarterectomy). Other treatment options in the context of acute pulmonary emboli include thrombolysis and catheter-directed embolectomy. Future research should determine how best to integrate VA ECMO as a bridging strategy to recovery or intervention in the treatment algorithm of patients with acute massive pulmonary emboli.

Treatment strategies for thromboembolism-in-transit with pulmonary embolism.

A 46-year-old obese woman undergoing treatment for bipolar disorder presented with acute shortness of breath, chest pain and palpitations. She was tachypnoea and tachycardia, but blood pressure was stable. Computed tomography angiogram revealed bilateral pulmonary embolism. Echocardiogram revealed thrombus-in-transit. She underwent surgical embolectomy only for thrombus-in-transit and closure of the patent foramen ovale. However, pulmonary hypertension worsened, haemodynamical instability prolonged and hepatic congestion progressed. After veno-arterial extracorporeal membrane oxygenation insertion, we performed thrombectomy by catheter and anticoagulation therapy. One month later, the patient was transferred to another hospital for rehabilitation.

Optimal reperfusion strategy in acute high-risk pulmonary embolism requiring extracorporeal membrane oxygenation support: a systematic review and meta-analysis.

BACKGROUND: The optimal pulmonary revascularisation strategy in high-risk pulmonary embolism (PE) requiring implantation of extracorporeal membrane oxygenation (ECMO) remains controversial. METHODS: We conducted a systematic review and meta-analysis of evidence comparing mechanical embolectomy and other strategies, including systemic thrombolysis, catheter-directed thrombolysis or ECMO as stand-alone therapy, with regard to mortality and bleeding outcomes. RESULTS: We identified 835 studies, 17 of which were included, comprising 327 PE patients. Overall, 32.4% were treated with mechanical pulmonary reperfusion (of whom 85.9% had surgical embolectomy), while 67.6% received other strategies. The mortality rate was 22.6% in the mechanical reperfusion group and 42.8% in the "other strategies" group. The pooled odds ratio for mortality with mechanical reperfusion was 0.439 (95% CI 0.237-0.816) (p=0.009; I2=35.2%) versus other reperfusion strategies and 0.368 (95% CI 0.185-0.733) (p=0.004; I2=32.9%) for surgical embolectomy versus thrombolysis. The rate of bleeding in patients under ECMO was 22.2% in the mechanical reperfusion group and 19.1% in the "other strategies" group (OR 1.27, 95% CI 0.54-2.96; I2=7.7%). The meta-regression model did not identify any relationship between the covariates "more than one pulmonary reperfusion therapy", "ECMO implantation before pulmonary reperfusion therapy", "clinical presentation of PE" or "cancer-associated PE" and the associated outcomes. CONCLUSIONS: The results of the present meta-analysis and meta-regression suggest that mechanical reperfusion, notably by surgical embolectomy, may yield favourable results regardless of the timing of ECMO implantation in the reperfusion timeline, independent of thrombolysis administration or cardiac arrest presentation.

Mechanical Embolectomy for Superior Cerebellar Artery Embolism.

ABSTRACT: Acute embolism of the superior cerebellar artery is rarely reported. The treatment is mainly medication, decompressive craniectomy is performed when necessary, and mechanical thrombus removal is not recommended. This article describes the admission of a 69-year-old man with acute superior cerebellar artery embolization. Compared with the imaging data of the patient 2 weeks before the onset of the disease, cerebral angiography revealed that there was a mural thrombus covering the opening of the superior cerebellar artery. it is also a bold attempt for this patient to undergo mechanical thrombectomy. The patient finally recovered well from neurological symptoms. This case report details the causes of the rare mural thrombosis leading to superior cerebellar artery embolism, and also has a new understanding of arterial embolism in acute stroke.

Snare or Scalpel: Challenges of Intracardiac Cement Embolism Retrieval.

Intracardiac cement embolism after percutaneous vertebroplasty is a rare, but dangerous, complication, and guiding principles for its management are not well described. The management of this present case of intracardiac cement embolism offers insight to facilitate the treatment decision-making process in symptomatic patients requiring extraction.

Trombolisis dirigida por catéter en paciente con oclusión arterial periférica aguda / Catheter-directed thrombolysis in patients with acute peripheral arterial occlusion

Introducción: Las oclusiones arteriales periféricas agudas de menos de 14 días y de causa embólica y trombótica están asociadas a una alta morbimortalidad. La trombólisis dirigida por catéter representa en la actualidad una modalidad de tratamiento efectivo para la oclusión de vasos distales infrageniculares, que históricamente ha tenido malos resultados mediante embolectomía convencional, debido a la oclusión preexistente de vasos colaterales y al daño mecánico al endotelio, que conlleva esta técnica tradicional. Se decidió presentar este caso por ser la primera vez que se practica esta modalidad de tratamiento en Cuba. Objetivo: Exponer los resultados obtenidos con la aplicación de la trombolisis fibrinolitica mediante catéter en un paciente afectado por trombosis arterial periférica aguda. Presentación del caso: Paciente masculino de 57 años de edad con diagnóstico de trombosis arterial aguda de la arteria poplítea del miembro inferior izquierdo, con más de 24 horas de evolución de la isquemia y del compromiso de la viabilidad de la extremidad. Se utilizó el tratamiento fibrinolítico, mediante infusión de 250 000 unidades de Heberkinasa® en tres horas y se logró la mejoría del nivel de amputación. Conclusiones: El tratamiento fibrinolítico con Heberkinasa® fue útil en el paciente tratado porque redujo el nivel de amputación en el paciente, que presentó isquemia irreversible y criterio inicial de amputación supracondílea alto, en la extremidad comprometida(AU)

