급성 중증 폐색전증의 임상양상과 예후에 미치는 인자

박윤수(Yoon Soo Park),하종원(Jong Won Ha),권기환(Ki Hwan Kwon),장양수(Yang Soo Jang),정남식(Nam Sik Chung),심원흠(Won Heum Shim),조승연(Seung Yun Cho),김성순(Sung Soon Kim) 대한내과학회 2000 대한내과학회지 Vol.58 No.3

Background : Pulmonary embolism is a relatively common disease but may also be manifestated as a lethal disease. Most previous studies on pulmonary embolism included hemodynamically stable patients who were able to tolerate a confirmative diagnostic workup, including ventilation-perfusion lung scan or pulmonary angiography. However, in most cases of acute massive pulmonary embolism, patients are unstable to tolerate a confirmative diagnostic workup. Studies of only stable patients with pulmonary embolism may have a bias on evaluating the clinical course and prognosis of pulmonary embolism. Therefore, we designed a study to observe the clinical manifestations, diagnostic methods, treatment modality, and to investigate the prognostic factors of patients with acute pulmonary embolism who present with overt or impending right heart failure using the diagnostic criteria suggested by MAPPET study. Methods : Among 103 patients diagnosed as pulmonary embolism from 1990 to 1997, 63 patients(male/female : 21/42, mean age : 56 15) were enrolled as acute major pulmonary embolism by MAPPET's diagnostic criteria. Patients were included in the study if they showed clinical, echocardiographic and cardiac catheterization findings signifying acute right heart failure or pulmonary hypertension due to pulmonary embolism, together with: 1) a diagnostic pulmonary angiogram, or 2) a lung scan indicating high probability of pulmonary embolism, or 3) at least 3 of the followings: ① syncope; ② tachycardia (heart rate > 100 beats /min); ③ dyspnea or tachypnea (> 24 breaths/min or need for mechanical ventilation); ④ arterial hypoxemia (partial arterial pressure of oxygen < 70mmHg while breathing room air) in the absence of pulmonary infiltrates on chest x-ray; ⑤ ECG signs of right heart strain. Results : Among the 63 patients, 15 patients(23.8%) did not have an underlying disease. Eleven patients(17.5%) had malignancy, 8 patients had an operation in the recent 20 days, 6 patients had chronic pulmonary disease, 5 patients had a history of congestive heart failure and cerebrovascular accident respectively, 4 patients had a previous history of pulmonary embolism, 3 patients had vasculitis such as Behcets' disease and systemic lupus erythematosus and a history of venous thrombosis, respectively. The main clinical manifestation on the time of diagnosis was dypnea in 55 patients(87.3%), which was the most frequent, and chest pain in 18 patients(28.6%), syncope in 10 patients(15.9%), and tachycardia in 2 patients(3.2%). The diagnostic methods were echocardiography(43 patients, 68.3%), lung perfusion scan(39 patients, 61.9%), chest computed tomography(16 patients, 26.4%), pulmonary angiography(4 patients, 6.3%) and right heart catherization(2 patients, 3.2%). In order to examine deep vein thrombosis, lower extremity Duplex ultrusonography and venography were performed in 11 patients(17.5%) and 7 patients(11.1%) respectively. The overall in-hospital mortality was 38.1%(24 patients). The factors influencing in-hospital mortality were associated malignancy(p<0.01) and unstable vital sign(systolic blood pressure of less than 90mmHg)(p<0.05). Conclusion : Acute pulmonary embolism with overt or impending right heart failure is a significant lethal disease with a high in-hospital mortality. The predictors of mortality were associated malignancy and unstable vital sign.(Korean J Med 58:293-300, 2000)

A case of pulmonary cement embolism treated by rivaroxaban

( Hyun Jung Kim ) 대한결핵 및 호흡기학회 2019 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.127 No.-

