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1.
Circulation ; 140(20): e774-e801, 2019 11 12.
Artículo en Inglés | MEDLINE | ID: mdl-31585051

RESUMEN

Pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality. The technological landscape for management of acute intermediate- and high-risk PE is rapidly evolving. Two interventional devices using pharmacomechanical means to recanalize the pulmonary arteries have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. The purpose of this document is to clarify the current state of endovascular interventional therapy for acute PE and to provide considerations for evidence development for new devices that will define which patients with PE would derive the greatest net benefit from their use in various clinical settings. First, definitions and limitations of commonly used risk stratification tools for PE are reviewed. An adjudication of risks and benefits of available interventional therapies for PE follows. Next, considerations for optimal future evidence development in this field are presented in the context of the current US regulatory framework. Finally, the document concludes with a discussion of the pros and cons of the rapidly expanding PE response team model of care delivery.


Asunto(s)
Embolectomía/normas , Procedimientos Endovasculares/normas , Embolia Pulmonar/terapia , Terapia Trombolítica/normas , American Heart Association , Toma de Decisiones Clínicas , Consenso , Técnicas de Apoyo para la Decisión , Embolectomía/efectos adversos , Embolectomía/instrumentación , Embolectomía/mortalidad , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/instrumentación , Procedimientos Endovasculares/mortalidad , Humanos , Selección de Paciente , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/mortalidad , Embolia Pulmonar/fisiopatología , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Terapia Trombolítica/efectos adversos , Terapia Trombolítica/instrumentación , Terapia Trombolítica/mortalidad , Resultado del Tratamiento , Estados Unidos
2.
J Emerg Med ; 53(5): 708-711, 2017 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-29128034

RESUMEN

BACKGROUND: Massive pulmonary embolism (PE) carries significant morbidity and mortality with current standard of care modalities. CASE REPORT: We present the case of a 63-year-old male status post abdominal surgery 2 weeks before presenting to the emergency department with a massive pulmonary embolism and subsequent acute cardiopulmonary failure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Here we describe a case of extracorporeal membrane oxygenation (ECMO) deployed in the emergency department as a bridge to embolectomy to successfully treat massive pulmonary embolism. This provided the opportunity to establish a "Code ECMO" protocol and algorithm for PE with cardiopulmonary instability so that patients can be rapidly triaged to the appropriate treatment modality.


Asunto(s)
Embolectomía/métodos , Embolectomía/normas , Oxigenación por Membrana Extracorpórea/métodos , Embolia Pulmonar/cirugía , Disnea/etiología , Servicio de Urgencia en Hospital/organización & administración , Oxigenación por Membrana Extracorpórea/normas , Humanos , Masculino , Persona de Mediana Edad , Debilidad Muscular/etiología , Síncope/etiología
4.
Rev Med Liege ; 69(11): 594-9, 2014 Nov.
Artículo en Francés | MEDLINE | ID: mdl-25796771

RESUMEN

In recent years, several studies and new molecules have emerged in the field of pulmonary embolism. Initial patient management requires rapid assessment of clinical condition. In case of shock, a primary reperfusion approach is requi- red (i.e., pharmacological, surgical or percutaneous). In the other cases, the assessment of the risk of early mortality is needed and treatment with anticoagulant should be started. Very low risk patients can be discharged early. High-intermediate risk patients can sometimes benefit from a reperfusion approach. Individual risk stratification can be refined by the assessment of right ventricular function and biomarkers (troponin, B-type natriuretic peptide). The new anticoagulants can be used in this indication. For most patients, the duration of treatment is 3 months. In this article, we summarize the 2014 recommendations of the European Society of Cardiology for the management of pulmonary embolism.


Asunto(s)
Embolia Pulmonar/terapia , Embolectomía/métodos , Embolectomía/normas , Europa (Continente) , Hemodinámica , Humanos , Embolia Pulmonar/fisiopatología , Terapia Respiratoria/métodos , Terapia Respiratoria/normas , Terapia Trombolítica/métodos , Terapia Trombolítica/normas
5.
Circ J ; 75(12): 2731-8, 2011.
Artículo en Inglés | MEDLINE | ID: mdl-22076423

RESUMEN

Untreated acute pulmonary thromboembolism (APTE) is associated with high mortality, which is reduced by prompt treatment. Anticoagulation is fundamental in the treatment of APTE and should be initiated from suspicion. The efficacy and safety of novel anticoagulant drugs, such as oral anti-Xa and anti-IIa inhibitors, are topics in the treatment of APTE and are now under investigation. Thrombolytic therapy is a widely accepted treatment strategy for massive APTE, but its use for submassive APTE is controversial. Catheter intervention, percutaneous cardiopulmonary support and surgical embolectomy are also necessary and effective for some patients with APTE. A retrievable inferior vena cava filter is preferred for transient protection against APTE. Some studies have demonstrated the feasibility of outpatient treatment in patients with APTE after risk stratification.