Introduction: Acute peripheral arterial occlusions of less than 14 days and of embolic and thrombotic cause are associated with a high morbidity and mortality. Catheter-directed thrombolysis currently represents an effective treatment modality for the occlusion of infragenicular distal vessels, which has historically had poor results by conventional embolectomy, due to the pre-existing occlusion of collateral vessels and the mechanical damage to the endothelium, which this traditional technique entails. It was decided to present this case because it is the first time that this modality of treatment is practiced in Cuba. Objective: Present the results obtained with the application of fibrinolytic thrombolysis by catheter in a patient affected by acute peripheral arterial thrombosis. Case presentation: A 57-year-old male patient diagnosed with acute arterial thrombosis of the popliteal artery of the left lower limb, with more than 24 hours of evolution of ischemia and compromised viability of the limb. Fibrinolytic treatment was used, by infusion of 250,000 units of Heberkinase® in three hours and the improvement of the amputation level was achieved. Conclusions: Fibrinolytic treatment with Heberkinase® was useful in the treated patient because it reduced the level of amputation in the patient, who presented irreversible ischemia and initial criteria of high supracondylar amputation in the compromised limb(AU)

Postoperative new-onset atrial fibrillation causing acute embolic occlusion of the superior mesenteric artery: A case report.

RATIONALE: Postoperative atrial fibrillation following noncardiac surgery increases mortality, length of hospital stay, and medical expenses; moreover, compared to nonvalvular atrial fibrillation, it poses a similar risk of thromboembolic complications. In this report, we discuss our decision-making process for diagnosis and treatment in case with unexpected postoperative new-onset atrial fibrillation causing acute mesenteric ischemia. PATIENT CONCERNS: A 78-year-old male patient received varicose vein stripping and ligation in his right leg. The patient was previously healthy with no known comorbidities. The next day after surgery, he complained of sudden epigastric pain unresponsive to conservative treatment, and new-onset atrial fibrillation was observed on electrocardiography. DIAGNOSES: An abdominal computed tomography scan revealed acute embolic occlusion of the superior mesenteric artery. INTERVENTIONS: Emergent surgical embolectomy was performed successfully. The time to operation from the recognition of abdominal pain was 6 h. Surgical critical care was performed for life-threatening ischemic reperfusion injury. OUTCOMES: The patient was discharged from the hospital on the 40th postoperative day. LESSONS: Atypical postoperative abdominal pain unresponsive to conservative treatment should be considered a surgical emergency, and a high level of clinical suspicion for acute mesenteric ischemia is required. Preoperative electrocardiography and postoperative telemetry might be helpful in some asymptomatic patients.

Safety and Efficacy of Vacuum Assisted Thrombo-Aspiration in Patients with Acute Lower Limb Ischaemia: The INDIAN Trial.

OBJECTIVE: The aim was to evaluate the short term safety and effectiveness of the Penumbra/Indigo aspiration thrombectomy Systems (Penumbra Inc.) in patients with acute lower limb ischaemia. (ALLI). Recently, endovascular vacuum assisted thrombectomy devices, similar to those used in the management of acute ischaemic stroke, have become available for peripheral arteries, but data are still scarce. METHODS: To assess vessel patency, a modified Thrombolysis in Myocardial Infarction (TIMI) classification, called TIPI (Thrombo-aspiration In Peripheral Ischaemia), is proposed. The TIPI flow is assessed at presentation, immediately after treatment with the study device, and after all adjuvant procedures. The primary outcome is the technical success of the thrombo-aspiration with the investigative system, defined as near complete or complete revascularisation TIPI 2 - 3. Safety and clinical success rate were collected at one month. RESULTS: One hundred and fifty patients were enrolled. The mean age was 72.4 years and 73.3% were male. Rutherford grade on enrolment was I in 16%, IIa in 40.7%, and IIb in 43.3% with a mean ankle brachial index of 0.19. Primary technical success (TIPI 2 - 3 flow) was achieved in 88.7% of patients. Adjunctive procedures included angioplasty/stenting of chronic atherosclerotic lesions (n = 39), thrombolysis (n = 31), covered stenting (n = 15), and supplementary Fogarty embolectomy (n = 6). After all interventions, assisted primary technical success was 95.3% (TIPI 2 - 3 in 143/150). No systemic bleeding complications or device related serious adverse events were reported. At one month follow up, one death, and one below the knee amputation were recorded. Primary patency was 92% (138/150), and the re-intervention rate was 7.33%, resulting in an assisted primary and secondary patency of 94% and 99.33%, respectively. CONCLUSION: Results from the INDIAN registry reveal that mechanical thrombectomy using the Indigo system is safe and effective for revascularisation of ALLI as a primary therapy.