Pulmonary cement embolism is one of several complications of percutaneous vertebroplasty. There are various treatment options for pulmonary cement embolism from no treatment for asymptomatic patients to surgical resection for the patients with unstable vital sign. Moreover, there are some controversies about anticoagulation treatment in the case of pulmonary cement embolism. We report a case of pulmonary cement embolism treated with rivaroxaban. A 73-yearold woman took a chest radiograph for medical checkup and pulmonary cement embolism was diagnosed. She complained nonspecific dyspnea on exertion but had no tachycardia, pleuritic chest pain or cough. She underwent percutaneous vertebroplasty in the L2-5 spine three years ago. Compared with chest radiograph taken before vertebroplasty (Fig.1A), central dense opacity outlining the pulmonary vessels was newly noted (Fig.1B). Inhalation and perfusion lung scan with Tc-99m MAA by SPECT technique revealed three moderate V/Q mismatched segmental perfusion defects on LUL and RML of the lung (Fig.1C). Then, she took a follow-up lung scan after six-month rivaroxaban treatment. It reveals disappearance of previous two of three moderate V/Q mismatched segmental perfusion defects on LUL and RML of the lung and subtle V/Q mismatched segmental perfusion defects on LUL of the lung (Fig.1D). She has been taking rivaroxaban without any adverse effect and she had no respiratory symptoms. There are no data about the effect of NOAC on pulmonary cement embolism and the change of perfusion defect after anticoagulation of pulmonary cement embolism, yet. This case showed that perfusion defect was resolved after anticoagulation in the patient with pulmonary cement embolism by lung scan and an anticoagulation treatment in asymptomatic pulmonary cement embolism patients might be helpful.

폐색전증의 수술적 치료

박병준,박표원,심영목,이영탁,박계현,김진국,김욱성,성기익 대한흉부외과학회 2009 Journal of Chest Surgery (J Chest Surg) Vol.42 No.4

Background: The treatment of acute pulmonary embolism is difficult, and it can be lethal when cardiogenic shock is involved with major pulmonary embolism. In the past, pulmonary embolectomy was considered as the last choice for patients with pulmonary embolism. Accordingly, we analyzed our experience with seven cases of pulmonary embolectomy as an alternative option for the early treatment of pulmonary embolism. Material and Method: A retrospective analysis of medical charts of all patients who underwent pulmonary embolectomy at our hospital over the past eight years was performed. The patients were observed during their hospital stay and followed until their last visit to the outpatient department. Result: Among 7 patients (4 men and 3 women), 4 had massive pulmonary embolism, and 3 had submassive pulmonary embolism. An extracorporeal membrane oxygenator was inserted in 3 patients before surgery. There was no mortality, and postoperative echocardiography showed no pulmonary hypertension in 6 patients. Conclusion: Pulmonary embolectomy can be performed with minimal mortality. We think that the use of an extracorporeal membrane oxygenator in patients with cardiogenic shock before surgery improves survival. 배경: 급성 폐색전증은 그 치료가 어려우며 대량의 색전증이 발생하여 심인성 쇼크를 동반할 경우 치명적인 결과를 초래할 수 있다. 과거 폐색전증 환자의 수술적 치료는 마지막 수단으로 여겨져 왔다. 하지만 저자들은 폐색전증 제거술을 시행한 7예의 경험을 토대로 치료 대안으로서 수술의 필요성을 검토하고자 하였다. 대상 및 방법: 8년간 본원에서 폐색전 제거술을 시행한 환자들의 의무 기록을 바탕으로 후향적 연구를 시행하였다. 입원 기간 및 마지막 외래 진료까지 경과 관찰하였다. 결과: 7명의 환자(남자 4명, 여자 3명) 가운데 4명의 환자가 대량 폐색전증이었으며 나머지 3명은 아급성 폐색전증이었다. 3명의 환자는 수술 전 체외막산소공급장치를 삽입하고 수술을 받았다. 사망한 환자 없이 모두 퇴원하였으며 수술 후 시행한 심초음파 결과상 6명의 환자에서 폐동맥 고혈압 소견 없었다. 결론: 폐색전증 제거술은 대량의 폐색전증 환자에서 낮은 사망률로 시행할 수 있으며 저자들은 수술 전 심인성 쇼크 상태인 환자에서 체외막산소공급장치가 생존율을 향상시킬 것으로 생각된다.

