Tim Daskivich Gillian Lieberman, MD

July 2003

Pulmonary Thromboembolism: Diagnosis and Imaging

Tim Daskivich Harvard Medical School Year III Gillian Lieberman, MD

Image from: http://erl.pathology.iupui.edu/C604/generator.cfm?FileName=/C604/images/Gross/10pue&Table=Gross

Tim Daskivich Gillian Lieberman, MD

Goals for Presentation

Learn why Pulmonary Embolism (PE) is a diagnostic juggernaut Learn an algorithm for radiologic evaluation of PE Learn advantages and disadvantages of each modality for evaluation of PE Use algorithm to work through an actual case
1

Tim Daskivich Gillian Lieberman, MD

Pulmonary Embolism: Facts and Figures

most often associated with DVT in popliteal, femoral, or iliac veins
PE is the 3rd most common cause of death in Americans (when CV causes are separated)1 only 30% are diagnosed antemortem treated, mortality rate: 2.5% untreated, mortality rate: 18.5%
Image from: http://www.eecs.utoledo.edu/~serpen/professional/Research/Students%20Advised/Students%20Advised_files/The sis%20Presentation%20R%20Iyer.ppt

Tim Daskivich Gillian Lieberman, MD

A Diagnostic Nightmare
(and not just for 3rd years)

Clinical Presentation2 : Chest Pain (70%) Tachypnea (70%) Cough (40%) Tachycardia (33%) SOB (25%) Syncope (5%) Differential Dx: MI, CHF, Aortic Dissection, Acute Asthma, COPD, PTX, Pneumonia, Pericarditis, Myocarditis, MSK 3 Good luck honing your dx

Tim Daskivich Gillian Lieberman, MD

Ingredients for a Proper Dx

Clinical Suspicion
Signs and Sxs Risk Factors Lab Tests

IMAGING
4

Tim Daskivich Gillian Lieberman, MD

Algorithm for PE evaluation3

Clinical Suspicion of PE CXR
Normal Abnormal

V/Q scan
Normal/Low Probability High Probability Intermediate Probability Negative

CT Angiography
Positive Alternative Dx Inconclusive

No PE

PE

Still Unsure?

PE

No PE

Angiography 5

Tim Daskivich Gillian Lieberman, MD

Clinical Suspicion
Signs and Symptoms: dyspnea, pleuritic chest pain, cough most common Risk Factors for hypercoagulability:
Inherited Acquired and Persistent: Age, APA, CA, Obesity Acquired and Transient: OCs, Surgery, Trauma

Tests
ABGs : hypoxemia, Increased Aa Gradient ECG: stereotypic S1Q1T3 pattern D-dimer: high sensitivity/specificity not reproducible yet in clinical studies

Tim Daskivich Gillian Lieberman, MD

Algorithm for PE evaluation3

Clinical Suspicion of PE CXR
Normal Abnormal

V/Q scan
Normal/Low Probability High Probability Intermediate Probability Negative

CT Angiography
Positive Alternative Dx Inconclusive

No PE

PE

Still Unsure?

PE

No PE

Angiography 7

Tim Daskivich Gillian Lieberman, MD

CXR
Westermarks Sign: Relative Oligemia (~10%/97%)1 Hamptons Hump: WedgeShaped Radioopacity (22%/82%)1 Other findings: Cardiomegaly (in 27% of PE) Pleural Effusion (23%) Elevated Hemidiaphragm (20%) Pulmonary Artery Large (19%) 8

Adv: Eliminate other diagnoses Disadv: Not sufficiently sensitive

Image from: http://80-content.nejm.org.ezp2.harvard.edu/content/vol345/issue18/images/large/05f1.jpeg

Tim Daskivich Gillian Lieberman, MD

Algorithm for PE evaluation3

Clinical Suspicion of PE CXR
Normal Abnormal

V/Q scan
Normal/Low Probability High Probability Intermediate Probability Negative

CT Angiography
Positive Alternative Dx Inconclusive

No PE

PE

Still Unsure?