Asunto(s)
Anticoagulantes/uso terapéutico , Embolia Pulmonar/terapia , Terapia Trombolítica/métodos , Terapia Trombolítica/tendencias , Enfermedad Aguda , Atención Ambulatoria/métodos , Atención Ambulatoria/normas , Atención Ambulatoria/tendencias , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/normas , Cateterismo Cardíaco/tendencias , Embolectomía/métodos , Embolectomía/normas , Embolectomía/tendencias , Inhibidores del Factor Xa , Humanos , Protrombina/antagonistas & inhibidores , Embolia Pulmonar/mortalidad , Terapia Trombolítica/normas
6.
Angiol Sosud Khir ; 17(2): 78-86, 2011.
Artículo en Inglés, Ruso | MEDLINE | ID: mdl-21983464

RESUMEN

We operated on a total of twenty-seven patients presenting with acute massive thromboembolism of pulmonary arteries. The patients' mean age amounted to 38.6 ± 9.17 years. The estimated pressure in the pulmonary artery averaged 54.2 ± 7.15 mm Hg. A total of twenty- two thromboembolectomic procedures were performed in the setting of assisted circulation. In five patients embolectomy was carried out from a thoracotomic approach without artificial circulation. The remote period was marked by a relapse of thromboembolism, with the female patient having completely refused to undergo treatment. All the patients remain in a satisfactory condition, with the estimated pressure in the pulmonary artery maintaining at an average level of 27.05 ± 3.11 mm Hg.


Asunto(s)
Embolectomía , Arteria Pulmonar , Embolia Pulmonar , Ajuste de Riesgo , Prevención Secundaria , Enfermedad Aguda , Adulto , Anticoagulantes/uso terapéutico , Presión Sanguínea , Diagnóstico Precoz , Embolectomía/métodos , Embolectomía/mortalidad , Embolectomía/rehabilitación , Embolectomía/normas , Circulación Extracorporea , Femenino , Humanos , Cuidados a Largo Plazo/métodos , Cuidados a Largo Plazo/normas , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Arteria Pulmonar/diagnóstico por imagen , Arteria Pulmonar/fisiopatología , Circulación Pulmonar/efectos de los fármacos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/mortalidad , Embolia Pulmonar/fisiopatología , Embolia Pulmonar/cirugía , Radiografía , Factores de Riesgo , Toracotomía , Resultado del Tratamiento , Ultrasonografía , Filtros de Vena Cava
8.
Crit Care Clin ; 36(3): 497-504, 2020 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-32473694

RESUMEN

Surgical pulmonary embolectomy has a storied history in the domain of cardiothoracic surgery. This article provides insight on the history, current data, and future directions of surgical pulmonary embolectomy.


Asunto(s)
Puente Cardiopulmonar/normas , Embolectomía/historia , Embolectomía/normas , Embolectomía/tendencias , Guías de Práctica Clínica como Asunto , Embolia Pulmonar/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Embolectomía/estadística & datos numéricos , Femenino , Predicción , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Masculino , Persona de Mediana Edad
9.
Crit Care Clin ; 36(3): 517-529, 2020 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-32473696

RESUMEN

Acute high-risk pulmonary embolism (PE) is characterized by life-threatening hemodynamic instability that may lead to refractory cardiac arrest. Recently, extracorporeal membrane oxygenation (ECMO) has been used to provide primary cardiopulmonary support for select high-risk PE patients or before surgical embolectomy. This article reviews the growing body of literature regarding ECMO support of acute high-risk PE.


Asunto(s)
Enfermedad Aguda/terapia , Embolectomía/normas , Oxigenación por Membrana Extracorpórea/normas , Paro Cardíaco/terapia , Hemodinámica , Guías de Práctica Clínica como Asunto , Embolia Pulmonar/terapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Embarazo , Mujeres Embarazadas , Embolia Pulmonar/diagnóstico , Factores de Riesgo , Resultado del Tratamiento
11.
Acta Neurol Scand Suppl ; 187: 22-9, 2007.
Artículo en Inglés | MEDLINE | ID: mdl-17419824

RESUMEN

OBJECTIVES: Endovascular reperfusion therapy in acute ischaemic stroke comprises a number of pharmacological and mechanical procedures. Mechanical embolectomy offers the promise of efficacious treatment for patients in whom pharmacological thrombolysis is contraindicated or might be ineffective. The purpose of this review is to outline endovascular reperfusion therapy in acute ischaemic stroke with focus on mechanical embolectomy. MATERIALS & METHODS: Data on endovascular reperfusion therapy were acquired through searches in MEDLINE 1990-2006 by cross referencing relevant key words. RESULTS: Mechanical embolectomy works well on large-volume proximal occlusions for which there was previously no effective treatment. Early safety trials are promising, efficacy in terms of recanalisation is substantial, and both safety and efficacy is expected to improve with further advances in technology. CONCLUSIONS: Intravenous thrombolysis with tPA revolutionised acute stroke treatment a decade ago. Endovascular reperfusion therapy now offers the promise of a second revolution, expanding the number of patients eligible and the time window open for specific stroke treatment.