소아 미세변화 신증후군에서 폐색전증에 대한 연구

성승준,홍기웅,김은령,김일수,조병수,Sung, Seung-Joon,Hong, Ki-Woong,Kim, Eun-Ryoung,Kim, Il-Soo,Cho, Byung-Soo 대한소아신장학회 2001 Childhood kidney diseases Vol.5 No.2

목 적 : 신증후군 환자에서 신정맥 혈전증, 폐동맥 혈전증 등의 합병증은 아직도 치명율이 높은 합병증으로 되어 있다. 본 연구는 소아 미세변화 신증후군 환아에서 폐관류스캔을 이용하여 폐색전증의 빈도와 위험요인에 대해 조사함으로 합병증의 조기발견 및 예방으로 신증후군의 치명률을 줄이는데 도움을 얻고자 시행하였다. 대상 및 방법 : 폐관류스캔을 관해기 초기에 Technetium 99-microaggregated albumin (99mTC- MAA)을 사용하여 시행하였으며 폐색전증이 발생한 환아 5명을 A군, 폐색전증이 발생하지 않은 환아 9명을 B군으로 나누고 두 군 간에 혈소판. 적혈구용적률, 알부민, 콜레스테롤, 중성기방, 24시간 뇨 단백분비양에 유의한 차이가 있는지 비교 관찰하였다. 결 과 : 폐색전증을 동반한 A군에서 혈소판 수치가 유의하게 높았으며, 적혈구용적률은 유의한 차이가 없었다. 혈청 알부민도 유의한 차이는 없었으나, 입원시 24시간 뇨 단백은 A군에서 더 심한 단백뇨를 보여 주었으며 통계적으로 유의한 결과를 보여주었다. 혈청 콜레스테롤과 중성지방도 두 군 간에 유의한 차이는 없었다. 결 론 : 폐색전증은 소아미세변화 신증후군에서의 중요 합병증중의 하나이다. 폐색전증의 발생빈도는 치료전의 단백뇨의 정도와 스테로이드 치료 후 초기 관해기에 지속적인 혈소판증가와 연관이 있을 것이다. 그러므로 심한 단백뇨와 혈소판의 증가를 보이는 위험군은 증상이 경미하거나 없더라도 반드시 조기에 폐관류스캔을 시행하여 조기 진단 및 예방적 처치가 필요하리라 생각된다. Purpose : We investigated the incidence and predisposing factors of pulmonary embolism in minimal change nephrotic syndrome(MCNS). Methods : Lung perfusion scan using 99mTC-MAA were done on 14 patients who were diagnosed to minimal change nephrotic syndrome. Group h: Five patients who had perfusion defects on scan, Group B; Nine patients who had no perfusion defect on scan. Between the two groups, the differences of platelet number, hematocrits, albumin, cholesterol, triglyceride, proteinuria were evaluated. Results : Five patients were found to have perfusion defect consistent with pulmonary embolism($35.7\%$). However, there were minimal or no respiratory symptoms and signs. In our laboratory studies, the mean proteinuria on admissions was $676{\pm}31\;mg/m2/hr$ in the group with pulmonary embolism, and $313{\pm}28\;mg/m2/hr$ in the group without pulmonary embolism. There were more severe proteinuria in group with pulmonary embolism(P<0.05). The mean platelet count at early stage of remission after steroid treatment was $746,600{\pm}280,000/mm3$ in the group with pulmonary embolism, $511,890{\pm}90,000/mm3$ in the group without pulmonary embolism. There were significant difference of platelet count between the two groups(P<0.01). In patients with pulmonary embolism, there were more higher and sustained increasement of platelet count. All cases of pulmonary embolism were treated with dipyridamole(5 mg/kg). In 4 cases the perfusion defects were improved in two weeks, however, one case showed persistent perfusion defect after 1 month. Conclusion : Our study suggested that pulmonry embolism might be one of tile major complications in childhood MCNS The occurrence rate was correlated with severity of proteinuria before treatment and sustained increasement of platelet counts in early remission state after steroid treatment. Therefore, the scintigraphic pulmonary perfusion study is mandatory in childhood MCNS, especially in the high risk patients, such as the patients with severe proteinuria and sustained increasement of platelet count. (J Korean Soc Pediatr Nephrol 2001;5 : 100-8)

Pulmonary embolism with massive hemoptysis from pulmonary artery aneurysm in patient with Behçet’s disease : a case report

