Embolisms, treatment

Unlabeled Uses Prevention of myocardial infarction, recurrent cerebral embolism treatment adjunct in transient ischemic attacks... 

It is indicated in the prophylaxis and treatment of deep vein thrombosis in major surgery and pulmonary embolism, treatment of atrial fibrillation with embolisation, prophylaxis and treatment of peripheral arterial embolism. 

Because resin microspheres carry less activity (50 Bq/ sphere) compared to glass microspheres, many more are used to deliver an adequate dose tumor. With upwards of 40 million-60 million delivered for a typical 2-GBq activity distributed in both lobes of the liver, many patients can experience temporary embolic side effects (pain, fever, nausea) which are similar but far less intense than is seen in TACE post-embolic symptoms. However, not all hepatic vascular beds can accept the number of microspheres desired from the pre-treatment planning formulae, and thus the delivery of microspheres discontinued prior to completely emptying the volume of microspheres planned. It is not the desire or plan to perform an embolic treatment, rather it is a brachyther-apy procedure and therefore it is recommended that the delivery of microspheres not cause stasis and/or reflux. Optimal implantation of microspheres is for the tumor only to have spheres, and the normal adjacent liver to be free of radiation. Once stasis has occurred, however, the normal liver arteries have also been filled with microspheres and the selectivity and therapeutic benefit to brachytherapy is lost. If the whole lobe or segment is receiving the same dose of radiation (tumor and normal liver) then external beam radiation could have been used instead. Also, many patients are selected for microsphere therapy specifically because an embolic treatment was not felt to be safe or in their best interests. 

Predisposing fiictors. The search for possible factors contributing to radioembolization induced liver toxicity has shown that the best pre-treatment risk indicator of liver toxicity is the total serum bilirubin level. There is a direct relationship between the pre-treatment total bilirubin value and risk of liver toxicity [11]. Radiation dose is also associated with the risk of liver toxicities, with doses ranging up to 150 Gy per treatment. It is not known how previous embolizing treatments (TAE and TACE) may influence radioembolization induced liver toxicity, however, concomitant chemotherapy with the... 

Reber PU, Baer HU, Patel AG, Wildi S, Triller J, Buchler MW (1998) Superselective microcoil embolization treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. J Am Coll Surg 186 325-330... 

Ahmad A, Qadan L et al (2002) Uterine artery embolization treatment of uterine fibroids effect on ovarian function in younger women. J Vase Interv Radiol 13 1017-20... 

One of the concerns of embolization treatment is the local radiation of the gonads. Reduction of radiation can be achieved with the combined approach of X-ray and ultrasound imaging to facilitate the supraselective embolization of the arteriocavern-ous fistula reducing the radiation exposure and the applied dose of contrast medium [8]. It seems rational to advise refrainment from reproductive activ-... 

Fig. 5 A proposed SMP foam for embolic treatment of aneurysms. A fiber optic cable is used for laser heating (a) and the expanded shape is shown to fiU the entire aneurysm in (b). (Reprinted with permission from [56] 2007, Springer publishing company)...

Chan RP, David E (2004) Reperfusion of splanchnic artery aneurysm following transcatheter embolization treatment with percutaneous thrombin injection. Cardiovasc Intervent Radiol 27 264-267... 

Maitland, D. J., et al. (2007). Prototype laser-activated shape memory polymer foam device for embolic treatment of aneurysms. BIOMEDO, 12(3), 030504-030501-030504-030503. 

Thrombolytic Enzymes. Although atherosclerosis and the accompanying vascular wall defects are ultimately responsible for such diseases as acute pulmonary embolism, arterial occlusion, and myocardial infarction, the lack of blood flow caused by a fibrin clot directly results in tissue injury and in the clinical symptoms of these devastating diseases (54). Thrombolytic enzyme therapy removes the fibrin clot by dissolution, and has shown promise in the treatment of a number of thrombo-occlusive diseases (60). 

Indications for treatment with streptokinase include acute occlusion of arteries, deep vein thrombosis, and pulmonary embolism. Streptokinase therapy in coronary thrombosis, which is the usual cause of myocardial infarction (54,71,72), has proved to be valuable. In this frequently fatal condition, the enzyme is adrninistered intravenously at a dose of 1.5 million units over 60 min, or given by intracoronary infusion at a 20,000- to 50,000-unit bolus dose followed by 2000 to 4000 units/min for 60 min therapy must be instituted as soon as practicable after the diagnosis of heart attack is made. For deep vein thrombosis, pulmonary embolism, or arterial occlusion, streptokinase is infused at a loading dose of 250,000 units given over 30 min, followed by a maintenance dose of 100,000 units over a 60-min period. 

Therapeutically t-PA and urokinase are the most important drugs for fibrinolytic therapy (myocardial infarction, stroke, massive pulmonary embolism). This treatment is associated with an enhanced risk of bleeding complications. 

Prevention and treatment of atrial fibrillation with embolization... 

