Pulmonary embolism

Dr Donna D'Souza et al.

Pulmonary embolism (PE) refers to embolic occlusion of the pulmonary arterial system. The majority of cases
result from thrombotic occlusion and therefore the condition is frequently termed pulmonary thrombo-
embolism which is what this article mainly covers.

Other embolic sources include:

air embolism
fat embolism
tumour embolism: comprised of tumour thrombus
hydatid pulmonary embolism
talc pulmonary embolism
iodinated oil pulmonary embolism
metallic mercury pulmonary embolism
amniotic fluid embolism
cement embolism: comprised of PMMA
catheter embolism
septic pulmonary embolism
Pathology
Risk factors
primary hypercoagulable states
o protein C deficiency
o protein S deficiency
o antithrombin III deficiency
o lupus anticoagulant
recent surgery
pregnancy
prolonged bed rest / immobility
malignancy
oral contraceptive use
Clinical assessment
Pretest probability scores are intended to replace empirical assessment of patients with suspected pulmonary
embolism:

Wells score
Geneva score
The ECG may show a S1Q3T3 pattern.

Serological tests
D-Dimer (ELISA)
Commonly used as a screening test in patients with a low and moderate probability clinical assessment, on these
patients:

normal D-dimer has almost 100% negative predictive value (virtually excludes PE): no further testing is
required
raised D-dimer is seen with PE but has many other causes and is therefore non-specific: it indicates the need
for further testing if pulmonary embolism is suspected 4
On patients with a high probability clinical assessment, a D-dimer test is not helpful because a negative D-dimer
result does not exclude pulmonary embolism in more than 15%. Patients are treated with anticoagulants while
awaiting the outcome of diagnostic tests 4.

Radiographic features
Depends to some extent on whether it is acute or chronic. Overall has a predilection for the lower lobes.

Plain film
Described chest radiographic signs include

Fleishner sign: enlarged pulmonary artery (20%)

Hampton hump: peripheral wedge of airspace opacity and implies lung infarction (20%)
Westermark's sign: regional oligaemia and highest positive predictive value (10%)
pleural effusion (35%)
knuckle sign 11
Sensitivity and specificity of chest x-ray signs 1

Westermark sign
o sensitivity: ~14%
o specificity: ~92%
o positive predictive value: ~38%
o negative predictive value: ~76%
vascular redistribution
o sensitivity: ~10%
o specificity: ~87%
o positive predictive value: ~21%
o negative predictive value: ~74%
Hampton hump
o sensitivity: ~22%
o specificity: ~82%
o positive predicitve value: ~29%
o negative predictive value: ~76%
pleural effusion
o sensitivity: ~36%
o specificity: ~70%
o positive predictive value: ~28%
 o negative predictive value: ~76%
elevated diaphragm
o sensitivity: ~20%
o specificity: ~85%
o PPV: ~30%
o NPV: ~76%
CT
Acute pulmonary emboli
CT pulmonary angiography (CTPA) will show filling defects within the pulmonary vasculature with acute
pulmonary emboli. When observed in the axial plane this has been described as the polo mint sign. The central
filling defect from the thrombus is surrounded by a thin rim of contrast, appearing like the popular sweet,
the polo mint 9.

Chronic pulmonary emboli

Features noted with chronic pulmonary emboli include

webs or bands, intimal irregularities 3

abrupt narrowing or complete obstruction of the pulmonary arteries 3
pouching defects which are defined as chronic thromboemboli organised in a concave shape that points
toward the vessel lumen 3
Nuclear medicine/VQ scan
Will show ventilation-perfusion mismatches. A high probability scan is defined as showing two or more
unmatched segmental perfusion defects acccording to thePIOPED criteria.

Complications
acute emboli
o pulseless electrical activity in the context of a large obstructing saddle embolus
acute or chronic emboli
o right ventricular dysfunction
CT features suggestive of right ventricular dysfunction include 8
abnormal position of the interventricular septum
inferior vena caval contrast reflux
RVD (right ventricular diameter):LVD (left ventricular diameter) ratio >1 on reconstructed four
chamber views
* a RVD:LVD ratio >1 on standard axial views is not considered to be good predictor of right
ventricular dysfunction 8
subacute-to-chronic emboli
o pulmonary infarction
o pulmonary hypertension
o pulmonary arterial sclerosis
o chronic cor pulmonale