Search Results (205)

Background: Pulmonary infarction (PI) is the result of the occlusion of distal pulmonary arteries resulting in damage to downstream lung areas that become ischemic, hemorrhagic, or necrotic, and it is often a complication of an underlying condition such as pulmonary embolism (PE). Since in most of cases it is located peripherally, lung ultrasound (LUS) can be a good evaluation tool. The typical radiological features of PI are well-known; however, there are limited data on its sonographic characteristics and its evolution. Methods: The aim of this study is to evaluate, using LUS, a convenience sample of patients with acute PE with computed tomography (CT) consolidation findings consistent with PI. Patients’ clinical characteristics were collected and LUS findings at baseline and their short-term progression was assessed. LUS was performed within 72 h of PE diagnosis (T0) and repeated after one (T1) and four weeks (T2). Each procedure started with a focused examination of the areas of lesions based on CT findings, followed by an exploration of the other posterior and lateral lung fields. The convex probe was used for initial evaluation integrating LUS evaluation with the linear one was employed for smaller and more superficial lesions and when appropriate. Color Doppler mode was added to study vascularization. Results: From June to October 2023, 14 consecutive patients were enrolled at the Respiratory Unit of the University Hospital of Pisa. The main population characteristics included the absence of respiratory failure and prognostic high-risk PE (100%), the absence of significant comorbidities (79%), and the presence of typical symptoms, such as chest pain (57%) and dyspnea (50%). The average number of consolidations per patient was 1.4 ± 0.6. Follow-up LUS showed the disappearance of some consolidations and some morphological changes in the remaining lesions: the presence of hypoechoic consolidation with a central hyperechoic area (“bubbly consolidation”) was more typical at T1 while the presence of a small pleural effusion often persisted both at T1 and T2. A decrease in wedge/triangular-shaped consolidations was observed (82% at T0, 67% at T1, 24% at T2), as was an increase in elongated shapes, representing a residual pleural thickening over time (9% at T0, 13% at T1, 44% at T2). A reduction in size was also observed by comparing the mean diameter, long axis, and short axis measurements of each consolidation at the three different studied time points: the average of the short axes and the median of the mean diameters showed a statistically significant reduction after four weeks. Additionally, a correlation between lesion size and pleuritic pain was described, although it did not achieve statistical significance. Conclusions: Patients’ clinical characteristics and ultrasound features are consistent with previous studies studying PI at PE diagnosis. Most consolidations detected by LUS change over time regarding size and form, but a minority of them do not differ. LUS is a safe and non-invasive exam that could help to improve patients’ clinical approach in emergency rooms as well as medical and pulmonology settings, clinically contextualized for cases of chest pain and dyspnea. Future studies could expand the morphological study of PI. Full article

Pulmonary embolism (PE) is one of the most serious complications of antiphospholipid syndrome (APS), a systemic autoimmune disorder defined by thrombotic events and persistent antiphospholipid antibodies (aPLA). PE occurs in 11–20% of patients and may constitute the initial clinical manifestation. Young and middle-aged women are most frequently affected, and triple-positive aPLA profiles markedly increase the risk of recurrence and long-term morbidity, including chronic thromboembolic pulmonary hypertension (CTEPH). This review article summarizes current evidence on the epidemiology, pathophysiology, diagnostic approach, and management of PE in APS. Key mechanisms include anti-β2-glycoprotein I-mediated endothelial and platelet activation, complement engagement, and neutrophil extracellular trap formation, resulting in immunothrombosis. Diagnostic pathways follow standard PE algorithms; however, chronically elevated D-dimer levels and lupus anticoagulant-related aPTT prolongation require careful interpretation and consideration. Long-term vitamin K antagonist therapy remains the standard of care, whereas direct oral anticoagulants are not recommended in high-risk APS. Future directions include improved risk stratification through detailed aPLA profiling and the use of emerging biomarkers, early screening for CTEPH, and the development of targeted therapies such as complement inhibition and anti-NETosis strategies. Full article

