Objectives. The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism.Background. The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated.Methods. The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies.Results. Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%).Conclusions. Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies. (C) 1997 by the American College of Cardiology.

In the diagnosis of pulmonary embolism, the physician must know not only the proper procedures for examination, but also the specific pathological factors that characterize the disease's definitive stages. Stages III and IV of the disease exhibit, for the first time, through electrocardiogram (EKG) and echocardiogram results, arterial blood gas analysis and pulmonary artery pressure, a specific pathological change. In Stages I and II, specific clinical parameters, anamnesis, certain predisposing factors and diseases, and a combination of symptomatic features and examination results sum to a presumed diagnosis. It is only through the application of scintiscanning and angiography that a conclusive diagnosis can be reached. Whether this particular medical regime was followed in hospitals, was previously not known. It was with this clinical study, Lungenemboliestudie, conducted by a group with the same name, that this information became available. in a prospective examination of 1,001 patients in 240 clinics, ii was found that a diagnosis became stage-specific in Stages III and IV of the disease. With worst-case fulminant lung emboly, long diagnostic procedures (e.g. scintiscanning and angiography) are, most times, eliminated. Time being of critical importance, a fully comprehensive array of diagnostic test is not called for, instead an expedient course of specific treatment is begun.

A 43-year-old woman presented with acute embolic occlusion of the left brachial artery. She was immediately treated by surgical embolectomy. After exclusion of other possible embolic sources, the transthoracic and transesophageal echocardiographic examination revealed a floating thrombus in the aortic arch. Thereupon an aortotomy and thrombectomy was performed and showed a normal wall structure of the thoracic aorta except for a minimal ulcerated lesion of the intima at the aortic arch. This case confirmes that transthoracic and trans-esophageal echocardiography are the diagnostic methods of choice for detecting thromboembolic sources originating in the heart or thoracic aorta.

A 43-year-old woman presented with acute embolic occlusion of the left brachial artery. She was immediately treated by surgical embolectomy. After exclusion of other possible embolic sources, the transthoracic and transesophageal echocardiographic examination revealed a floating thrombus in the aortic arch. There-upon an aortotomy and thrombectomy was performed and showed a normal wall structure of the thoracic aorta except for a minimal ulcerated lesion of the intima at the aortic arch. This case confirms that transthoracic and transesophageal echocardiography are the diagnostic methods of choice for detecting thromboembolic sources originating in the heart or thoracic aorta.

PURPOSE: To evaluate the long-term results of recanalization of occluded iliac arteries with local low-dose thrombolysis, angioplasty, and, if necessary, stent implantation.MATERIALS AND METHODS: Forty-seven patients with acute or chronic occlusions of the common or external iliac artery, or both, underwent local low-dose thrombolysis (n = 47), percutaneous transluminal angioplasty (PTA) (with balloon dilation [n = 43] and rotational angioplasty [n = 30] in the patients in whom a retrograde recanalization was performed), and, if needed, intravascular stent placement (n = 18). Follow-up lasted 3-53 (mean, 21) months.RESULTS: The primary recanalization rate was 98% (46 of 47). The mean ankle-brachial index increased from 0.33 to 0.81 within 14 days after treatment and was 0.76 at the most recent follow-up. Two early (< 14 days) and two late reocclusions (after 24 and 30 months) occurred; one restenosis detected with duplex sonography and angiography was observed after 19 months.CONCLUSION: This therapy represents a true alternative to vascular surgery and a first-line treatment for acute or chronically occluded iliac arteries.