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Echo Rounds

Echo Case

Vladislav Melnyk, MD; Travis Schisler, MD; Kathrivel Subramaniam, MD MPH; Dennis Phillips, DO; University of Pittsburgh Medical Center, Pittsburgh, PA

A 47-year-old male with cystic fibrosis and type 1 diabetes presented for double lung transplantation. At that time, the patient reported stable oxygen requirements. He reported no new symptoms including chest pain. Preoperative workup revealed only mild anemia and sinus tachycardia. The patient was taken to the operating room where he underwent uneventful induction and intubation. Femoral vein cannulation using landmark technique was not successful in spite of repeated attempts. Subsequent ultrasound imaging of groin showed mass lesion occupying femoral vein. Simultaneous transesophageal echo (TEE) revealed evidence of right ventricular pressure overload and echo density on the right main pulmonary artery.

Video and Figure Legends

Video 1 and Figure 1: Ultrasound imaging of the groin vessels demonstrated a large occlusive echo density within a lumen of noncompressible right common femoral vein. Femoral artery is visualized medial and deep to the vein.

Video 2 and Figure 2: Transesophageal echocardiography (midesophageal ascending aortic views) showing mass lesion in the right pulmonary artery.

Questions

  1. What is the diagnosis?
    1. Angiosarcoma with metastasis
    2. Fungal lesions in the lung and vasculature
    3. Deep vein thrombosis (DVT) and pulmonary embolism (PE)
    4. Imaging artifacts
  2. What is the next step in patient management?
    1. Pulmonary embolectomy and continue with the planned lung transplantation
    2. Immediate thrombolysis
    3. Cancel the lung transplantation; anticoagulation and re-evaluation
    4. Inferior vena cava (IVC) filter insertion and continue with the planned lung transplantation