Background: Nutritional deficiency anemias—including iron, vitamin B12, and folate deficiencies—are common worldwide and are increasingly recognized as potential contributors to venous thromboembolism (VTE). Mechanistic and epidemiologic data suggest that anemia may promote thrombosis through hypoxia, endothelial activation, reactive thrombocytosis, and hyperhomocysteinemia. However, a focused synthesis of clinical and genetic evidence specifically linking nutritional deficiency anemia to VTE has been lacking. Methods: We conducted a systematic search of PubMed and the Cochrane Library from inception to 30 September 2025 to identify studies assessing nutritional deficiency anemia in relation to VTE outcomes. Eligible studies included observational designs, case reports, case series, and Mendelian randomization (MR) analyses. Quality assessment followed the Newcastle–Ottawa Scale (NOS), Joanna Briggs Institute (JBI) checklists, and ROB-MR. The review was registered in PROSPERO (CRD420251235479). Results: Seven studies met the inclusion criteria. Observational analytical studies consistently showed that anemia was associated with adverse VTE-related outcomes. Lower hemoglobin predicted higher short-term mortality in acute pulmonary embolism (HR 1.16 per 1 g/dL decrease), increased symptomatic VTE among hospitalized patients (RR 1.94), and greater long-term bleeding and mortality risk in VTE cohorts (HRs 1.41–2.89). Iron-deficiency anemia increased the odds of VTE in population-based data (OR 1.43), and case reports described unprovoked DVT in young adults with moderate to severe anemia. The MR study indicated a potential causal association between anemia traits and thrombosis at unusual anatomical sites (OR 1.446). No study demonstrated a significant association with recurrent VTE. Most analytical studies were rated as good–high quality. Conclusion: Across multiple study designs, anemia—particularly iron-deficiency anemia and low baseline hemoglobin—appears to be an underrecognized factor associated with elevated VTE risk and adverse VTE-related outcomes. However, direct evidence for vitamin B12- and folate-deficiency anemia remains limited, and further well-designed prospective studies are required to confirm causality and clarify the contribution of specific nutritional deficiency subtypes, as well as to support integration of anemia assessment into VTE risk models. Full article

Background/Objectives: Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive fibrotic interstitial lung disease with high mortality and limited treatment options. Despite recent therapeutic advances, predicting survival remains challenging. Given the challenge of predicting disease progression in IPF, identifying reliable prognostic markers may support individualized treatment strategies, guide follow-up intensity, and improve clinical decision making. This study aimed to evaluate mortality rates and factors associated with poor prognosis in patients with IPF over a 10-year period at a tertiary care center. Methods: Medical records of 268 patients diagnosed with IPF between 2015 and 2024 were retrospectively reviewed. Demographic characteristics, comorbidities, radiological findings, pulmonary function test results, frequency of exacerbations and hospitalizations, treatment details, and survival outcomes were analyzed. Univariate and multivariate logistic regression analyses were performed to identify predictors of mortality. Results: This study included 268 patients (77.2% male; median age, 72 years). During a median follow-up of 24 months, 44% (n = 118) of patients died. Deceased patients were older (p < 0.001) and had higher rates of coronary artery disease, pulmonary embolism, pulmonary hypertension, and malignancy (all p < 0.05). A definite UIP pattern was more common among deceased patients (71.2% vs. 52.4%, p = 0.02). Acute exacerbations (23.3% vs. 8.1%) and hospitalizations (61.9% vs. 23.3%) were significantly more frequent in this group (p < 0.001). In multivariate analysis, GAP score (OR 11.68, p = 0.001), pulmonary hypertension (OR 15.39, p = 0.02), history of exacerbation (OR 56.2, p = 0.04), baseline FVC (OR 1.10, p = 0.02), mean platelet volume (OR 0.29, p = 0.01), and AST level (OR 1.12, p = 0.04) were independent predictors of mortality. Conclusions: Despite advances in management, IPF continues to carry a high mortality risk. This study represents one of the largest single-center IPF cohorts from our region with long-term real-life follow-up and additionally evaluates laboratory biomarkers such as MPV and AST, which have not been widely investigated as prognostic indicators in IPF. Advanced age, reduced pulmonary function, comorbidities, and acute exacerbations are major prognostic factors. Early recognition and proactive management of these parameters may help improve survival outcomes. Full article

