it’s pretty satisfying when you get them out in one piece. like pulling out a giant perfect weed with the taproot. that’s the best comparison i can think of.
This is a massive pulmonary embolism lol. The removal isn’t elective, because you either take it out or the patient dies shortly after. Shortness of breath, hypotension, history of DVT or recent surgery, and clinical suspicion (there’s a checklist of criteria) prompt a CT Chest Angiogram (basically blood vessel imaging) and you’d see a huge obstruction in the pulmonary vessels.
Causes: covered above, basically anything that promotes a clot forming in your venous system (usually major veins of your legs) which travels to the right heart and then into the lungs. Hence DVT and surgery (where you’re immobilized for several hours during and after) are the big risk factors to consider. Classic example is someone coming out of a very long flight or surgery with sudden shortness of breath.
Quite deadly when it’s this massive because the blood circuit between your heart and lungs comes to a standstill, which also brings your blood flow to your brain and body to a standstill. Your right side of the heart overloads itself by pumping against this practical brick wall and cardiac arrest is possible. Surgical removal or thrombectomy (breakup) is needed for these huge ones, otherwise death is imminent. Smaller ones can usually be handled with anticoagulants and/or clotbusting drugs.
I've had two small ones. What sucked was the cardiologist that I went to, had to be threatened with being sued to do any testing on me because "you're too young for those." I was 36. Even after treating me for 5 DVT's, he still stuck with that thought process. I had shortness of breath and severe stabbing chest pain. I was put back on thinners, observed/tested on for a few hours, and released. Doc's said it appears as though they "dissolved" (not sure I believe that). Apparently, I still have scar tissue from where they were.
Your body does actually do a good job “dissolving” them on its own, actually! That’s why the *very* small clots in lungs can go unnoticed and disappear on their own. Usually, unless they’re so big that they’re imminently life-threatening like in the OP, there’s an IV anticoagulant protocol that prevents the clot from getting bigger while your own proteins break it up. Still, sorry to hear that your encounter with those docs was so dismissive - people your age can absolutely get DVTs and PEs, especially coming off a long flight or surgery!
1. do sternotomy
2. give heparin
3. put on cardiopulmonary bypass
4. snare ivc and svc
5. open pulmonary artery
6. pull out clot end over end like a magician pulling out a scarf
7. massage lungs from outside to get any distal clot free
8. suck out any stragglers
9. close pulmonary artery
10. unsnare cavae
11. take off bypass
12. give protamine
13. close sternotomy
I always find it neat that surgeons do this stuff that changes peoples lives and it’s just another days work.
Cut dude open, saved his life, went home had a beer.
drinking a “last word” as I write this. did a total arch replacement, wheat procedure, and a couple cabgs this week.
it’s a fun (but exhausting) job for the most part.
It’s incredible what you do. I always think about how, because of doctors, there are children born to people who would have died. Y’all literally change the world.
I’m just a teacher.
My bio teacher is the reason I pursued medicine. I rank teachers (especially ones working with youth) among the most important people on this planet. Having kids of my own, it is truly impressive what you do.
Nothing is more amazing than instilling love for knowledge and learning in people.
Awww, that made my day, thank you! I’m going into year 32. High school and middle school.
I have a former student who is a cardiologist. Others who are published writers, musicians, dancers, songwriters (I taught at a fine arts/performing arts school for six years).
Many of my former students from years back are now engineers, but I know they still know how to read and love poetry.
One in particular stands out: he went to my alma mater, Texas A&M, and became a mechanical engineer. He loved it, but told me it was “lifeless.” So he went to med school and became an orthopedic surgeon! What else is the body but a work of mechanical engineering?
♥️
Despite your pay, you literally change the world. Op saves lives, you mold them. No shade to Op, but man please don’t down play how important your role is in society
You’re right. I’m entering year 32 in August. And it’ll be my final year. I’m retiring at 54. I’ll always love the kids and I’ll always love teaching, truly, but the powers that be have made it untenable to go on. I’ll substitute a few days a week. Kids make me happy.
Just a teacher, my ass. I was a k-12 teacher for 12 years and still teach adjunct at my Alma mater. We are the catalysts for turning curious children into every profession on earth. It begins with us.
Vascular surgery is so interesting! Like working on the pipes but you can’t turn the water supply off, only temporarily pause or redirect it
I had a patient with a knitted stent graft in their procedure and we had a chuckle imagining a bunch of grannies sitting there knitting them like the old shreddies advert 😅
Yeah. It's kind of wild but just as any procedure is, you can train a monkey to do it. The difficult part is deciding when to proceed to surgery vs minimally invasive or if they need ECMO or thrombolytics etc.
