Interesting Case Interesting Case PresentationPresentation

March 1, 2012March 1, 2012Franklin C. Margaron, MDFranklin C. Margaron, MD

HPI- TRJNotumHPI- TRJNotum

66 yo male initially presenting 2/9 for 66 yo male initially presenting 2/9 for a crush and degloving injury to his a crush and degloving injury to his left hand at work, no other traumaleft hand at work, no other trauma

PMH: HypercholesterolemiaPMH: Hypercholesterolemia PSH: NonePSH: None Meds: SimvastatinMeds: Simvastatin All: NKDAAll: NKDA Soc Hx: Denies EtOH, smokingSoc Hx: Denies EtOH, smoking

To OR 2/9 for complex laceration repair, To OR 2/9 for complex laceration repair, ORIF, and integra placementORIF, and integra placement

Initially on Lovenox for 2 days, then this Initially on Lovenox for 2 days, then this was discontinued. Pt on ASA 325, statin, was discontinued. Pt on ASA 325, statin, ancefancef

Pt intermittently ambulatory but left hand Pt intermittently ambulatory but left hand in stockinette suspended from IV pole in stockinette suspended from IV pole while in bedwhile in bed

2/17 returned to OR for debridement, 2/17 returned to OR for debridement, Integra placementIntegra placement

Kept in hospital for complex wound careKept in hospital for complex wound care

2/24 while walking had syncopal episode 2/24 while walking had syncopal episode Apneic, cyanotic, unresponsive for 3 minApneic, cyanotic, unresponsive for 3 min BVM initiated, pulse ox 91%BVM initiated, pulse ox 91% Awoke spontaneously and became Awoke spontaneously and became

appropriate and conversiveappropriate and conversive c/o some pain in left lower chestc/o some pain in left lower chest SBP 100, HR 130s, RR 30s, sats 93% on SBP 100, HR 130s, RR 30s, sats 93% on

4L NC4L NC EKG sinus tachEKG sinus tach Troponin 0.4->1.22Troponin 0.4->1.22 PE CT orderedPE CT ordered

TTE: TTE: Moderate to severe reduction in right Moderate to severe reduction in right

systolic functionsystolic function Mild right atrial and ventricular dilationMild right atrial and ventricular dilation Flattening of interventricular septumFlattening of interventricular septum Mild reduction in left systolic functionMild reduction in left systolic function

CT surgery consultedCT surgery consulted Heparin gtt initiatedHeparin gtt initiated Pt taken for emergent for pulmonary Pt taken for emergent for pulmonary

embolectomy with cardiopulmonary embolectomy with cardiopulmonary bypassbypass

Initially transferred to ICU on 2 pressorsInitially transferred to ICU on 2 pressors Venous duplex revealed bilateral LE DVT Venous duplex revealed bilateral LE DVT

and pt underwent IVC filter placementand pt underwent IVC filter placement Hypercoagulable workup initiatedHypercoagulable workup initiated Extubated 2/26Extubated 2/26 Weaned off pressors 2/27Weaned off pressors 2/27 Currently On floor tolerating diet, >97% Currently On floor tolerating diet, >97%

on 2L NC, HR 90s, SBP 140s on 2L NC, HR 90s, SBP 140s Repeat TEE: EF 50%, mild reduction in Repeat TEE: EF 50%, mild reduction in

systolic function, no pulmonary systolic function, no pulmonary hypertensionhypertension

Pulmonary EmbolectomyPulmonary Embolectomy

Massive PE has up to 70% mortality Massive PE has up to 70% mortality within the first hourwithin the first hour HD instabilityHD instability >50% occlusion of PA>50% occlusion of PA Right heart strain on EchoRight heart strain on Echo

90 day mortality following PE- 17.4%90 day mortality following PE- 17.4%

Review looking at 1742 studies on PE and management Review looking at 1742 studies on PE and management strategiesstrategies

Heparin anticoagulation universalHeparin anticoagulation universal Roles of thrombolysis and embolectomy (catheter, Roles of thrombolysis and embolectomy (catheter,

surgical) not well definedsurgical) not well defined Surgical embolectomy traditionally reserved forSurgical embolectomy traditionally reserved for

Severe RV dysfunctionSevere RV dysfunction Failure of thrombolysisFailure of thrombolysis Contraindication to thrombolysisContraindication to thrombolysis

Improvements in operative techniques and ICU care have Improvements in operative techniques and ICU care have significantly decreased mortality from surgical significantly decreased mortality from surgical thrombectomythrombectomy

Complications related to thrombolysisComplications related to thrombolysis HemorrhageHemorrhage Fragmentation with distal lodging causing pulmonary Fragmentation with distal lodging causing pulmonary

hypertensionhypertension

Several randomized controlled trials looking at Several randomized controlled trials looking at thrombolysis vs heparinthrombolysis vs heparin

