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From Ovarian Coils to Pulmonary Emboli
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A3700 - From Ovarian Coils to Pulmonary Emboli
Author Block: J. Tonkin1, B. Madden2; 1Respiratory Medicine, St George's Hospital, London, United Kingdom, 2St Georges Hospital, Tooting, United Kingdom.
Ovarian vein embolization is an emerging treatment for pelvic congestion syndrome. Coils are inserted, through a transcatheter approach, to treat pelvic varices and provide symptom relief. We present three patients who have developed pulmonary coil emboli as a consequence of this procedure.
Two patients presented with sudden onset atypical chest pain in the months following the procedure. One patient was detected incidentally after pelvic venography, performed for persistent pelvic pain, was unable to visualize some of the coils within the pelvic veins.
CT pulmonary angiography was performed in all cases. This identified the position of the coils, whether they had fragmented and whether pulmonary perfusion was reduced as a consequence. In addition to coils in pulmonary arteries, one patient had a coil lodged in the tricuspid valve. Associated thrombus could also be evaluated to determine the need for anticoagulation.
All three patients underwent two-dimensional transthoracic echocardiography to assess the tricuspid and pulmonary valve for damage during migration of the coils. Echocardiography was also used as a screening tool for pulmonary hypertension associated with pulmonary artery obstruction (group 4.2 pulmonary hypertension). None of these patients had abnormal findings warranting right heart catheterisation. We performed pulmonary function testing including transfer factor to evaluate the impact on gas exchange.
In the absence of associated thrombus or pulmonary hypertension, we elected not to commence anticoagulation in two of these patients. However, anticoagulation with Rivaroxaban was used in the patient with a coil fragment in the right ventricle. Management was conservative in each case, with the decision made not for removal of the embolized coils. However, each patient was followed up prospectively with clinical evaluation, echocardiography and CT imaging to look for further coil migration.
Foreign body embolism is an uncommon occurrence within the pulmonary vasculature. Management is conservative with either surgical or radiological removal restricted to those with significant complications. Decisions regarding anticoagulation should be made on a case by case basis. We would advocate anticoagulation in those with associated thrombus seen on CT or those with coils that present an increased thrombotic risk such as location within the valve apparatus. Turbulent blood flow due to the presence of a foreign body could put these patients at risk of recurrent pulmonary embolism. There is no evidence to suggest which anticoagulant is more effective. We chose a direct oral anticoagulant in this case based on patient preference.
Author Block: J. Tonkin1, B. Madden2; 1Respiratory Medicine, St George's Hospital, London, United Kingdom, 2St Georges Hospital, Tooting, United Kingdom.
Ovarian vein embolization is an emerging treatment for pelvic congestion syndrome. Coils are inserted, through a transcatheter approach, to treat pelvic varices and provide symptom relief. We present three patients who have developed pulmonary coil emboli as a consequence of this procedure.
Two patients presented with sudden onset atypical chest pain in the months following the procedure. One patient was detected incidentally after pelvic venography, performed for persistent pelvic pain, was unable to visualize some of the coils within the pelvic veins.
CT pulmonary angiography was performed in all cases. This identified the position of the coils, whether they had fragmented and whether pulmonary perfusion was reduced as a consequence. In addition to coils in pulmonary arteries, one patient had a coil lodged in the tricuspid valve. Associated thrombus could also be evaluated to determine the need for anticoagulation.
All three patients underwent two-dimensional transthoracic echocardiography to assess the tricuspid and pulmonary valve for damage during migration of the coils. Echocardiography was also used as a screening tool for pulmonary hypertension associated with pulmonary artery obstruction (group 4.2 pulmonary hypertension). None of these patients had abnormal findings warranting right heart catheterisation. We performed pulmonary function testing including transfer factor to evaluate the impact on gas exchange.
In the absence of associated thrombus or pulmonary hypertension, we elected not to commence anticoagulation in two of these patients. However, anticoagulation with Rivaroxaban was used in the patient with a coil fragment in the right ventricle. Management was conservative in each case, with the decision made not for removal of the embolized coils. However, each patient was followed up prospectively with clinical evaluation, echocardiography and CT imaging to look for further coil migration.
Foreign body embolism is an uncommon occurrence within the pulmonary vasculature. Management is conservative with either surgical or radiological removal restricted to those with significant complications. Decisions regarding anticoagulation should be made on a case by case basis. We would advocate anticoagulation in those with associated thrombus seen on CT or those with coils that present an increased thrombotic risk such as location within the valve apparatus. Turbulent blood flow due to the presence of a foreign body could put these patients at risk of recurrent pulmonary embolism. There is no evidence to suggest which anticoagulant is more effective. We chose a direct oral anticoagulant in this case based on patient preference.
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