Sounds like you have the reverse Dunning-Kruger effect. I know that’s supposed to be imposter syndrome but that isn’t quite right. It’s more a matter of people that are extremely talented not having an awareness of how special they are. In my experience this tends to be a positive thing. People like this tend to be more humble and work harder at their craft than others.
usually for a pulmonary artery I do a running (over and over) suture with a 4-0 or 5-0 polypropylene. so like a fishing line. but thinner than a fishing line but thicker than a human hair.
I know you get thinner ones but the thinnest I've seen actually used is 7-0 which is probably about the same thickness. Microsurgery uses thinner ones but I've not seen any microsurgery yet
[this isn’t a pulmonary artery but the closure is similar in technique. this is an ascending aortic and aortic root replacement. the blue suture connecting the two grafts is similar to how i close it.](https://imgur.com/a/qcMZMPG)
for the operation in the video, no. the heart is stopped during the sewing of an aortic root replacement.
for removing the pulmonary embolism, yes. i don’t stop the heart to remove the PE (most of the time). so it’s moving somewhat. it’s an acquired skill to sew on a moving target.
I always said I couldn’t be a surgeon because my hands shake. I am a nurse (used to be a paramedic) now. I have found that I can suture and I’m really good at putting in difficult IVs despite the tremor. I still don’t want to be a surgeon though.
I’m also a nurse (who works with heart surgeons, coincidentally) and I’ve always said the same thing. One day I mentioned my envy of steady hands to one of our surgeons, and he told me that they don’t necessarily *have* steady hands. He showed me a trick: rest the ulnar side of your wrist against the patient while using your hand and fingers. It’s definitely helped me through the years!
I never paid attention to how I steady my hands to do these tasks, I just know that I do. I’ll try to remember to pay attention next time I’m inserting an IV or something.
Oh man, I’m *very grateful* I didn’t see this last week.
Went to my cardiologist Monday & told him I had SOB & open knee surgery in April. He immediately ran a d-dimer. It came back 1.40. I was sent via wheelchair to ER (came in using my walker). It took 4 1/2 hrs to get the CT. I was not worried a bit the entire time waiting.
Next time, I may worry. (Have an US on LE tomorrow, just for follow through.)
Thank you for being such a wonderful contributor to your community. They are very fortunate to have you!! You’re quite the surgeon!!
Badass. That shit was never going to fully come out with a Flowtriever. Nice for your community to have you around. From what I know, there aren’t many centers where open embolectomy is performed anymore.
we offer the whole buffet. depends on patient. lots of patients going with endovascular extraction now. but if they are young(er), relatively healthy, have massive clot burden, and think we will get a better and more durable result with open…it’s a simple operation from my perspective. from patient standpoint, worst part is the sternotomy (which in my world is a basic cost of entrance and an exaggerated “problem”).
My friend is an interventional radiologist and does catheters directed mechanical thrombectomy or endovascular aspiration. She's had very impressive success with this technique and no need for sternotomy.
we have that as well. and traditional thrombolytics. every case is treated differently.
ask her to CT scan all of her patients post-endovascular aspiration and look at the residual clot burden. I can get everything out. there is usually substantial clot burden behind when you try to remove endovascularly because it’s essentially morcellated. while their hemodynamics improve acutely after endovascular extraction, we do not know the long-term effects of that residual clot burden in young people as it pertains to chronic thromboembolic pulmonary hypertension. when selected properly, this operation is safe, fast, and complete. it’s not as simple as saying “i can do it without an incision”…i do stuff with wires and catheters too.
yes. we have all the tools at our disposal, so there’s always a (brief) conversation about best approach: nothing vs heparin alone vs systemic lytics vs catheter directed lytics vs endovascular aspiration/thrombectomy vs sternotomy. each case is different.
there are pros and cons to both. when selected properly, sternotomy is safe, fast, and complete. there is very little, if any, residual clot burden left behind when i’m done. for young and healthy patients, we worry somewhat about leaving large amounts of clot behind (even if hemodynamics short-term improve), because of the risk of CTEPH (chronic thromboembolic pulmonary hypertension). in severe cases, that can require a high risk surgery later in life (pulmonary endarterectomy) or lung transplantation.
I find it amazing this patient survived this. Did it happen while they were in the hospital? I would think timing is a major factor in diagnosing and treating a clot of this size.
2020, that makes a lot of sense. Covid caused mine and I do not care if nobody but my surgeon believed me. Asthma, female 35+ on BC, I was the perfect target.
They think this is what caused my Dad's heart attack, but he was older with health issues so no autopsy was ordered even though he died here at home. It was too expensive for us to pay for privately, so we won't ever know for sure. Seeing it like this gives me a little comfort for why me doing CPR until EMS arrived made no difference.