Background: The management of acute pulmonary embolism (PE) in the Emergency Department (ED) remains challenging, particularly in hemodynamically and respiratory stable patients with minimal symptoms. Diagnostic and therapeutic difficulties are further compounded when the condition is complicated by a mobile right atrial (RA) thrombus, representing an extreme-risk phenotype. Case Presentation: We report the case of a 65-year-old male with a single known venous thromboembolism risk factor-chronic venous insufficiency-who presented to the ED following a transient episode of severe dyspnea at home. On admission, he was hemodynamically and respiratory stable, without the need for oxygen supplementation. Arterial blood gas analysis revealed a metabolically compensated acidosis with elevated lactate, while cardiac biomarkers were moderately increased. Emergency point-of-care transthoracic echocardiography (POCUS-TTE) demonstrated severe right ventricular (RV) dysfunction and a large, mobile intracardiac thrombus prolapsing through the tricuspid valve. Computed Tomography Pulmonary Angiography confirmed pulmonary embolism and revealed a massive and extensive bilateral thrombotic burden (Qanadli score 32 points). Given the extreme risk for fatal embolization, immediate full-dose systemic thrombolysis with Alteplase (100 mg over 2 h) was initiated in the ED. Thrombolysis was completed without hemorrhagic complications. Follow-up POCUS-TTE at 2 h showed complete resolution of the intracardiac thrombus and significant improvement of RV function (RV/RA gradient reduced from 40 mmHg to 28 mmHg). Conclusions: This case highlights the effectiveness and safety of early systemic thrombolysis guided by ED POCUS-TTE in PE with a massive thrombotic burden, complicated by a mobile intracardiac thrombus, even in the absence of shock. Such prompt intervention may reduce mortality risk in intermediate-to-high-risk PE subsets, despite limited guidance in current clinical recommendations. Full article

Background/Objectives: Prevention and treatment of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major clinical issue in hospitalized patients. Some aspects of VTE management lack clarity due to differing physicians’ opinions and behaviors. Methods: A multidisciplinary steering committee identified two main areas of uncertainty: VTE prophylaxis and PE management in special settings. A multiple-choice questionnaire including 10 statements was circulated to 183 doctors trained in VTE management. The expected benefit-to-harm ratio was represented on a nine-point Likert scale, with consensus (≥75% agreement) on scores of 1–3 indicating inappropriate and 7–9 indicating appropriate care measures. Results: In online voting, a consensus was reached for 9/10 statements. Respondents considered the following to be appropriate: risk assessment of VTE (93.44%) and bleeding (91.6%) in hospitalized medical patients; low-molecular weight heparin (LMWH) prophylaxis for inpatients with pneumonia and malignancy (82.78%); therapeutic doses of LMWH/fondaparinux in patients with intermediate/high risk of PE with (80.9%) or without (77.97%) instability criteria; and echocardiography to manage patients with a post-PE syndrome (93.99%). Respondents considered the following to be inappropriate: use of 4000 IU LMWH in chronic renal failure (80.46%); use of 2000 IU LMWH in persons on dual antiplatelet therapy (77.01%); and use of low-dose apixaban (2.5 mg) in pregnancy (88.57%) or in subsegmental PE with hypoxemia (82.46%). No consensus was reached on the identification of PE cases eligible for outpatient treatment. Conclusions: Our findings show persistent gaps between guideline recommendations and clinical implementation despite improved awareness among physicians. Uncertainty persists regarding criteria for outpatient PE eligibility and/or for validation of bleeding-risk models. Full article