장준용,김양기,어수택,김기업,구소미,이보영 대한결핵 및 호흡기학회 2018 대한결핵 및 호흡기학회 추계학술대회 초록집 Vol.126 No.0

Objective: Behçet’s disease(BD) is an idiopathic systemic vasculitis with variable clinical manifestation. Diagnosis of BD of a patient initially presented with vascular complication such as pulmonary embolism can be challenging and the exact role of anticoagulation therapy is still debated. So we report the case of a 27-year-old man with Behcet’s disease who initially presented with pulmonary embolism. Case Report: A 27-year-old Ethiopian male with no medical history presented with complaint of chest pain. A computerized tomography (CT) showed pulmonary thromboembolism with pulmonary infarctions in the both mid to lower lungs and Budd-Chiari syndrome due to thrombus in IVC and hepatic veins. Anti-coagulant therapy with rivaroxaban was started, and four months later, he was readmitted for massive hemoptysis. CT showed multifocal aneurysms in the both pulmonary arteries, diffuse alveolar hemorrhage, and resolution of previously seen pulmonary. Further examination revealed that the patient have BD. Anticoagulant therapy was stopped and high dose intravenous corticosteroid with cyclophosphamide was given. After 3 month, CT showed improvement of pulmonary aneurysm and recurrence of pulmonary embolism. Conclusion: We present a case of pulmonary embolism and pulmonary artery aneurysm associated with BD. Pulmonary aneurysm was successfully treated with immunosuppressant with steroid but pulmonary embolism was not. Further studies are needed about the role of anticoagulation therapy.

The Pulmonary Embolism Severity Index in Predicting the Prognosis of Patients With Pulmonary Embolism

( Won Ho Choi ),( Sung Uk Kwon ),( Yoon Jung Jwa ),( Jung A Kim ),( Yun Ho Choi ),( Je Ho Chang ),( Hoon Jung ),( Joon Hyung Doh ),( June Namgung ),( Sung Yun Lee ),( Won Ro Lee ) 대한내과학회 2009 The Korean Journal of Internal Medicine Vol.24 No.2

Background/Aims: Many prognostic models have been developed to help physicians make medical decisions on treating patients with pulmonary embolism. Among these models, the Pulmonary Embolism Severity Index (PESI) has been shown to be a successful risk stratification tool for patients with acute pulmonary embolism. The PESI, however, had not been applied to patients with pulmonary embolism in Korea. Methods: The patients included in this study were diagnosed by computed tomography at Inje University`s Ilsan Paik Hospital between December 1999 and March 2007. Risk stratification for the patients was performed using the PESI. The mortality rate was calculated according to each PESI risk class. Results: Of the 90 patients enrolled in this study, ten were assigned to PESI class I, 29 to PESI class II, 22 to PESI class III, eight to PESI class IV, and ten to PESI class V. The mortality rate after 30 days in each class was 0, 10.3, 9.1, 0, and 50% (p=0.0016), respectively, whereas the respective hospital mortality rate was 4.8, 13.8, 13.6, 12.5, and 50% (p=0.0065). The overall mortality was 9.5, 27.6, 31.8, 50.0, and 60%, respectively (p=0.0019). The mortality rate was significantly associated with the PESI class. Conclusions: The PESI class was found to be significantly correlated with the 30-day mortality rate, hospital mortality, and overall mortality. Our data indicate that the PESI can be used to predict the prognosis of patients with pulmonary embolism and in making medical decisions regarding the treatment of patients with pulmonary embolism. (Korean J Intern Med 2009;24:123-127)

폐색전증의 약물치료: 새로운 항응고제

황헌규,김양기 대한의사협회 2022 대한의사협회지 Vol.65 No.7

Background: Pulmonary embolism is associated with reduced survival and considerable economic burden worldwide. In Korea, the incidence of pulmonary embolism has been gradually increasing. Older individuals are at an increased risk for pulmonary embolism and anticoagulation-related bleeding events. Typically, heparin and vitamin K antagonists are employed to treat pulmonary embolism; however, these agents present numerous limitations. Hence, novel anticoagulants with improved safety and efficacy profiles are urgently needed. Current Concepts: Direct oral anticoagulants (DOACs), including direct thrombin (coagulation factor II) inhibitors and selective inhibitors of coagulation factor Xa, have emerged as alternative agents. Phase III, large-scale clinical trials have revealed that DOACs are non-inferior to standard therapy during initial and long-term treatment of pulmonary embolism, considering the safety profile. Evidence-based clinical guidelines recommend that primary care clinicians employ DOACs over warfarin to achieve anticoagulation. Discussion and Conclusion: For over 70 years, the standard therapy for most patients with pulmonary embolism has involved heparin administration, overlapped and followed by a vitamin K antagonist. Recently developed DOACs against coagulation factor Xa or thrombin might overcome limitations of standard therapy, including the need for injection and regular dose adjustment with laboratory monitoring. These limitations hinder the management of patients with pulmonary embolism and negatively impact the patient’s quality of life. Four DOACs, including apixaban, dabigatran, edoxaban, and rivaroxaban, are currently available for treating pulmonary embolism in Korea, which could simplify the therapeutic strategy.