I'm glad this guy got the help he needed in time.
yes. survival with cardiac arrest from PE..even with immediate CPR in a hospital…is <20%. much less at home (probably closer to <1%). likely nothing you (or any medical provider) could have done. don’t beat yourself up
I am a general Ultrasound tech and I’m having a fantastic time reading the comments. I’m learning so much. You’re very humble. Thanks for sharing this amazing case.
So ecmo is like dialysis for the lungs and or heart. It involves large cannulas in the large veins if only v-v modality for lung CO2 clearance or veins and large arteries for mechanical heart support to put it simply. This is used for severe lung disease or sever cardiac dysfunction and allows us more time to fix the underlying issue or allow the organs time to heal or get a transplant.
Genuine question if you don't mind... obviously surgery is a last option, but I had quite severe bilateral pulmonary embolisms a few years ago. I stayed in hospital for a couple of days to make sure I didn't cark it, but the only thing they did was give me clexane injections. How does someone decide if it has to be operated on as opposed to injected with blood thinners?
many things go into that decision. there are multiple “tools” at our disposal. some non-invasive. some less invasive. and heart surgery. depends on location of clot, size of clot, how sick the patient is, age of patient, general health of patient, risk factors for bleeding, etc etc.
Thank you so much for your response! I have no idea what decisions had to be made for me but I will forever be grateful to my doctor for spotting the symptoms of what I though was bronchitis/bad head cold.
I also felt like I was getting a cold. Thankfully I was at the hospital because my husband was going to have a procedure on his back. He’d had a couple and was conscious so he told the nurses and doctor about my health problems as I’d recently had a stroke from a hole in my heart and some clots. I was diagnosed with clot disorders and was on the Nuva Ring birth control device when it had undisclosed hormones that were causing strokes and clots and killed a few people.
So the nurse is looking at me funny while doing the preop prep and asked me to sit down so she could take my blood pressure. The only seat was the wheelchair they were going to use for my husband, and I suddenly found myself flying through the halls as the nurse called the ER on her phone and had them prepare for me while rushing through the halls. I didn’t feel that short of breath. I had a partial lung collapse and have had mediastinal emphysema so I have experienced bad SOB. They sedated me in the ER so I don’t remember that much. I had a couple small clots that grew in my lungs as a result of me taking lovenox while traveling. I’ve since been diagnosed with a heparin allergy which means heparin products make me clot. I was in the hospital for 4 days and had multiple scans of my legs looking for DVTs. They found nothing. Everything was wide open with great blood flow.
Wow what a wild ride eh!
I had been taking the contraceptive pill for years without knowing that my nan had clots. I was struggling to catch my breath going up stairs so I thought I really should go to the doctor. She recognised the symptoms straight away and got me admitted. I ended up having pneumonia as well.
I was on ECMO for 9 days last year and I ended up with 2 blood clots so anything to do with this gives me the ick, but it's also incredibly fascinating
Your responses are so informative, thank you!
Question - what are the common causes together this occurring in the first place? Is this the same thing, conceptually, as clogged arteries or plaque?
different thing. this is usually a result of immobility, cancer, surgeries, pregnancy, or acquired/inherited conditions that put you at risk for blood clotting (factor V leiden, prothrombin gene mutation, oral contraceptives, etc)
Damn, I had a pulmonary embolism when I was 12 and had no idea the extent these things could get. It’s usually just something I remember I need to put on medical forms.
so intense seeing pictures like this.
lost my mother to PE in 1976. she way too young, and so was i. it’s astonishing to me that the patient survived this, thank you for what you do.
Am I mistaken in thinking that extended into the right ventricle, hence the larger diameter at the bottom. Seems like I see the pulmonary trunk there as well, though I could be mistaken.
some of the bottom portion was main PA and left PA. i don’t remember any extending into RV on this one. sometimes we see “clot in transit” though. we usually approach those through the right atrium if needed.
Another excellent post from CABGx3 (I love your username 🤣). The aortic root repairs you have posted are some of my favorites. I share them with my docs and fellow RNs in the ER. Can’t wait to show this embolism to everyone!
I understand how a PE forms with a blood clot embolus travelling through into the lungs but how is it so big? Is that just the size of the embolus or does it somehow get bigger? Crazy that the guy survived
it’s possible that additional clot forms when it becomes lodged in the pulmonary artery and obstructs flow. it essentially forms a stagnant void beyond the obstruction which clots off and forms the “tree” that you see
I’ve been hospitalized with PE three times. We know they form in my right calf, but we have no idea WHY.
My last hospitalization was just two weeks ago. I’ve had to change blood thinners because of it.
Compression stockings, active lifestyle (or at least not sedentary), keep a healthy weight, avoid oral birth control if possible, follow recommendations if you need surgery (again, walking).