Background and Clinical Significance: Intermediate-high-risk pulmonary embolism is characterized by right-ventricular dysfunction and positive cardiac biomarkers in the absence of hemodynamic instability. Current guidelines recommend anticoagulation with vigilant monitoring, and reserve systemic fibrinolysis for patients who deteriorate hemodynamically. However, some patients may experience physiologic decompensation manifested by refractory hypoxemia rather than hypotension, despite preserved systemic perfusion and normal lung parenchyma. In such cases, oxygenation failure reflects the severity of perfusion impairment and incipient right-ventricular-circulatory collapse. Whether this scenario justifies systemic fibrinolysis remains uncertain. Case Presentation: We present a 75-year-old man, five days after arthroscopic meniscus repair, presenting with acute dyspnea, tachycardia, and severe respiratory failure despite normal chest radiography. Laboratory findings revealed elevated troponin-I and brain natriuretic peptide, and echocardiography demonstrated marked right-ventricular dilation. Computed tomographic pulmonary angiography confirmed extensive bilateral central emboli with preserved lung parenchyma. Despite high-flow nasal oxygen at 100% fraction of inspired oxygen, respiratory failure worsened, necessitating intubation under lung-protective settings. With catheter-directed therapy unavailable and transfer unsafe, a multidisciplinary team administered staged systemic fibrinolysis with alteplase, pausing heparin during infusion. No bleeding or surgical complications occurred. Oxygenation and right-ventricular indices improved promptly. The patient was extubated on day 2, discharged from intensive care unit on day 7, and remained asymptomatic with normal echocardiography at 3 months. Conclusions: Refractory hypoxemia in intermediate-high-risk, normotensive pulmonary embolism, particularly when parenchymal disease and ventilator confounding are excluded, may represent an early form of circulatory decompensation warranting rescue reperfusion. In the absence of catheter-directed options and with acceptable bleeding risk, staged full-dose systemic fibrinolysis can be life-saving and physiologically justified. This case supports expanding the concept of “clinical deterioration” in intermediate-risk pulmonary embolism to include isolated, unexplained respiratory failure, highlighting the need for future trials to refine individualized reperfusion thresholds. Full article

Tricuspid atresia (TA) is a cyanotic congenital heart defect defined by agenesis of the tricuspid valve and resultant right ventricular hypoplasia, representing 1.4–2.9% of congenital heart disease. Survival depends on interatrial and interventricular shunts that permit systemic and pulmonary blood flow, with staged surgical palliation culminating in the Fontan procedure. While surgical advances have improved long-term outcomes, Fontan circulation remains a delicate physiology characterized by preload dependence, elevated pulmonary vascular resistance, chronic venous hypertension, and a prothrombotic state. These features predispose patients to arrhythmias, lymphatic complications, hepatic congestion, and progressive circulatory failure. For anesthesiologists, perioperative management of TA and Fontan patients is uniquely complex. Anesthetic considerations include meticulous preload optimization, modulation of systemic and pulmonary vascular resistance, and ventilatory strategies that minimize adverse effects on venous return. Additional challenges include the high risk of air embolism, individualized anticoagulation needs, and hemodynamic sensitivity to patient positioning. Preoperative evaluation with echocardiography and electrocardiography provides critical insight into anatomy and physiology, while intraoperative planning must emphasize goal-directed fluid management, careful agent selection, and tailored ventilation. Postoperatively, vigilant monitoring, effective pain control, and prevention of complications are essential. This review synthesizes classification systems, pathophysiology, and the evolution of surgical palliation, while emphasizing anesthetic principles for the perioperative care of patients with TA and Fontan circulation. As survival improves and the population of Fontan patients expands, a nuanced understanding of this physiology is essential for optimizing outcomes across cardiac and non-cardiac surgical settings. Full article

High-risk pulmonary embolism (PE) is a life-threatening condition characterized by hemodynamic instability, often leading to catastrophic outcomes such as cardiac arrest and cardiogenic shock. We conducted a retrospective analysis of patients diagnosed with high-risk PE at a single tertiary center between 2018 and 2024. Catastrophic PE was defined as high-risk PE with hemodynamic collapse, including cardiac arrest and/or the requirement for high-dose vasopressors. Data on clinical characteristics, treatments, and outcomes were analyzed. Catastrophic PE accounted for 59% of cases. Systemic thrombolysis was the most frequent reperfusion strategy (67%), while catheter-directed therapies (35.4%) and VA-ECMO (11.4%) were used selectively. Despite aggressive management, catastrophic PE exhibited significantly higher mortality rates at 7 days (40%) and 30 days (49%) compared to non-catastrophic cases (9% and 12.5%, respectively). These patients also showed higher rates of multiorgan failure and required more invasive support. This study underscores the importance of early recognition and tailored treatment strategies for catastrophic PE, highlighting its distinct clinical presentation and worse outcomes compared to non-catastrophic high-risk PE. Further research is essential to refine treatment protocols and improve survival in this critically ill population, emphasizing the utility of a standardized classification to enhance clinical management and research consistency. Full article