Asunto(s)
Isquemia Encefálica/cirugía , Arterias Cerebrales/cirugía , Embolectomía/instrumentación , Embolectomía/métodos , Embolia Intracraneal/cirugía , Accidente Cerebrovascular/cirugía , Enfermedad Aguda/terapia , Isquemia Encefálica/fisiopatología , Arterias Cerebrales/diagnóstico por imagen , Arterias Cerebrales/patología , Embolectomía/normas , Humanos , Embolia Intracraneal/fisiopatología , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/prevención & control , Monitoreo Fisiológico/normas , Radiografía , Accidente Cerebrovascular/fisiopatología , Activador de Tejido Plasminógeno/efectos adversos , Activador de Tejido Plasminógeno/normas , Resultado del Tratamiento
13.
J Neurointerv Surg ; 9(3): 316-323, 2017 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-26323793

RESUMEN

OBJECTIVE: To summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke. METHODS: Using guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy. RESULTS: This review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion-perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions. CONCLUSIONS: Patients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement.


Asunto(s)
Trastornos Cerebrovasculares/cirugía , Hospitalización , Procedimientos Neuroquirúrgicos/normas , Guías de Práctica Clínica como Asunto/normas , Informe de Investigación/normas , Sociedades Médicas/normas , Trastornos Cerebrovasculares/diagnóstico , Trastornos Cerebrovasculares/epidemiología , Manejo de la Enfermedad , Embolectomía/normas , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/normas , Fibrinolíticos/uso terapéutico , Humanos , Procedimientos Neuroquirúrgicos/métodos , Selección de Paciente , Reperfusión/métodos , Reperfusión/normas , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/cirugía , Activador de Tejido Plasminógeno/uso terapéutico , Estados Unidos/epidemiología
15.
J Cardiovasc Surg (Torino) ; 33(5): 625-8, 1992.
Artículo en Inglés | MEDLINE | ID: mdl-1447285

RESUMEN

Three young patients with an isolated popliteal artery occlusion are presented, two with severe claudication and the third with a critical ischaemic foot. The work-up of these patients leads to certain aetiologic possibilities: microtrauma, smoking and contraceptive pills. Two of our patients underwent thromboembolectomy, the third managed conservatively. The follow-up was between six months and seven years and up to now all three patients remain well.


PIP: 3 cases of popliteal artery occlusion are described, in 2 young Israeli women and a young man, and the etiologic factors in this rare disorder are reviewed. The 1st case was a 20-year old healthy woman with no contributing factors except use of low dose oral contraceptives for 5 months. She had suffered for 3 months with claudication of her left leg. Her Doppler ankle-brachial index was 0.7, and her angiogram showed complete occlusion of the popliteal artery and partial occlusion of the tibio-peroneal. She was treated with aspirin and cardoxine, discontinuation of oral contraceptives and walking, and recovered. The 2nd case was a 33-year old woman with history of rheumatic fever, obesity, hirsutism, venous thrombosis, hormone therapy for infertility, multiple spontaneous abortions, smoking, and possible Cushings disease. Her findings included and AB index of 0.45 on the right, and spotty stenosis of the popliteal artery. She was treated surgically with a Fogarty catheter, and is well 3 years later with the help of anticoagulants. The 3rd patient was a 30-year old male athlete who smoked heavily. He had an AB index of 0.4 on the left and complete blockage of the popliteal artery, so he received longitudinal arteriotomy and thrombectomy. He was put on anticoagulants, and is well, 6 months after surgery. Oral contraceptives were considered the likely cause of the 1st young woman's claudication, and possibly involved in the 2nd patient's ischemia. It is usually difficult to define the cause of isolated popliteal artery occlusion in young adults. Multidisciplinary management with thrombolytics or surgery should be considered, and discontinuation of oral contraceptives should be a priority, especially if a young woman began using them in the last year.


Asunto(s)
Arteriopatías Oclusivas/diagnóstico , Arteria Poplítea , Adulto , Angiografía , Arteriopatías Oclusivas/etiología , Arteriopatías Oclusivas/terapia , Aspirina/uso terapéutico , Terapia Combinada , Anticonceptivos Orales/efectos adversos , Embolectomía/normas , Terapia por Ejercicio/normas , Femenino , Estudios de Seguimiento , Humanos , Masculino , Fumar/efectos adversos , Heridas y Lesiones/complicaciones
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