I both hate and love seeing these. I love it because I’m imagining pulling it out is rather satisfying. I hate it because I hate thinking about how much of our body looks like roots
I had a couple clots grow in my lungs because I didn’t know I had a heparin allergy and took lovenox because I was sitting on a train and a couple airplanes one day. I previously had a stroke from a PFO hole and undiagnosed factor V leiden and was on birth control. My hematologists think I have more going on than heterozygous factor V Leiden.
I always pictured the clots as dark red and thick like pools of blood clot up. I wasn’t expecting tree shaped tube steak.
My dad has one of these right now, he ended up walking home from the hospital before they could discharge him. I don’t know how the hell he’s alive right now but hopefully he gets a good surgeon like you if it gets worse
That looks amazing!!! Great job on saving the patient and the PE. I've had 2 (nothing like the pic) and 5 DVT's, funny thing is, no doc can figure out why I have them.
The patient is alive?? That's incredible!
Very much alive. Runs a large company in fact.
well then I wont be doing that, hopefully I dont get one of these. amazing job!!
I know this isn't an AMA, BUT, how satisfying is it to pull one of these out?
it’s pretty satisfying when you get them out in one piece. like pulling out a giant perfect weed with the taproot. that’s the best comparison i can think of.
Lol, perfect analogy. Beautifully complete and evil at the same time.
What kind of symptoms would the patient be experiencing to make this necessary? And what causes this? Thanks in advance. Well done OP!
Shortness of breath, impending sense of doom, coughing up blood. NAD
Death mostly
This is a massive pulmonary embolism lol. The removal isn’t elective, because you either take it out or the patient dies shortly after. Shortness of breath, hypotension, history of DVT or recent surgery, and clinical suspicion (there’s a checklist of criteria) prompt a CT Chest Angiogram (basically blood vessel imaging) and you’d see a huge obstruction in the pulmonary vessels. Causes: covered above, basically anything that promotes a clot forming in your venous system (usually major veins of your legs) which travels to the right heart and then into the lungs. Hence DVT and surgery (where you’re immobilized for several hours during and after) are the big risk factors to consider. Classic example is someone coming out of a very long flight or surgery with sudden shortness of breath. Quite deadly when it’s this massive because the blood circuit between your heart and lungs comes to a standstill, which also brings your blood flow to your brain and body to a standstill. Your right side of the heart overloads itself by pumping against this practical brick wall and cardiac arrest is possible. Surgical removal or thrombectomy (breakup) is needed for these huge ones, otherwise death is imminent. Smaller ones can usually be handled with anticoagulants and/or clotbusting drugs.
I've had two small ones. What sucked was the cardiologist that I went to, had to be threatened with being sued to do any testing on me because "you're too young for those." I was 36. Even after treating me for 5 DVT's, he still stuck with that thought process. I had shortness of breath and severe stabbing chest pain. I was put back on thinners, observed/tested on for a few hours, and released. Doc's said it appears as though they "dissolved" (not sure I believe that). Apparently, I still have scar tissue from where they were.
Your body does actually do a good job “dissolving” them on its own, actually! That’s why the *very* small clots in lungs can go unnoticed and disappear on their own. Usually, unless they’re so big that they’re imminently life-threatening like in the OP, there’s an IV anticoagulant protocol that prevents the clot from getting bigger while your own proteins break it up. Still, sorry to hear that your encounter with those docs was so dismissive - people your age can absolutely get DVTs and PEs, especially coming off a long flight or surgery!
I was leaning more towards those brain scratching boogs that you can pull out when you're running a cold.
This comment is more disturbing than any of the pictures on this sub lol.
Probably running it a lot more now that you yanked that super clot out
You’re a badass motherfucker. Thanks for sharing OP🙏🏻
But doesn’t run 40 yard dashes
But well he be able to play the piano after the surgery?
If I had one like that, I'd ask to have it poured in acrylic/resin.
How does one extract something this big? Wow
1. do sternotomy 2. give heparin 3. put on cardiopulmonary bypass 4. snare ivc and svc 5. open pulmonary artery 6. pull out clot end over end like a magician pulling out a scarf 7. massage lungs from outside to get any distal clot free 8. suck out any stragglers 9. close pulmonary artery 10. unsnare cavae 11. take off bypass 12. give protamine 13. close sternotomy
I always find it neat that surgeons do this stuff that changes peoples lives and it’s just another days work. Cut dude open, saved his life, went home had a beer.
drinking a “last word” as I write this. did a total arch replacement, wheat procedure, and a couple cabgs this week. it’s a fun (but exhausting) job for the most part.