Background/Objectives: Cement-augmented fenestrated pedicle screws (CAFPSs) are widely used to enhance fixation strength in osteoporotic vertebrae; however, cement leakage remains a major concern because it can lead to severe complications. This study aimed to clarify the frequency, patterns, and risk factors of cement leakage using postoperative computed tomography (CT). Methods: A total of 302 screws placed in 79 osteoporotic patients who underwent spinal fixation with CAFPSs between March 2022 and December 2024 were retrospectively analyzed. Cement leakage was evaluated using postoperative CT, and risk factors were examined by logistic regression and receiver operating characteristic (ROC) curve analysis. Results: Cement leakage was observed in 46 patients (58.2%) and 71 screws (23.5%), but no severe complications such as symptomatic pulmonary embolism occurred. Multivariate analysis identified right-sided screw insertion (OR = 2.498, 95% CI: 1.270–4.913, p = 0.008) and shorter lateral cortical wall distance (OR = 0.547, 95% CI: 0.469–0.638, p < 0.001) as independent risk factors. ROC curve analysis demonstrated high predictive accuracy for lateral cortical wall distance (area under the curve = 0.842), with a cutoff value of 9.21 mm (sensitivity = 0.845; specificity = 0.719). Cement leakage occurred significantly more frequently in the thoracic spine than in the lumbar spine (34.2% vs. 17.0%, p < 0.001). Conclusions: Right-sided screw insertion and shorter lateral cortical wall distance were identified as major risk factors for cement leakage with CAFPSs. Quantitative CT-based assessment may contribute to risk stratification and optimization of screw placement planning to improve surgical safety. Full article

Primary cardiac tumors are rare, with an estimated incidence of 0.001% to 0.3% in autopsy series. Most are benign, the most common being cardiac myxomas, which typically originate in the left atrium. Right ventricular myxoma is among the rarest primary cardiac tumors, and its true incidence is difficult to determine, as most data come from isolated case reports. This paper aims to report a case of right ventricular myxoma in a young woman with a history of childhood malignancy and to discuss the possible association between the two conditions. Echocardiography, thoracic computed tomography (CT), and pulmonary CT angiography were used to assess the presence, location, and size of the tumor. The definitive diagnosis was established by histopathological examination. A 34-year-old woman, with a past medical history of acute lymphoblastic leukemia (ALL) in childhood, presented with a dry cough and exertional dyspnea persisting for three weeks. Transthoracic echocardiography revealed a mass located in the right ventricular outflow tract (RVOT), attached near the tricuspid valve and intermittently prolapsing into the pulmonary trunk. CT imaging confirmed the presence of the tumor in the RVOT and the main pulmonary artery. Because of the high risk of massive pulmonary embolism, the patient underwent urgent surgical excision of the tumor. Histopathological analysis confirmed the diagnosis of cardiac myxoma. The postoperative recovery was uneventful, and the three-month follow-up showed no recurrence or signs of pulmonary embolism. The patient’s history of ALL raised the question of a possible association; however, a review of the literature revealed no previously reported link. In conclusion, right ventricular myxomas are extremely rare. The occurrence of cardiac myxoma in this patient following childhood ALL appears to be incidental. Further research is needed to determine whether ALL survivors have an increased predisposition to subsequent cardiac tumors. Full article