Prevention and treatment of venous thrombosis, PE, peripheral arterial embolism ... 

The well-known adverse reaction formerly often observed after intramuscular injection of clemizol penicilUn in the treatment of syphilis with anaphylaxis-like symptoms plus CNS involvement in the absence of immimological sensitization to penicillin was called the Hoigne syndrome or embolic-toxic reaction, and might be explained by intravasal appUcation of LA with subsequent toxic effects [8]. 

Streptokinase is administered by intravenous or intra-arterial infusion in the treatment of thrombo-embolic disorders, e g. pulmonary embolism, deep-vein thrombosis and arterial occlusiorrs. It is also used in acute myocardial irtfarclioa... 

Dijkhuizen RM, Asahi M, Wu O, Rosen BR, Lo EH. Delayed rt-PA treatment in a rat embolic stroke model Diagnosis and prognosis of ischemic injury and hemorrhagic transformation with magnetic resonance imaging. J Cereb Blood Flow Metab. 2001 21 964-971. 

Mahon BR, Nesbit GM, Barnwell SL, Clark W, Marotta TR, Weill A, Teal PA, Qureshi Al. North American clinical experience with the EKOS MicroLysUS infusion catheter for the treatment of embolic stroke. Am J Neuroradiol 2003 24 534-538. 

The Heparin in Acute Embolic Stroke Trial (HAEST) was a multicenter, randomized trial of the effect of LMWH (dalteparin 100 lU/kg sc twice daily) or aspirin (160 mg once daily) for the acute treatment of 449 patients with ischemic stroke and atrial fibrillation (AF). The primary outcome was the rate of recurrent stroke within 14 days. No difference in rates of early recurrence (8.5% dalteparin treated vs. 7.5% aspirin treated) or good 3-month functional outcome was found. The frequency of early slCH was 2.7% on dalteparin versus 1.8% on aspirin. 

In stroke patients presenting to the ED, the first goal of treatment is immediate cardiac and respiratory stabilization. The systemic blood pressure is most often elevated in the setting of an acute stroke as the result of a catecholamine surge, and if the patient is hypotensive, the clinician should consider a concomitant cardiac process, such as myocardial infarction (MI), congestive heart failure (CHF), or pulmonary embolism (PE). 

Pulmonary embolism most commonly develops in patients with risk factors for VTE (Table 7-2) during or following a hospitalization. While many patients will have symptoms of DVT prior to developing a PE, many do not. Patients may die suddenly before effective treatment can be initiated. 

FIGURE 7-11. Treatment of venous thromboembolism. LMWH, low-molecular-weight heparin PE, pulmonary embolism SBP, systolic blood pressure UFH, unfractionated heparin VTE, venous thromboembolism. (Reproduced from Haines ST, Zeolla M, Witt DM. Venous thromboembolism. In DiPiro JT, Talbert RL, Yee GC, et al, (eds.) Pharmacotherapy A Pathophysiologic Approach. 6th ed. New York McGraw-Hill 2005 398, with permission.)... 

FIGURE 14-2. Treatment of venous thromboembolism (VTE). (LMWH, low-molecular-weight heparin PE, pulmonary embolism SBP, systolic blood pressure UFH, unfractionated heparin.)... 

Tamoxifen users present also a doubling incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) (118 vs. 62 cases). This increase is similar to that seen with HRT. There are some aspects of this side effect that should be commented on to improve the management of women eligible for tamoxifen treatment and at risk for DVT (Goldhaber 2005). In the subanalysis of the Italian study (Decensi et al. 2005), the venous thromboembolism definition included DVT, PE, and superficial phlebitis. Most of the VTE that the authors reported were, in fact, cases of superficial phlebitis, whereas the admitted definition of venous thromboembolism excludes this entity. Such conceptual differences, together with differences in age and background characteristics between the four studies, can explain the diversity in the incidences observed. 

Uterine leiomyomas, or fibroids, are the most common type of solid tumors in adult women, clinically apparent in at least 25% of those of reproductive age [24-26]. Abnormal menstrual bleeding, pelvic pain, and infertility are the most commonly experienced symptoms in these women. Uterine fibroids are the leading cause of hysterectomies performed in the United States, accounting for over 200,000 of these procedures each year. Other invasive surgical interventions for the treatment of uterine fibroids include myomectomy and uterine artery embolization. Leiomyomas are estrogen-responsive tumors that can be treated... 

In CEA, the total cost and the total benefits, measured in terms of an efficacy parameter, associated with two or more treatment pathways are added, and the increment is calculated. The incremental costs are then compared (in a ratio) with incremental outcomes (as measured in physical or natural emits). Physical and natural units can include both intermediate (surrogate) clinical endpoints (e.g. millimetres of mercury blood pressure reduction, changes in FEVi) or final endpoints (e.g. deaths averted or life-years gained). In a study that assessed the cost per deaths due to pulmonary embolism averted, Hull and associates reported that subcutaneous administration of... 

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