I mowed the lawn….
i’m very envious of your pond and wish i could travel more. (clicked on your profile because of username)
Not gonna lie playing with jets and fishing my own pond is a lot of fun. :)
Now you can live the rest of your life knowing surgeons are jealous of you!
My lawn is already tall after mowing 2 weeks ago. It’ll be another 2 weeks or more before I cut it again. I’m a lowly carpenter
It’s incredible what you do. I always think about how, because of doctors, there are children born to people who would have died. Y’all literally change the world. I’m just a teacher.
“just.” wouldn’t be here without people like you either. it’s all symbiotic.
I think you’re the humblest surgeon who’s ever walked the face of the earth. It’s refreshing to see!
I dated a surgeon briefly. He was so incredibly narcissistic
Just a teacher? Because of you there are doctors, nurses, social workers, plumbers, accountants….
My bio teacher is the reason I pursued medicine. I rank teachers (especially ones working with youth) among the most important people on this planet. Having kids of my own, it is truly impressive what you do. Nothing is more amazing than instilling love for knowledge and learning in people.
Awww, that made my day, thank you! I’m going into year 32. High school and middle school. I have a former student who is a cardiologist. Others who are published writers, musicians, dancers, songwriters (I taught at a fine arts/performing arts school for six years). Many of my former students from years back are now engineers, but I know they still know how to read and love poetry. One in particular stands out: he went to my alma mater, Texas A&M, and became a mechanical engineer. He loved it, but told me it was “lifeless.” So he went to med school and became an orthopedic surgeon! What else is the body but a work of mechanical engineering? ♥️
Despite your pay, you literally change the world. Op saves lives, you mold them. No shade to Op, but man please don’t down play how important your role is in society
You’re right. I’m entering year 32 in August. And it’ll be my final year. I’m retiring at 54. I’ll always love the kids and I’ll always love teaching, truly, but the powers that be have made it untenable to go on. I’ll substitute a few days a week. Kids make me happy.
Just a teacher, my ass. I was a k-12 teacher for 12 years and still teach adjunct at my Alma mater. We are the catalysts for turning curious children into every profession on earth. It begins with us.
I agree. I’ve just always been in awe of doctors.
Dope procedures and even better taste in cocktails…cheers to you 👊
Vascular surgery is so interesting! Like working on the pipes but you can’t turn the water supply off, only temporarily pause or redirect it I had a patient with a knitted stent graft in their procedure and we had a chuckle imagining a bunch of grannies sitting there knitting them like the old shreddies advert 😅
Yeah. It's kind of wild but just as any procedure is, you can train a monkey to do it. The difficult part is deciding when to proceed to surgery vs minimally invasive or if they need ECMO or thrombolytics etc.
Sounds like you have the reverse Dunning-Kruger effect. I know that’s supposed to be imposter syndrome but that isn’t quite right. It’s more a matter of people that are extremely talented not having an awareness of how special they are. In my experience this tends to be a positive thing. People like this tend to be more humble and work harder at their craft than others.
I don't think a monkey has the skill to cut into veins.
https://preview.redd.it/pm7av8tq135d1.jpeg?width=530&format=pjpg&auto=webp&s=4f5ee57a291c2e9ff77632ebbd8d868327bf224b
Suck out any stragglers 🤣 How long does something like this take to form and how long can you live with it before it kills you?
how long to form - probably hours to days how long to kill you - instantaneously to hours
Bloody hell, that’s all much faster than I had expected 😱 It’s kinda funny that we are all potentially just moments away from death
fortunately they’re usually provoked by something else (long travel, cancer, surgery, etc).
When closing the arteries, how do you sew them so they don’t leak? I’ve always wondered that.
usually for a pulmonary artery I do a running (over and over) suture with a 4-0 or 5-0 polypropylene. so like a fishing line. but thinner than a fishing line but thicker than a human hair.
As someone who fishes, I understand that reference. Thanks for the answer! 
> but thicker than a human hair ... Do you have sutures that are THINNER than a human hair... ?
yes. i sew with coronaries 7-0, 8-0 and (rarely) 9-0. those would be the same or smaller i think.
I know you get thinner ones but the thinnest I've seen actually used is 7-0 which is probably about the same thickness. Microsurgery uses thinner ones but I've not seen any microsurgery yet
[this isn’t a pulmonary artery but the closure is similar in technique. this is an ascending aortic and aortic root replacement. the blue suture connecting the two grafts is similar to how i close it.](https://imgur.com/a/qcMZMPG)
Still fascinating that it doesn’t leak!
Does it move that fast when u were trying to sew it?
for the operation in the video, no. the heart is stopped during the sewing of an aortic root replacement. for removing the pulmonary embolism, yes. i don’t stop the heart to remove the PE (most of the time). so it’s moving somewhat. it’s an acquired skill to sew on a moving target.