Background/Objectives: The D-dimer/fibrinogen ratio (D-d/F) has been proposed as a composite marker of fibrinolysis–coagulation balance. Whether D-d/F reflects CT-quantified thrombus burden and right ventricular dysfunction (RVD) in acute pulmonary embolism (PE) remains uncertain. Methods: Single-center retrospective cohort of consecutive adults with CTPA-confirmed PE (January 2022–October 2024). D-d/F = D-dimer (µg/mL)/fibrinogen (mg/dL). Thrombus burden: Qanadli and Mastora indices. RVD: RV/LV ratio, septal bowing, and IVC reflux. Associations: Spearman’s ρ with Steiger’s Z for between-marker comparisons. Discrimination for Qanadli ≥ 40% and RV/LV ≥ 1.0 by ROC. Two exploratory logistic models predicted Qanadli ≥ 40%: Model-1 (age, sex, D-d/F) and Model-2 adding RV/LV. Results: Among 112 patients (mean age 65.4 ± 15.6; 60% men), D-d/F correlated modestly with Qanadli (ρ = 0.233, p = 0.013) and Mastora (ρ = 0.274, p = 0.0034); strengths were similar to D-dimer (no between-marker difference: Steiger’s Z both p > 0.5). D-d/F correlated with RV/LV (ρ = 0.335, p < 0.001) and with IVC reflux (ρ = 0.247, p = 0.0085). CT indices related more strongly to hemodynamic markers (e.g., Qanadli with RV/LV ρ = 0.571, p < 0.0001; Mastora with RV/LV ρ = 0.620, p < 0.0001). Patients with septal bowing had higher D-dimer (median 4.65 vs. 2.74 µg/mL, p = 0.0037), higher D-d/F (1.04 vs. 0.61, p = 0.0018), and higher clot-burden scores (both p < 0.0001). For Qanadli ≥ 40%, AUCs were 0.621 for D-d/F (cut-off > 0.795; sens 58.8%, spec 62.3%) and 0.618 for D-dimer (>1.894 µg/mL; 84.3%, 37.7%); AUCs did not differ (p = 0.93). For RV/LV ≥ 1.0, AUCs were 0.693 for D-d/F (>0.607; 83.8%, 52.0%) and 0.684 for D-dimer (>2.849 µg/mL; 75.7%, 54.7%); p = 0.72. In Model-1, D-d/F predicted Qanadli ≥ 40% (OR = 1.43 per unit, p = 0.043; AUC = 0.64). After adding RV/LV (Model-2), discrimination improved (AUC = 0.796), RV/LV remained a strong predictor (p < 0.0001), and D-d/F was not retained (p = 0.287). Conclusions: In acute PE, D-d/F tracks thrombus burden and RVD to a degree comparable to D-dimer, but effects are modest. CT-based markers—particularly RV/LV—better reflect disease severity and are more predictive of high clot burden. Risk prediction and incremental utility of D-d/F were not assessed and warrant prospective evaluation. Full article

Acute pulmonary embolism (APE) carries significant 30-day mortality and morbidity. When APE is characterized by progressive hypoxia, hypotension, and right ventricular dysfunction, the risk of cardiovascular collapse and cardiac arrest is high, and intervention is recommended. As a result, there has been increasing impetus to utilize extracorporeal membrane oxygenation (ECMO) to provide rapid oxygenation support, immediate reduction in right ventricular (RV) overload, and hemodynamic support. Veno-arterial-ECMO modality is deployed to provide hemodynamic stability and restore tissue oxygenation and provides a bridge to recovery from percutaneous and open APE therapy. While many patients are placed on ECMO for a short period of time to treat APE, applying ECMO over an extended period pf time carries substantial multisystem morbidity due to systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding. It appears that the initiation of ECMO alone, with or without administration of systemic thrombolysis, will not improve outcomes over conventional therapy for high-risk APE. The current literature demonstrates that ECMO is best paired with open or percutaneous thrombectomy to reduce or eliminate the clot burden and rapidly stabilize cardiovascular status; these dual outcomes translate into patient survival. However, a series of meta-analyses have not demonstrated that the use of ECMO in hemodynamically unstable APE results in a significant survival advantage compared to patients treated without ECMO. Full article

