University of British Columbia, Pathology & Laboratory Medicine, Vancouver, BC, Canada; Vancouver General Hospital, Anatomical Pathology, Vancouver, BC, Canada.
University of British Columbia, Division of Neurology, Stroke Program, BC, Canada.
Cardiovasc Pathol. 2019 May-Jun;40:12-18. doi: 10.1016/j.carpath.2019.01.003. Epub 2019 Jan 19.
Iatrogenic embolization following cardiac investigative procedures may result from hydrophilic polymer emboli (HPE) from catheter valve and vessel wall calcifications, and air embolism from open heart surgery. This retrospective clinical pathologic analysis was undertaken to ascertain the frequency and extent of these potentially fatal complications.
This retrospective clinical pathologic autopsy analysis with premortem diagnostic imaging correlation identified 110 individuals who had undergone endovascular procedures between 2010 and 2016 within 90 days of death and followed by hospital autopsy. Clinical outcomes, radiologic studies, and autopsy materials were reviewed.
Iatrogenic emboli were assessed as causing death in 9/110 autopsy cases (8.2%) and 9/34 (26.5%) cases with proven iatrogenic emboli. Iatrogenic emboli caused strokes in 10/110 (9.1%) autopsy cases including calcified emboli (CE, n=6), HPE (n=2), cardiac valvular tissue (n=1), and air embolism (n=1). Seven cases of calcified emboli complicating endovascular procedures were identified: four of the CE were thought to be the cause of death due to fatal strokes (n=2) and fatal myocardial (n=1) and colonic infarction (n=1). The CE likely originated from calcified aortic valves and atherosclerotic aortic plaques. Histologic evidence of HPE was found in 23% (25/110) of cases; 54% (26/48) showed evidence of infarction in postprocedural imaging, with radiologic evidence of infarction in 32% (8/25) of cases with HPE histology. Endovascular aortic repair was associated with the greatest density/distribution of HPE. HPE material showed degradation with time and was often associated with an inflammatory response. HPE directly contributed to death in three cases. One fatal air embolism followed open heart surgery, and one cardiac tissue embolus resulted in a major stroke.
We advocate for greater awareness of these underrecognized and occasionally fatal complications of endovascular procedures. Targeted postprocedural imaging has a role in the identification of iatrogenic embolic infarcts.
心脏介入性检查后可能发生医源性栓塞，其原因包括亲水聚合物栓塞（HPE）来自导管瓣膜和血管壁钙化，以及体外循环心脏手术中的空气栓塞。进行这项回顾性临床病理分析是为了确定这些潜在致命并发症的频率和程度。
本研究采用回顾性临床病理尸检分析，结合生前诊断影像学相关性，确定了 110 例在 2010 年至 2016 年期间接受血管内介入治疗的个体，死亡后 90 天内进行医院尸检。对临床结果、放射学研究和尸检材料进行了回顾。
医源性栓塞被评估为 110 例尸检病例中的 9 例（8.2%）和 34 例有明确医源性栓塞的病例中的 9 例（26.5%）导致死亡。医源性栓塞导致 10/110 例尸检病例（9.1%）中风，包括钙化栓塞（CE，n=6）、HPE（n=2）、心脏瓣膜组织（n=1）和空气栓塞（n=1）。发现 7 例血管内介入过程中并发钙化栓塞：4 例 CE 被认为是致命性中风（n=2）、致命性心肌（n=1）和结肠梗死（n=1）的死亡原因。CE 可能源自钙化主动脉瓣和粥样硬化主动脉斑块。组织学证据显示 HPE 见于 110 例病例中的 23%（25/110）；54%（26/48）在术后影像学检查中显示有梗死证据，25 例 HPE 组织学病例中有 32%（8/25）有放射学证据。血管内主动脉修复与 HPE 密度/分布最密切相关。HPE 材料随着时间的推移而降解，通常与炎症反应有关。HPE 直接导致 3 例死亡。1 例致命性空气栓塞发生在体外循环心脏手术后，1 例心脏组织栓塞导致严重中风。
我们主张提高对这些被低估的、偶尔致命的血管内介入并发症的认识。有针对性的术后影像学检查在识别医源性栓塞性梗死方面具有一定作用。