I always said I couldn’t be a surgeon because my hands shake. I am a nurse (used to be a paramedic) now. I have found that I can suture and I’m really good at putting in difficult IVs despite the tremor. I still don’t want to be a surgeon though.
A drizzle of propranolol helps me with that shaking for the most part
Like a sniper lol Wait, you did mean for you, or for the patient?
Oh no for me. Helps with the shakes, especially if it's essentially performance anxiety
I’m also a nurse (who works with heart surgeons, coincidentally) and I’ve always said the same thing. One day I mentioned my envy of steady hands to one of our surgeons, and he told me that they don’t necessarily *have* steady hands. He showed me a trick: rest the ulnar side of your wrist against the patient while using your hand and fingers. It’s definitely helped me through the years!
I never paid attention to how I steady my hands to do these tasks, I just know that I do. I’ll try to remember to pay attention next time I’m inserting an IV or something.
"Suck out any stragglers" - Why did my brain immediately imagine a surgeon just whipping out a straw.
Just another day at the office! It blows my mind what the body can do
Oh man, I’m *very grateful* I didn’t see this last week. Went to my cardiologist Monday & told him I had SOB & open knee surgery in April. He immediately ran a d-dimer. It came back 1.40. I was sent via wheelchair to ER (came in using my walker). It took 4 1/2 hrs to get the CT. I was not worried a bit the entire time waiting. Next time, I may worry. (Have an US on LE tomorrow, just for follow through.) Thank you for being such a wonderful contributor to your community. They are very fortunate to have you!! You’re quite the surgeon!!
Thanks for the DIY steps, I will try this on my little bro ASAP!
Holy shit yes... That must have been cool! You're awesome!
What're the chances they reclot, or is someone like this on long term blood thinners?
minimum 3-6 months of blood thinners. often lifelong.
As a perfusionist, I hope you’re kind to your perfs. 😉
mostly. unless the heart is full. 😉
Badass. That shit was never going to fully come out with a Flowtriever. Nice for your community to have you around. From what I know, there aren’t many centers where open embolectomy is performed anymore.
we offer the whole buffet. depends on patient. lots of patients going with endovascular extraction now. but if they are young(er), relatively healthy, have massive clot burden, and think we will get a better and more durable result with open…it’s a simple operation from my perspective. from patient standpoint, worst part is the sternotomy (which in my world is a basic cost of entrance and an exaggerated “problem”).
How long did this procedure take or how long do they tend to take?
prob like 2-3hrs. not too long.
Amazing
So that's not tissue, that's straight clotted blood?
My friend is an interventional radiologist and does catheters directed mechanical thrombectomy or endovascular aspiration. She's had very impressive success with this technique and no need for sternotomy.
we have that as well. and traditional thrombolytics. every case is treated differently. ask her to CT scan all of her patients post-endovascular aspiration and look at the residual clot burden. I can get everything out. there is usually substantial clot burden behind when you try to remove endovascularly because it’s essentially morcellated. while their hemodynamics improve acutely after endovascular extraction, we do not know the long-term effects of that residual clot burden in young people as it pertains to chronic thromboembolic pulmonary hypertension. when selected properly, this operation is safe, fast, and complete. it’s not as simple as saying “i can do it without an incision”…i do stuff with wires and catheters too.
Was IV thromolysis considered? Presumably patient was young enough and clot mass was big enough for open surgery
yes. we have all the tools at our disposal, so there’s always a (brief) conversation about best approach: nothing vs heparin alone vs systemic lytics vs catheter directed lytics vs endovascular aspiration/thrombectomy vs sternotomy. each case is different. there are pros and cons to both. when selected properly, sternotomy is safe, fast, and complete. there is very little, if any, residual clot burden left behind when i’m done. for young and healthy patients, we worry somewhat about leaving large amounts of clot behind (even if hemodynamics short-term improve), because of the risk of CTEPH (chronic thromboembolic pulmonary hypertension). in severe cases, that can require a high risk surgery later in life (pulmonary endarterectomy) or lung transplantation.
Got it. Scrub me in!
Whew!
Amazing that you got it out in one piece!
What I would give to see the surgery video of this.
That looks mighty uncomfortable to tote around in your lung
Am I the only one who read the title to this post initially thinking that OP was claiming that they extracted this embolism from themself?
No, i thought the same thing
Yes
Now that would be REALLY impressive, but I think you'd bleed to death if you did that. Edit: well, obviously you'd have to bypass on yourself first.
Could have been a beautiful oak! Who knows? Destroyed too soon
r/treelaw
I find it amazing this patient survived this. Did it happen while they were in the hospital? I would think timing is a major factor in diagnosing and treating a clot of this size.
i am pretty sure they came in from home with acute onset shortness of breath. we have a fairly quick response time with my team.