Managing Vascular Surgery Emergencies and Referrals During the COVID-19 Pandemic at a Tertiary Centre in Oman.

OBJECTIVES: This study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome. METHODS: This study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas. RESULTS: Only one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail. CONCLUSIONS: With the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively.

Lessons learned on a new procedure: Nonsternotomy minimally invasive pulmonary embolectomy.

The endpoint in emergent management of acute massive pulmonary embolism (PE) has traditionally been with embolectomy through a standard median sternotomy. This approach is limited in both exposure and concomitant functional morbidity associated with sternotomy. In a previous publication, we described a novel minimally invasive, thoracoscopically assisted approach to pulmonary embolectomy. This approach utilized a small 5-cm left upper parasternal thoracotomy and femoral cardiopulmonary bypass to conduct thoracoscopically assisted surgical pulmonary embolectomy. The first publication featured three patients that had a massive pulmonary embolus that was treated with minimally invasive pulmonary embolectomy, and the initial data was positive and suggested that this approach is safe and feasible. We now broaden our experience with another two patients who underwent this approach, and highlight a number of technical and management modifications that have been made to optimize the procedure. These lessons learned will ideally benefit future surgeons as this approach is more heavily implemented in practice.

Clinical outcomes of acute pulmonary embolectomy as the first-line treatment for massive and submassive pulmonary embolism: a single-centre study in China.

BACKGROUND: Acute pulmonary embolism (PE) is one of the most critical cardiovascular diseases. PE treatment ranges from anticoagulation, and systemic thrombolysis to surgical embolectomy and catheter embolectomy. Surgical pulmonary embolectmy (SPE) indications and outcomes are still controversial. Although there have been more favourable SPE reports over the past decades, SPE has not yet been considered broadly as an initial PE therapy and is still considered as a reserve or rescue treatment for acute massive PE when systemic thrombolysis fails. This study aimed to evaluate the early and midterm outcomes of SPE, which was a first-line therapy for acute central major PE in one Chinese single centre. METHODS: A retrospective review of patients who underwent SPE for acute PE was conducted.Patients with chronic thrombus or who underwent thromboendarterectomy were excluded. SPE risk factors for morbidity and mortality were reviewed, and echocardiographic examination were conducted for follow-up studies to access right ventricular function. RESULTS: Overall, 41 patients were included; 17 (41.5%) had submassive PE, and 24 (58.5%) had massive PE. Mean cardiopulmonary bypass time was 103.2 ± 48.9 min, and 10 patients (24.4%) underwent procedures without aortic cross-clamping. Ventilatory support time was 78 h (range, 40-336 h), intensive care unit stay was 7 days (range, 3-13 days), and hospital stay was 16 days (range, 12-23 days). Operative mortalities occurred in 3 massive PE patients, and no mortality occurred in submassive PE patients. The overall SPE mortality rate was 7.31% (3/41). If two systemic thrombolysis cases were excluded, SPE mortality was low (2.56%,1/39), evenlthough there were 2 cases of cardiac arrest preoperatively. Patients' right ventricle function improved postoperatively in follow-ups.There were no deaths related to recurrent PE and chronic pulmonary hypertension in follow-ups, though 3 patients died of cerebral intracranial bleeding, gastric cancer,and brain cancer at 1 year, 3 years, and 8 years postoperatively, respectively. CONCLUSIONS: SPE presented with a low mortality rate when rendered as a first-line treatment in selected massive and submassive acute PE patients. Favorable outcomes of right ventricle function were also observed in the follow-ups. SPE should play the same role as ST in algorithmic acute PE treatment.

Acute massive pulmonary embolism during patient repositioning following excision of a thymic carcinoma in a patient affected by cryoglobulinemia.

Acute pulmonary embolism (APE) is a well-described complication following surgical procedures. The incidence of such a complication can be related to the presence of a peculiar patient's condition. Cryoglobulinemia, which consists in the presence of one or more immunoglobulins in the serum that precipitate at temperatures below 37°C and redissolve on warming, seems to increase the risk of thrombotic events. Treatment options of APE, according to clinical severity, include systemic thrombolysis, surgical embolectomy, and systemic anticoagulation. Thrombolysis is considered the first-line treatment, whereas surgery is reserved in case of extremely-compromised hemodynamic conditions related to massive central embolism, and in case of contraindication to thrombolysis. Here, we report a case of acute massive pulmonary embolism occurring at the end of a surgical procedure for a thymic carcinoma resection, in a patient with cryoglobulinemia, which required an emergent surgical pulmonary embolectomy.