Background: Hip fracture surgery in elderly patients carries significant risks of both bleeding and thrombotic complications. Anaesthetists frequently face a dilemma between neuraxial anaesthesia, which may reduce thrombotic risk but is often limited by contraindications, and general anaesthesia, which is widely applicable but may exacerbate bleeding. Previous reviews have not specifically addressed bleeding and thrombotic outcomes, leaving a critical gap that this meta-analysis seeks to answer. Study objective: To evaluate the effect of neuraxial anaesthesia compared to general anaesthesia on the incidence of bleeding and thrombotic complications in acute neck of femur fracture surgery. Methods: Relevant studies comparing neuraxial and general anaesthetic for hip fracture surgery were searched for through Medline, Embase, Scopus, CINAHL and PubMed. Inclusion criteria were randomised control trials of hip fracture surgery patients aged >16 years with relevant outcome data. In total, 24 randomised control trials were included, with 5479 patients. A meta-analysis was performed using RevMan 5.4 software. The study was registered with PROSPERO ID: CRD42022348039. Outcome measurement: Primary outcomes were intra-operative blood loss, intra- or post-operative blood transfusion and post-operative deep vein thrombosis. Secondary outcomes were post-operative pulmonary embolism, post-operative myocardial infarction and post-operative stroke. Results: Neuraxial anaesthesia reduced deep vein thrombosis incidence by 45% and reduced blood loss by 58 mL, both of which reached statistical significance (p < 0.05). Albeit not reaching statistical significance, neuraxial anaesthesia also had a 35% relative risk reduction in myocardial infarction, and a 35% relative decrease in stroke in current studies published after 2010. Despite practise evolution over the decades, protective neuraxial trends have remained. Conclusions: Patients undergoing acute hip fracture surgery under general anaesthesia have higher volumes of blood loss, without requiring increased blood transfusion. General anaesthesia is also associated with higher thrombotic complications, with a 45% increased relative risk of deep vein thrombosis, compared to neuraxial anaesthesia. Multi-modal thromboprophylaxis is important, as up to a third of DVT cases occur in the non-operative leg. In frail patients with a low cardiopulmonary reserve for bleeding or in high-thrombotic-risk patients, extra consideration and optimisation for neuraxial technique is advised. Future studies on comorbidities and operation type may reveal a subgroup of patients which would benefit from a specific anaesthetic type. Full article

Background: Pulmonary embolism (PE) is a life-threatening condition with high mortality, particularly in high-risk cases where rapid clinical deterioration is common. The optimal management strategy for high-risk PE remains debated. Systemic thrombolysis (ST) is widely used but is associated with substantial bleeding risks. Surgical pulmonary embolectomy (SPE) has re-emerged as a viable alternative, particularly in patients with contraindications to thrombolysis or failed response. However, the evidence comparing SPE and ST in critically ill patients remains limited, and current guidelines provide only limited guidance. This study aims to evaluate the outcomes between SPE and ST in critically ill patients, focusing on mortality and complication rates. Methods: This retrospective study included 96 high risk patients with severe acute pulmonary embolism treated between 2015 and 2023, with 48 undergoing SPE and 48 receiving ST who were matched 1:1 based on baseline variables and hemodynamic presentation. Outcomes assessed included in-hospital mortality, PE-related death, neurological complications, bleeding events, hospitalization duration, as well as further postinterventional complications. Results: In-hospital mortality was 16.6% in the SPE group in contrast to 25.0% in the ST group (p = 0.765). Neurological complications were significantly lower in SPE (2.1%) compared to ST (12.5%) (p = 0.05). Life-threatening hemorrhage occurred at similar rates in both groups (SPE: 18.8%, ST: 14.6%); however, non-life-threatening bleeding was more common in ST (16.7% vs. 2.1%, p = 0.014). Hospitalization duration was significantly longer for SPE patients (mean 17.4 vs. 11.4 days, p < 0.001), who also presented with more severe disease, including higher ECMO utilization. Conclusions: SPE is a safe and effective alternative to ST in PE, offering comparable mortality, fewer neurologic complication and a reduced risk of bleeding. These findings highlight the importance of individualized, risk-adapted treatment pathways and support the inclusion of SPE as a frontline consideration in the management of PE in critically ill patients in experienced centers with multidisciplinary support. Full article