**Introductory Chapter: Embolic Diseases - Unusual Therapies and Challenges**

Michael S. Firstenberg

sive or surgical options should be considered early for acute or chronic embolic

Probably the most important concept is that embolisms can often be a manifestation of a much more complex or serious medical condition. Without a doubt, such problems—espe‐ cially in terms of prevention, diagnosis, and management—require an integrated multidisci‐ plinary team to help coordinate care. As with many problems in medicine, such a coordinated team approach must consist of a full spectrum of disciplines and expertise fo‐ cused on the ability to assess and manage complex problems in a timely and efficient man‐ ner. As some of the chapters emphasize, prevention is crucial—especially in various highrisk patient populations. However, since embolisms can occur at any time—and they can present with immediate life or organ-threatening problems (such as neurologic events or limb-threatening ischemia)—dedicated response teams must be organized in advance and

Embolisms, by definition, are pathologic and often associated with severe and potentially fatal complications. This text will hopefully serve as a guide to some of the more challenging and unusual patient populations and problems that occur when medical teams encounter embolic complications. The primary goal of this text is to emphasize the importance of a timely, efficient, and multidisciplinary approach to patient management to achieve optimal

> **Michael S. Firstenberg, MD, FACC** Director, Adult ECMO Program

Northeast Ohio Medical Universities Department of Surgery (Cardiothoracic) Akron City Hospital—Summa Health System

Akron, Ohio, USA

Associate Professor of Surgery and Integrative Medicine

complications.

VIII Preface

outcomes. Thank you.

be able to respond immediately.

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.68936

#### **1. Introduction**

Embolic problems are a well‐established cause of substantial morbidity and mortality. The challenging aspect of management is recognition of the multi‐factorial events that ultimately result in an embolic problem. First and foremost in management is often the acute events that bring the patient to medical attention. While such events, in themselves, can be dramatic in their morbidity and/or mortality—and, therefore, require immediate attention—emphasis must also focus on the precipitating factors that precipitate the embolism. When possible, and reasonable, it is important to identify the source of the embolism, the destination (or des‐ tinations) of the embolic material, and the characteristics that might have contributed to the development of the primary source. Management is often structured around controlling the embolism and its clinical consequences.

#### **2. Principles of care**

One of the most common thrombo‐embolic complications is stroke. Cerebrovascular conse‐ quences can span the spectrum of clinical presentations from events that can be minor, self‐ limited, and potentially asymptomatic events to those that are catastrophically debilitating or fatal. Common causes include thrombotic material from a cardiac source—typically clots from the left atrial appendage in patients with atrial fibrillation [1]. Other cardiac sources include left ventricular thrombus in patients with significant wall motion abnormalities or apical aneurysms/dysfunction in the setting of previous myocardial infarctions or a depressed ejec‐ tion fraction, infectious sources from endocarditis (also typically intra‐cardiac), paradoxical emboli from intra‐cardiac shunts (such as a patent foramen ovale), and less common cardiac causes—including benign and malignant tumors [2]. While much energy is focused on cardiac

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

source and systemic effects, it is critical to recognize that there are many others—and often less common or unusual causes. In addition, the foundations for embolic therapy include [3]:


Even though neurologic complications tend to be the most fear, it is important to realize that systemic complications to visceral organ (i.e., hepatic, renal, intestinal) and the extremities can be just as morbid or potential fatal [4, 5]. The focus of many chapters in this text is an update and review of some of these unusual embolic sources. While it is important to recog‐ nize that many common clinical problems and their treatments, can lend themselves to the development of protocols and guidelines, some of the more uncommon or unusual presenta‐ tions and problems can present as considerable diagnostic and therapeutic challenges. The purpose of many of the chapters in this text is to review the data and collective experiences of some of the different types of embolic diseases and to serve as a guide to therapy.

#### **3. Project focus**

In addition, even though there are extensive reviews of some of the more common embolic problems—such as left atrial appendage clots, stroke in the setting of either cardiac or non‐ cardiac sources, and the diagnosis and medical management of the full spectrum of acute and chronic pulmonary thromboembolic disease, these important clinical topics are not considered, other than rarely discussed surgical management, in the contents of this book. The reasons for their exclusion are simple—each topic can clearly be a book in outright (and there are already entire texts devoted to each topic) and even a basic review would overwhelm the primary purpose of this project. Furthermore, the fields in these areas are changing so quickly in terms of diagnostic tools, medical therapies, interventional options, and the standards of care and professional society guidelines that inclusion of some of those topics would only quickly result in an out‐of‐date reference [6]. Nevertheless, there are some principles that are evolving in the management of embolic disease that are comment regardless of the etiologies. The common principles are echoed as themes throughout this text, but warrant specific discussion.

