Major Pulmonary Embolism: Review of a Pathophysiologic Approach to the Golden Hour of Hemodynamically Significant Pulmonary Embolism

BACKGROUNDThe Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) addressed the value of ventilation/perfusion scans in acute pulmonary embolism (PE). The present study evaluates the risks and diagnostic validity of pulmonary angiography in 1,111 patients who underwent angiography in PIOPED:METHODS AND RESULTSComplications were death in five (0.5%), major nonfatal complications in nine (1%), and less significant or minor in 60 (5%). More fatal or major nonfatal complications occurred in patients from the medical intensive care unit than elsewhere: five of 122 (4%) versus nine of 989 (1%) (p less than 0.02). Pulmonary artery pressure, volume of contrast material, and presence of PE did not significantly affect the frequency of complications. Renal dysfunction, either major (requiring dialysis) or less severe, occurred in 13 of 1,111 (1%). Patients who developed renal dysfunction after angiography were older than those who did not have renal dysfunction: 74 +/- 13 years versus 57 +/- 17 years...

Complications and validity of pulmonary angiography in acute pulmonary embolism.

Authors/Task Force Members: Adam Torbicki, Chairperson (Poland)*, Arnaud Perrier (Switzerland), Stavros Konstantinides (Germany), Giancarlo Agnelli (Italy), Nazzareno Galiè (Italy), Piotr Pruszczyk (Poland), Frank Bengel (USA), Adrian J.B. Brady (UK), Daniel Ferreira (Portugal), Uwe Janssens (Germany), Walter Klepetko (Austria), Eckhard Mayer (Germany), Martine Remy-Jardin (France), and Jean-Pierre Bassand (France)

Guidelines on diagnosis and management of acute pulmonary embolism

Complications of right heart catheterization procedures in patients with pulmonary hypertension in experienced centers.

Adrenocortical carcinoma (ACC) is a rare and in most cases steroid hormone-producing tumor with variable prognosis. The purpose of these guidelines is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with ACC based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions, which we judged as particularly important for the management of ACC patients and performed systematic literature searches: (A) What is needed to diagnose an ACC by histopathology? (B) Which are the best prognostic markers in ACC? (C) Is adjuvant therapy able to prevent recurrent disease or reduce mortality after radical resection? (D) What is the best treatment option for macroscopically incompletely resected, recurrent or metastatic disease? Other relevant questions were discussed within the group. Selected Recommendations: (i) We recommend that all patients with suspected and proven ACC are discussed in a multidisciplinary expert team meeting. (ii) We recommend that every patient with (suspected) ACC should undergo careful clinical assessment, detailed endocrine work-up to identify autonomous hormone excess and adrenal-focused imaging. (iii) We recommend that adrenal surgery for (suspected) ACC should be performed only by surgeons experienced in adrenal and oncological surgery aiming at a complete en bloc resection (including resection of oligo-metastatic disease). (iv) We suggest that all suspected ACC should be reviewed by an expert adrenal pathologist using the Weiss score and providing Ki67 index. (v) We suggest adjuvant mitotane treatment in patients after radical surgery that have a perceived high risk of recurrence (ENSAT stage III, or R1 resection, or Ki67 >10%). (vi) For advanced ACC not amenable to complete surgical resection, local therapeutic measures (e.g. radiation therapy, radiofrequency ablation, chemoembolization) are of particular value. However, we suggest against the routine use of adrenal surgery in case of widespread metastatic disease. In these patients, we recommend either mitotane monotherapy or mitotane, etoposide, doxorubicin and cisplatin depending on prognostic parameters. In selected patients with a good response, surgery may be subsequently considered. (vii) In patients with recurrent disease and a disease-free interval of at least 12 months, in whom a complete resection/ablation seems feasible, we recommend surgery or alternatively other local therapies. Furthermore, we offer detailed recommendations about the management of mitotane treatment and other supportive therapies. Finally, we suggest directions for future research.

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European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults, in collaboration with the European Network for the Study of Adrenal Tumors

Pulmonary angiography is sensitive and specific in the diagnosis of pulmonary thromboembolism, but it remains an invasive procedure. Experience with 1,350 pulmonary angiograms was reviewed to ascertain the incidence, etiologies, and avoidance of complications. There were three deaths, all of which were secondary to cor pulmonale in patients with pulmonary hypertension and right ventricular end diastolic pressure (RVEDP) equal to or greater than 20 mmHg. Other complications consisted of cardiac perforation in 14 patients and endocardial or myocardial injury in six without sequelae, 11 significant arrhythmias and five cardiac arrests successfully treated, minor contrast material reactions in 11 patients, and a few insignificant complications. Carefully performed pulmonary angiography is safe if one avoids injecting contrast material into a patient with an elevated RVEDP.

The incidence, etiologies, and avoidance of complications of pulmonary angiography in a large series.

The evaluation of bladder neck dysfunction

Renal failure from urographic contrast media is a serious potential hazard of excretory urography and is usually recognized by the clinician 24--48 hr after the procedure. The association of an abnormally increasing nephrogram with development of oliguric renal failure in children was described in 1969, but in 112 subsequent reported cases of contrast-induced renal failure, a persistent nephrographic pattern was described only once. With special attention to the abnormally persistent nephrogram, we were able to detect nine cases of contrast-induced renal failure after excretory urography. Two of these cases are discussed in detail and pertinent data on the other seven are presented.

Contrast-induced acute renal failure: persistent nephrogram as clue to early detection.

To determine the accuracy of scintigraphy in distinguishing true renal masses from normal variants, 40 patients with excretory urographic findings indicating a possible, but not definite, mass lesion were studied. Scintigraphy correctly identified 17 true masses and 17 normal variants. Four false positive and two false negative results were obtained.

Robert A. Older

Papers

The incidence, etiologies, and avoidance of complications of pulmonary angiography in a large series.

The evaluation of bladder neck dysfunction

Contrast-induced acute renal failure: persistent nephrogram as clue to early detection.

Accuracy of radionuclide imaging in distinguishing renal masses from normal variants.

Retrocaval ureter in turner syndrome