No reduction in 90 day mortality or PE No reduction in 90 day mortality or PE recurrence (6.7% vs. 9.6%; 95% CI 0.40–1.12)recurrence (6.7% vs. 9.6%; 95% CI 0.40–1.12)

Subgroup analysis in one meta-analysis (Wan Subgroup analysis in one meta-analysis (Wan et al. – 11 RCTs) Pts with HD compromise did et al. – 11 RCTs) Pts with HD compromise did have reduction in mortality and PE recurrence have reduction in mortality and PE recurrence (9.4% vs. 19.0%; 95% CI 0.22–0.92)(9.4% vs. 19.0%; 95% CI 0.22–0.92)

No difference in major bleeding (9.1% vs. No difference in major bleeding (9.1% vs. 6.1%; 95% CI 0.81–2.46)6.1%; 95% CI 0.81–2.46)

Statistically significant difference in minor Statistically significant difference in minor bleeding (22.7% vs. 10.0%; 95% CI 1.53–4.54)bleeding (22.7% vs. 10.0%; 95% CI 1.53–4.54)

Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC. MedicalFC. Medical

compared with surgical treatment for massive pulmonary compared with surgical treatment for massive pulmonary embolism.embolism.

Eur J Cardiothorac Surg 1994;343:576–560Eur J Cardiothorac Surg 1994;343:576–560

Thrombolysis vs Surgical Thrombolysis vs Surgical embolectomyembolectomy mortality rate (33% vs. 23%), mortality rate (33% vs. 23%), major hemorrhage (25% vs. 15%)major hemorrhage (25% vs. 15%) PE recurrence rates (21% vs. 7.7%)PE recurrence rates (21% vs. 7.7%)

Meneveau N et al. In-hospital and long-term outcome after Meneveau N et al. In-hospital and long-term outcome after submassivesubmassive

and massive pulmonary embolism submitted to thrombolyticand massive pulmonary embolism submitted to thrombolytictherapy. Eur Heart J 2003;24:1447–1454.therapy. Eur Heart J 2003;24:1447–1454.

227 pts surviving acute phase of PE 227 pts surviving acute phase of PE thrombolysisthrombolysis 56% survival at 10 years56% survival at 10 years 36% with PE-related events36% with PE-related events

Recurrent DVTRecurrent DVT Recurrent PERecurrent PE CHF class III-IVCHF class III-IV

15-25% have only partial resolution of 15-25% have only partial resolution of clot leading to persistent pulmonary Htn clot leading to persistent pulmonary Htn and increased mortalityand increased mortality

American College of Chest American College of Chest Physicians Evidence-Based Clinical Physicians Evidence-Based Clinical

Practice Guidelines: 2012Practice Guidelines: 2012 Low dose unfractionated heparinLow dose unfractionated heparin

18% reduction in the odds of death from any cause18% reduction in the odds of death from any cause 47% reduction in the odds of fatal PE47% reduction in the odds of fatal PE 41% reduction in the odds of nonfatal PE41% reduction in the odds of nonfatal PE 57% increase in the odds of nonfatal major 57% increase in the odds of nonfatal major

bleeding bleeding LMWHLMWH

reduced the risk of clinical PE and clinical VTE by reduced the risk of clinical PE and clinical VTE by 70% 70%

50% increase in odds of major bleeding and 50% increase in odds of major bleeding and hematomahematoma

American College of Chest American College of Chest Physicians Evidence-Based Clinical Physicians Evidence-Based Clinical

Practice Guidelines: 2012Practice Guidelines: 2012 51 RCTs comparing LDUH and LMWH51 RCTs comparing LDUH and LMWH >48,000 general and abdominal surgical >48,000 general and abdominal surgical

patientspatients risk of VTE was 30% lower in the LMWH groupsrisk of VTE was 30% lower in the LMWH groups difference was not apparent when the analysis difference was not apparent when the analysis

was restricted to blinded, placebo-controlled was restricted to blinded, placebo-controlled trialstrials

No difference inNo difference in Clinical PEClinical PE Death from any causeDeath from any cause Major bleedingMajor bleeding Wound hematomaWound hematoma

ConclusionsConclusions

DVT prophylaxis is an imperative step in DVT prophylaxis is an imperative step in the management of surgical patientsthe management of surgical patients

Massive PE has high mortality and needs Massive PE has high mortality and needs to be treated early and aggressivelyto be treated early and aggressively

Surgical pulmonary embolectomy is now Surgical pulmonary embolectomy is now the preferred management strategy for the preferred management strategy for patients with HD compromise or patients with HD compromise or evidence of significant right heart strainevidence of significant right heart strain