#### **4. Team‐base care**

As with many other contemporary disease management guidelines—such as cancers and struc‐ tural heart disease—the focus is on a multi‐disciplinary team approach to the diagnosis and management [7, 8]. The purposes and goals of a team approach should be inherently obviously, but developing and maintaining them often requires substantial leadership in bringing together various disciplines with a patient‐centered focus. Professional and disease centric "silos" and traditional models of patient care, including sometimes one‐way, fragmented, and ill‐coordi‐ nated referrals have evolved in the team‐based care. Often such teams will have a coordina‐ tor—aptly called a "navigator"—whose primary purpose is to help navigate and coordinate the care of the individual patients [9]. As with all journeys, the Navigator will ensure a safe and effective travel, through what is often a complex and challenging path from initial diagnosis to cure. While a Navigator might not be the first healthcare provider a patient encountered when entering into a disease management process, they ultimately serve as the focal point person for care. Even as a patients is individually evaluated by members of the Team, internal referral to the Navigator can help organize the clinical data and help track and coordinate a management plan. Navigators can arrange for testing and follow‐up appointments to help not only insure a timely and efficient work‐up, but also insure that team‐defined care plans are maintained. Typically, a Navigator will help compile all of the relevant diagnostic testing, including critical components of the history and physical exams and provide a framework such that each patient's unique presentation is discussed in a timely manner by all of the disciplines represented by the team. Disciplines represented on such teams can vary, but are often comprised of the core spe‐ cialties that traditionally manage either the organ systems or the diseases in question. However, there are some key disciplines that often serve as critical team members:


source and systemic effects, it is critical to recognize that there are many others—and often less common or unusual causes. In addition, the foundations for embolic therapy include [3]:

(1) Anticoagulation or anti‐platelet therapies to potentially minimize the impact of the initial

(2) Interventions—either pharmacologic or mechanical to try to dissolve or remove the distal

(4) Long‐term therapies to control the circumstances that resulted in the initial primary

Even though neurologic complications tend to be the most fear, it is important to realize that systemic complications to visceral organ (i.e., hepatic, renal, intestinal) and the extremities can be just as morbid or potential fatal [4, 5]. The focus of many chapters in this text is an update and review of some of these unusual embolic sources. While it is important to recog‐ nize that many common clinical problems and their treatments, can lend themselves to the development of protocols and guidelines, some of the more uncommon or unusual presenta‐ tions and problems can present as considerable diagnostic and therapeutic challenges. The purpose of many of the chapters in this text is to review the data and collective experiences of

In addition, even though there are extensive reviews of some of the more common embolic problems—such as left atrial appendage clots, stroke in the setting of either cardiac or non‐ cardiac sources, and the diagnosis and medical management of the full spectrum of acute and chronic pulmonary thromboembolic disease, these important clinical topics are not considered, other than rarely discussed surgical management, in the contents of this book. The reasons for their exclusion are simple—each topic can clearly be a book in outright (and there are already entire texts devoted to each topic) and even a basic review would overwhelm the primary purpose of this project. Furthermore, the fields in these areas are changing so quickly in terms of diagnostic tools, medical therapies, interventional options, and the standards of care and professional society guidelines that inclusion of some of those topics would only quickly result in an out‐of‐date reference [6]. Nevertheless, there are some principles that are evolving in the management of embolic disease that are comment regardless of the etiologies. The common

(3) Control or management of the primary source to reduce the risks for recurrence.

some of the different types of embolic diseases and to serve as a guide to therapy.

principles are echoed as themes throughout this text, but warrant specific discussion.

As with many other contemporary disease management guidelines—such as cancers and struc‐ tural heart disease—the focus is on a multi‐disciplinary team approach to the diagnosis and

event.

embolism.

2 Embolic Diseases - Unusual Therapies and Challenges

sources.

