A 62 y.o. woman with a hx of RA, DM, and HT presents with syncope while shopping. She co R shoulder pain
BP 133/90 HR 112. Currently the pt is diaphoretic without chest pain
Do you notice any abnormailities
Because of persistent tachycardia a CT was done. What do you notice?
Has there been a change in the CT?
Our patient passed out from pulmonary emboli which are estimated to occur at an annual rate of 1-2 per 1,000. The first CT image shows a “clot in transit” and the second shows it has gone on to embolize to the lungs. “Clot in transit” is estimated to occur in 4-18% of patients with a pulmonary embolus. It is associated with a mortality of 45% if the clot propagates.
There is a therapeutic dilemma involved in the treatment of PE. Studies report that mortality associated with no therapy, anticoagulation therapy, surgical embolectomy and thrombolysis are : 100%, 28.6%, 23.8% and 11.3% respectively. There is an argument made to use TPA for “clots in transit” because propagation of the clot can lead to hemodynamic compromise.
Clots in transit are most often found with ultrasound
Our patient underwent reduction of her shoulder dislocation . She was admitted to the SICU and vascular, thoracic surgery, and vascular were consulted. On echo she had evidence of R heart strain with a stable BP. She was started on heparin. On the following day she underwent mechanical thrombectomy of the clot with VA ECMO. The procedure note follows:
Procedure Findings: Successful procedures as above. Initial PA pressure normal (avg 21 mmHg).
Right pulmonary artery thrombus was successfully thrombectomized with the clot grossly appearing mixed acute and chronic in nature. The right heart thrombus was seen ejecting into and through the RVOT on ICE. Pulmonary angiography demonstrated the thrombus to have transited into the right main pulmonary artery and it was unable to be thrombectomized. 6mg tPA was injected in the right main pulmonary artery to aid in clearance of this thrombus.
The patient developed hypotension with embolization of the clot and was placed on vaso and epi drips. She had a post procedure echo showing no clot in the RV but a persistent “D”shape of the septum. A bovine pericardial patch was placed for a superficial femoral artery repair. She was decannulated and discharged.. She has been seen following discharge for severe neuropraxia secondary to ECMO surgery.
What happens after a PE? How do you test for hypercoagulability?
These are some of the hematologic problems causing hypercoagulatbility
Basic tests for hypercoagulability include: factor V Leiden(activated protein C resistance) and prothrombin gene mutation (G20210A), Protein C, Antithrombin activity,Protein S , and homocysteine.
TOO MUCH INFORMATION:
Russell’s viper is found in India
If you have a patient with an elevated PTT you can mix the patients plasma with normal plasma in a 1:1 ratio. If normal plasma corrects the PTT there was a factor deficiency or inhibitor in the patients plasma that is replaced by the normal plasma .
If you want to find a lupus anticoagulant (an antiphopholipid Ab) in a pt with an elevated PTT, you can use dilute Russell viper venom. Russell’s viper venom has been known to clot blood since 1934.
Patel M, Raza A, Murabia A, et al. Clot in Transit: A therapeutic dilemma. Pulmonary vascular Disease Vol 152(4) Supplement A1023 2017 DOI: https://doi.org/10.1016/jchest2017.08.1056.
Shostak E, Abe O. Management of massive pulmonary embolism with right heart emboli-in-transit. Chest 2012;142.
Van der Hulle T, Dronkers C, Klok F, wt al. (Leiden University Medical Center, Leiden, The Netherlands). Recent developments in the diagnosis and treatment of pulmonary embolism. (Review) J Intern Med 2016;279:16-29.
Macfarlane R. Russell’s viper venom 1934-64. British Journal of Haematology 13 (4) 437-51.