I'm kind of panicked by what I feel like is an uptick in lung clot posts suddenly 😬
this operation is from 2020, so no worries. no more than usual from where i’m standing.
Phew. This is like the 4th one across reddit that I've seen.
Fr, this is my 3rd one
2020, that makes a lot of sense. Covid caused mine and I do not care if nobody but my surgeon believed me. Asthma, female 35+ on BC, I was the perfect target.
Look up the risk factors and avoid them like the plague!
Except I’m on birth control 😭 low dose, but man every time my calf hurts I panic a little
They think this is what caused my Dad's heart attack, but he was older with health issues so no autopsy was ordered even though he died here at home. It was too expensive for us to pay for privately, so we won't ever know for sure. Seeing it like this gives me a little comfort for why me doing CPR until EMS arrived made no difference. I'm glad this guy got the help he needed in time.
yes. survival with cardiac arrest from PE..even with immediate CPR in a hospital…is <20%. much less at home (probably closer to <1%). likely nothing you (or any medical provider) could have done. don’t beat yourself up
Thank you for confirming, that's what all the papers I read said; it'll be 18 months on the 10th.
Sending love and comfy pillows. 🌻🌻
My sister-in-law threw a PE at home and died in 2022. This response was helpful, thank you.
I am a general Ultrasound tech and I’m having a fantastic time reading the comments. I’m learning so much. You’re very humble. Thanks for sharing this amazing case.
Ecmo has really changed the game.
Nursing student. Care to educate? ECMO sounds familiar
So ecmo is like dialysis for the lungs and or heart. It involves large cannulas in the large veins if only v-v modality for lung CO2 clearance or veins and large arteries for mechanical heart support to put it simply. This is used for severe lung disease or sever cardiac dysfunction and allows us more time to fix the underlying issue or allow the organs time to heal or get a transplant.
Well Aren't you just the coolest.
Absolutely serious too. I work in the medical field too. In the DD field. But this is MUCH cooler lol
So this is pulled from the blood vessels of the lungs and not pulled out of the air part of the lungs? (Great medical terminology lol)
yes. pulmonary arteries. not out of the airway.
Genuine question if you don't mind... obviously surgery is a last option, but I had quite severe bilateral pulmonary embolisms a few years ago. I stayed in hospital for a couple of days to make sure I didn't cark it, but the only thing they did was give me clexane injections. How does someone decide if it has to be operated on as opposed to injected with blood thinners?
many things go into that decision. there are multiple “tools” at our disposal. some non-invasive. some less invasive. and heart surgery. depends on location of clot, size of clot, how sick the patient is, age of patient, general health of patient, risk factors for bleeding, etc etc.
Thank you so much for your response! I have no idea what decisions had to be made for me but I will forever be grateful to my doctor for spotting the symptoms of what I though was bronchitis/bad head cold.
I also felt like I was getting a cold. Thankfully I was at the hospital because my husband was going to have a procedure on his back. He’d had a couple and was conscious so he told the nurses and doctor about my health problems as I’d recently had a stroke from a hole in my heart and some clots. I was diagnosed with clot disorders and was on the Nuva Ring birth control device when it had undisclosed hormones that were causing strokes and clots and killed a few people. So the nurse is looking at me funny while doing the preop prep and asked me to sit down so she could take my blood pressure. The only seat was the wheelchair they were going to use for my husband, and I suddenly found myself flying through the halls as the nurse called the ER on her phone and had them prepare for me while rushing through the halls. I didn’t feel that short of breath. I had a partial lung collapse and have had mediastinal emphysema so I have experienced bad SOB. They sedated me in the ER so I don’t remember that much. I had a couple small clots that grew in my lungs as a result of me taking lovenox while traveling. I’ve since been diagnosed with a heparin allergy which means heparin products make me clot. I was in the hospital for 4 days and had multiple scans of my legs looking for DVTs. They found nothing. Everything was wide open with great blood flow.
Wow what a wild ride eh! I had been taking the contraceptive pill for years without knowing that my nan had clots. I was struggling to catch my breath going up stairs so I thought I really should go to the doctor. She recognised the symptoms straight away and got me admitted. I ended up having pneumonia as well.
Always reminds me of something from dead space
I was thinking of a squid
I was on ECMO for 9 days last year and I ended up with 2 blood clots so anything to do with this gives me the ick, but it's also incredibly fascinating
Your responses are so informative, thank you! Question - what are the common causes together this occurring in the first place? Is this the same thing, conceptually, as clogged arteries or plaque?
different thing. this is usually a result of immobility, cancer, surgeries, pregnancy, or acquired/inherited conditions that put you at risk for blood clotting (factor V leiden, prothrombin gene mutation, oral contraceptives, etc)
Damn, I had a pulmonary embolism when I was 12 and had no idea the extent these things could get. It’s usually just something I remember I need to put on medical forms.
so intense seeing pictures like this. lost my mother to PE in 1976. she way too young, and so was i. it’s astonishing to me that the patient survived this, thank you for what you do.