신경외과 환자에서 발생한 폐 색전증에 대한 고찰

권오기,오창완,정영섭,한대희 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.9

The purpose of this study was to understand the general features of pulmonary embolism in neurosurgical patients. The authors retrospectively reviewed 24 cases of pulmonary embolism from 1981 to 1994. The overall incidence of pulmonary embolism was 0.2%, but in the most prevalent year(1994) it was 1.3%. Lower extremity weakness and immobilization was the most common predisposing condition. Of 24 patients with pulmonary embolism, 23 patients showed lower extremity weakness, and the mean duration of immobilization was 47 days. Most patients (80%) had symptoms of pulmonary embolism within 4 weeks after operation. Medical prophylactic method had not been used in patients other than physical prophylactic method-graduated compression stocking. position change or physical therapy. Heparinization was given to 18 patients(75%), and minor hemorrhagic complication developed in 2 patients, but no major bleeding occurred. Inferior vena cava filter was applied in 2 patients. Only one patient suffered from recurrence and it was not fatal. Of the 24 patients. 7 died, however only one patient died of pulmonary embolism. In our study, the prognosis of pulmonary embolism was not as serious as it has been reported in the literature. However, more precise studies will be needed to understand the fate of pumonary embolism in Korean neurosurgical patients.

Pulmonary Edema after Catastrophic Carbon Dioxide Embolism during Laparoscopic Ovarian Cystectomy

이윤기,김은성,이해진 연세대학교의과대학 2008 Yonsei medical journal Vol.49 No.4

Laparoscopy is a surgical procedure used both for diagnosis and for various treatments. A rare but sometimes fatal complication of laparoscopy is pulmonary embolism with CO₂ resulting in pulmonary edema. During laparoscopic gynecological surgery in a 29-year-old woman who had previously undergone lower abdominal surgery, the end-tidal CO₂ suddenly increased from 40mmHg to 85mmHg and then decreased to 13mmHg with hemodynamic deterioration. These events are characteristic of a CO₂ embolism. When this occurred, CO₂ insufflation was immediately stopped and the patient was resuscitated. The patient's condition gradually improved with aggressive treatment, but the clinical course was complicated by bilateral pulmonary edema. This case of pulmonary edema was soon resolved with supportive management. The formation of a CO₂ embolism during laparoscopy must be suspected whenever there is a sudden change in the end-tidal CO₂. In addition, the possibility of pulmonary edema should be considered when a CO₂ embolism occurs.

호습기 대복재 정맥 혈전을 동반한 급성 폐색전증

유승민 ( Seung Min Ryu ),장문 ( Moon Jang ),권상창 ( Sang Chang Kwon ),김동현 ( Dong Hyun Kim ),김령훈 ( Ryung Hun Kim ),최영미 ( Young Mi Choi ),김준형 ( Jun Hyung Kim ) 대한내과학회 2015 대한내과학회지 Vol.88 No.6

Pulmonary embolism is most commonly related to deep vein thrombosis of the lower extremities. However, recent studies show that the thrombosis of superficial veins can also progress to deep vein thrombosis and pulmonary embolism. To our knowledge, there is no Korean report of pulmonary embolism associated with superficial vein thrombosis. We experienced an 82-year-old woman complaining of dyspnea and chest pain. On chest dynamic computed tomography (CT), pulmonary embolism was diagnosed. To evaluate the origin of the pulmonary embolism, abdominal CT, Doppler ultrasonography, and ascending venography of both lower extremities were done. We found no deep vein thrombosis, while thrombus of the proximal left greater saphenous vein was seen. We report a case of pulmonary embolism accompanying greater saphenous vein thrombosis without deep vein thrombosis. (Korean J Med 2015;88:696-700)