**3. Project focus**

**4. Team‐base care**

**7.** Advanced practice healthcare providers (e.g., nursing, respiratory therapy, pharmacy, perfusionists, imaging technicians)

In addition, such teams need to be open to all healthcare providers who would be interested in attending and participating. Additional specialists, in specific cases, should be asked to par‐ ticipate to lend their expertise and insights when patients present with a more advanced set of circumstances—such as a nephrologist might be asked to participating in the discussion of a patient who also immunosuppressed from a kidney transplant, or a neurologist and infec‐ tious disease experts might be called upon to discuss a patient with a stroke from infectious endocarditis. The overriding principle behind such team‐based care is that each case is pre‐ sented with a focus on evidence based medicine guidelines, local or regional experiences or expertise, objective review of all of the key tests, and a unified consensus as to "best" approach to the management of the patient and their problems. The management of a patient with embolic diseases should also follow such a framework. While the acuteness of a presentation and need for immediate or emergent therapy might preclude a "weekly team conference," it should not change from the borrowing of an established institutional structured approach to the problem. A physical or virtual meeting and discussion of the core disciplines can occur at any time, and hopefully with an existing algorithm in place for disease triage and manage, such meetings can be arranged and effective care‐plans determined at any time—even in the absence of a formal "on‐call" schedule provided the members are committed to the principles of such team‐based care. The current models that are used for Structural Heart Disease or Acute Pulmonary Embolism Teams, throughout of the scope of this text, are being written about more extensively in the literature and might help provide a structure [10, 11].

Important concepts that represent themes throughout this text are that include:


#### **5. Conclusions**

It is important to recognize that when faced with a patient with an embolic complication, management can be complexed. Clearly, early and aggressive diagnostic and therapeutic initiatives are critical to prevent further complications. As with many problems, a multi‐dis‐ ciplinary team approach to care is an evolving foundation that is important for optimizing outcomes. Unusual embolic complications, thought far less common than atherosclerotic or those of an intrinsic cardiac source, must be considered and managed using a similar paradigm of care. It is the fundamental purpose of this text to hopefully outline some of the more unusual causes of embolic diseases and emphasize the experiences and data that can guide therapy.

#### **Author details**

and need for immediate or emergent therapy might preclude a "weekly team conference," it should not change from the borrowing of an established institutional structured approach to the problem. A physical or virtual meeting and discussion of the core disciplines can occur at any time, and hopefully with an existing algorithm in place for disease triage and manage, such meetings can be arranged and effective care‐plans determined at any time—even in the absence of a formal "on‐call" schedule provided the members are committed to the principles of such team‐based care. The current models that are used for Structural Heart Disease or Acute Pulmonary Embolism Teams, throughout of the scope of this text, are being written

about more extensively in the literature and might help provide a structure [10, 11].

**1.** Not all sources of embolic disease reflect in here patient co‐morbidities—such as atrial fibril‐ lation, atherosclerotic vascular disease, endocarditis, or deep vein thrombosis—just to name a few common intrinsic causes. Some sources may be initially extrinsic to the patient or iatrogenic, such as retained foreign bodies (e.g., guide wires lost during central line place‐ ment) or objects that erode into the vascular system after trauma (i.e., bullet fragments). **2.** However, it is important to also realize—as emphasized in several chapters—that the pathophysiologic consequences of several chronic disease states, such as liver and renal disease, might predispose patients to increased risks for complex embolic problems. An

understanding of the complex biology is a cornerstone to effective management.

tioned above) that some embolic material might not be organic, or biologic.

management options must be considered.

**5. Conclusions**

**3.** Similarly, when evaluating a patient with an embolic problem, it is important to consider that not all embolisms are "organic" in nature. While most embolic material consists of bio‐ logic material such as clot, atherosclerotic debris, infectious material (i.e., vegetations)—or typically, a combination of one or more components, it is important to consider (as men‐

**4.** Another important concept that is addressed in some of the chapters in this text is that management might vary based upon not only the patient's clinical status, but also the na‐ ture of the embolic material. While anti‐coagulation or anti‐platelet agents still represent a cornerstone to treatment of most embolic complications with the underlying principle that such therapies might minimize the consequences of vascular occlusion with propagation or worsening thrombotic material, acute or definitive treatment might require more inva‐ sive therapies. Several of the chapters in this text outline the role and specific techniques for surgical management of embolic complication. With so much emphasis on therapies that focus on manipulations of the clotting cascade—such as anticoagulation, fibrinolysis, or anti‐platelets agents—as with all multi‐disciplinary approach to complex problems, surgical

It is important to recognize that when faced with a patient with an embolic complication, management can be complexed. Clearly, early and aggressive diagnostic and therapeutic

Important concepts that represent themes throughout this text are that include:

4 Embolic Diseases - Unusual Therapies and Challenges

Michael S. Firstenberg

Address all correspondence to: msfirst@gmail.com

Department of Surgery (Cardiothoracic), Akron City Hospital – Summa Health System, Northeast Ohio Medical Universities, Akron, Ohio, USA

#### **References**