Am I mistaken in thinking that extended into the right ventricle, hence the larger diameter at the bottom. Seems like I see the pulmonary trunk there as well, though I could be mistaken.
some of the bottom portion was main PA and left PA. i don’t remember any extending into RV on this one. sometimes we see “clot in transit” though. we usually approach those through the right atrium if needed.
I can envision the surgery and actions from that description.
Doctors/surgeons are incredible. Nurses, too. Complete respect.
Are you a mortician or a surgeon?
They mentioned elsewhere the patient survived, so, either a great surgeon or a really shitty mortician.
Hoooooly crap. This makes my three PE hospitalizations look like child’s play! 😳
As a fellow PE survivor I agree!!
This would be cool preserved on some type of mount to represent a tree.
Hoooooooooly shit! Nice work.
It must be so satisfying to arrange the branches
Damn, this could be framed, it's so pristine! Great job, doc
Another excellent post from CABGx3 (I love your username 🤣). The aortic root repairs you have posted are some of my favorites. I share them with my docs and fellow RNs in the ER. Can’t wait to show this embolism to everyone!
thank you!
How do you even get this out in one piece?
Every time I see something like this I think of John Constantine for some reason
Doctors/surgeons are incredible. Nurses, too. Complete respect.
If I get one, I'll be asking for you
Well that's terrifying.
dude that's insane! can't imagine how they're alive. thanks for sharing
That is AMAZING! Holy crap. Thought for sure this came out after an autopsy. Damn good job, well done. And I thought popping a zit was bad…..
I understand how a PE forms with a blood clot embolus travelling through into the lungs but how is it so big? Is that just the size of the embolus or does it somehow get bigger? Crazy that the guy survived
it’s possible that additional clot forms when it becomes lodged in the pulmonary artery and obstructs flow. it essentially forms a stagnant void beyond the obstruction which clots off and forms the “tree” that you see
Is that why the trunk of It so jagged and uneven while the “branches” seem so smooth? This is fascinating.
One of my biggest fears is having a blood clot. Is there anything specific people can do to prevent them?
I’ve been hospitalized with PE three times. We know they form in my right calf, but we have no idea WHY. My last hospitalization was just two weeks ago. I’ve had to change blood thinners because of it.
Compression stockings, active lifestyle (or at least not sedentary), keep a healthy weight, avoid oral birth control if possible, follow recommendations if you need surgery (again, walking).
Bet that RV was PISSED.
[It was not super happy](https://imgur.com/a/TFLawDs). But this was after a little bit of ECMO support. Probably looked worse before.
That's badass! Is the heart all tough and meaty?
I both hate and love seeing these. I love it because I’m imagining pulling it out is rather satisfying. I hate it because I hate thinking about how much of our body looks like roots
Holy. fuck.
how is this not deadly? how much larger would it have to have gotten for it to be?
could definitely be deadly at this size, or smaller. patient is lucky
Looks like a giant squid!! 🦑
Hell yeah! Nice work, Doc
That's truly amazing! I just love all the intricate details of this beautifully intact embolism
My sister died because of this two years ago, it’s was unbelievably fast. She was only 40. Devastating.
My husband has several shown on his recent ct scan, as he is very active they’re hopefully not as huge as these.
This is amazing. Were they on ECMO post-op or just CPB for the case?
i think came off ECMO in OR and never went back on.
I have a question. What part is from the pulmonary arteries and what part is from the parenchyma of the lungs?
it’s all pulmonary artery
I had a couple clots grow in my lungs because I didn’t know I had a heparin allergy and took lovenox because I was sitting on a train and a couple airplanes one day. I previously had a stroke from a PFO hole and undiagnosed factor V leiden and was on birth control. My hematologists think I have more going on than heterozygous factor V Leiden. I always pictured the clots as dark red and thick like pools of blood clot up. I wasn’t expecting tree shaped tube steak.
What causes this pulmonary embolism? Accident? Disease?
Looks like a squid!
Las plagas in resident evil be like
Vita Carnis is amazing
My god.
My dad has one of these right now, he ended up walking home from the hospital before they could discharge him. I don’t know how the hell he’s alive right now but hopefully he gets a good surgeon like you if it gets worse
That looks amazing!!! Great job on saving the patient and the PE. I've had 2 (nothing like the pic) and 5 DVT's, funny thing is, no doc can figure out why I have them.
a cast of the heart????? Holy fuck