I. Pulmonary embolism
Pulmonary embolism (PE) is defined as a condition of blockage of blood flow due to a blood clot of either in main artery of the lung or somewhere else in the body. In most cases, it is in the deep veins of the legs or pelvic. The disease is a common and affects as many as 500,000 persons annually in the United States.
A. In conventional medicine perspective
1. Anticoagulants, including
Heparin,Warfarin (Coumadin) and rivaroxaban (Xarelto). In the study of 256 patients with acute pulmonary embolism and pulmonary hypertension or right ventricular dysfunction but without arterial hypotension or shock. The patients were randomly assigned in double-blind fashion to receive heparin plus 100 mg of alteplase or heparin plus placebo over a period of two hours. found that when given in conjunction with heparin, alteplase can improve the clinical course of stable patients who have acute submassive pulmonary embolism and can prevent clinical deterioration requiring the escalation of treatment during the hospital stay(48).
2. Clot dis solvers
Patients with acute pulmonary embolism are at risk for early death or chronic morbidity. Appropriate therapy can dramatically reduce the incidence of both. Appropriate therapy can dramatically reduce the incidence of both. Oxygen and heparin therapy should be started as soon as the diagnosis is suspected. The condition of a hypotensive patient with right ventricular overload from acute pulmonary embolism usually is made worse by a fluid challenge; hypotension may be relieved by preload reduction or even by gentle diuresis. Norepinephrine (Levophed), isoproterenol hydrochloride (Isuprel), and epinephrine are the pressor agents of choice. Immediate thrombolysis is the standard of care for any patient with significant hypoxemia or hypotension due to proven pulmonary embolism. Beyond this, the potential benefit of using thrombolytic agents should be considered routinely for every patient with proven pulmonary embolism(49).
B. Surgical treatments
1. Clot removal
The aim is to remove the existed large blood clot with a thin flexible tube (catheter) through your blood vessels. According to the study by Harvard Medical School, pulmonary suction thrombectomy can be a successful interventional tool in the treatment of pulmonary thromboembolism. Removal of clot burden typically results in prompt recovery of hemodynamic stability and improved oxygenation. However, in rare cases, clot removal does not sufficiently improve the clinical situation. Herein, two patients with massive pulmonary thromboembolism are presented whose condition improved only after they received nitric oxide as an adjunct to pulmonary suction thrombectomy(50).
2. Vein filter
The aim of placing a filter in the main vein called the inferior vena cava that leads from your legs to the right side of your heart is to filter catches and stops blood clots moving through the blood stream toward your lungs. In the study to investigate clinical experience with the Recovery filter as a retrievable inferior vena cava (IVC) filter, in one hundred seven Recovery filters were placed in 106 patients with an initial clinical indication for temporary caval filtration, found that although all the filters were placed with the intention of being removed, a large percentage of filters were not retrieved. The Recovery filter was safe and effective in preventing PE when used as a retrievable IVC filter(51).
In case of acute pulmonary embolism, emergency surgery may be the only option to remove as much as clot as possible, specially there is a large clot in your main (central) pulmonary artery, if patients are in shock and thrombolytic medication isn’t working quickly enough. In the study to investigate the effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support (ECLS) in high-risk acute pulmonary embolism (aPE) treated with pulmonary embolectomy, indicated that among the 25 patients, 24 had a PAOI≥0.5 and 23 had a RV-to-LV diameter ratio≥1.0. Four patients had right heart thrombi. Sixteen patients developed preoperative instability requiring inotropic and/or mechanical support. Eight in the 16 had a preoperative cardiac arrest (CA) and six of these were bridged to surgery on ECLS. Three in the 6 patients weaned ECLS after surgery and survived to discharge. The overall in-hospital mortality was 20% (n=5). A preoperative CA (Odds ratio [OR]: 16, 95% confidence interval [CI]: 1.4-185.4, p=0.027, c-index: 0.80) and a postoperative requirement of ECLS (OR: 36, 95% CI: 2.1-501.3, p=0.008, c-index: 0.85) was the pre- and postoperative predictor of in-hospital mortality. No late deaths or re-admission for recurrence were found during a median follow-up of 19 months(52).
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