PE

No PE

Angiography 9

Tim Daskivich Gillian Lieberman, MD

V/Q Scan

Normal

High Probability of PE

Image from: http://www.nwahs.sa.gov.au/clinical/Imaging/nucmed/vq.htm

10

Tim Daskivich Gillian Lieberman, MD

V/Q Scan: Scoring4

Normal (<5%) Low (<19%) Normal Q Small Q defects Intermediate (2080%) High (>80%) >2 large segmental mismatched Q defects (V and CXR nl) 41% sens, 97% spec 1-3 moderate 9% of PE are Nonsegemental mismatched Q normal Q defects defects Diffuse matched Single large V & Q defects c mismatched Q nl CXR defect

11

Tim Daskivich Gillian Lieberman, MD

V/Q Scan: Advantages & Disadvantages

Advantages: High specificity at high probability; easy to read Disadvantages: Not sensitive, even at high probability; no other dxs tested; 45 min long

12

Tim Daskivich Gillian Lieberman, MD

Algorithm for PE evaluation3

Clinical Suspicion of PE CXR
Normal Abnormal

V/Q scan
Normal/Low Probability High Probability Intermediate Probability Negative

CT Angiography
Positive Alternative Dx Inconclusive

No PE

PE

Still Unsure?

PE

No PE

Angiography 13

Tim Daskivich Gillian Lieberman, MD

CT Angiography
Sensitivity5: 88-100% Specificity5: 75-97% Advantages: Speed; r/o other processes; often done incidentally; less expensive than V/Q Disadvantages: poor at visualizing subsegmental PE (5% of total)
Image from: Fam N. P., Verma A. Thrombolysis of a Massive Pulmonary Embolism. N Engl J Med 2002; 347:1161, Oct 10, 2002.

14

Tim Daskivich Gillian Lieberman, MD

Algorithm for PE evaluation3

Clinical Suspicion of PE CXR
Normal Abnormal

V/Q scan
Normal/Low Probability High Probability Intermediate Probability Negative

CT Angiography
Positive Alternative Dx Inconclusive

No PE

PE

Still Unsure?

PE

No PE

Angiography 15

Tim Daskivich Gillian Lieberman, MD

Pulmonary Angiography: The Gold Standard

Advantages: Gold Standard for diagnosis; Interventional Pulmonary Embolectomy Disadvantages: Long; Invasive; $$$; limited availability

16
Image from: Kearon C. Diagnosis of pulmonary embolism. CMAJ - 21-JAN-2003; 168(2): 183-94

Tim Daskivich Gillian Lieberman, MD

Patient C.I.
C.I. is a 36 y.o. male who was airlifted to the BIDMC following a head-on MVA with a stationary pole. He sustained multiple left-sided rib fractures with lung contusion, fractures of the maxillary sinus, bilateral orbital fractures, and potential fractures of the ethmoid sinuses. On HD#6 , he experienced acute hypotensionSBP in the 60s and his oxygen sats dropped to 50% (on 100% O2). After neosynephrine was administered, a CXR was obtained.

17

Tim Daskivich Gillian Lieberman, MD

Portable CXR, AP View

Possible Westermarks Sign

Left pleural effusion

Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

18

Tim Daskivich Gillian Lieberman, MD

CT Angiography

RA AR
RPA

PT

LPA

A Az Pl. Eff.

19
Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

Tim Daskivich Gillian Lieberman, MD

CT Angiography

A SVC

PT

R&L Bronchi

20
Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

Tim Daskivich Gillian Lieberman, MD

CTA Reconstruction
LS SVC AA PT

21
Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

Tim Daskivich Gillian Lieberman, MD

Algorithm for PE evaluation3

Clinical Suspicion of PE CXR
Normal Abnormal

V/Q scan
Normal/Low Probability High Probability Intermediate Probability Negative

CT Angiography
Positive Alternative Dx Inconclusive

No PE

PE

Still Unsure?

PE

No PE

Angiography 22

Tim Daskivich Gillian Lieberman, MD

Conventional Angio: RL, Early Arterial Phase

Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

23

Tim Daskivich Gillian Lieberman, MD

Conventional Angio: RL, Middle Arterial Phase

24
Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

Tim Daskivich Gillian Lieberman, MD

Conventional Angio: RL, Venous Phase

Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

25

Tim Daskivich Gillian Lieberman, MD

Conventional Angio: LL, Late Arterial Phase

26
Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

Tim Daskivich Gillian Lieberman, MD

Conventional Angio: LL, Venous Phase

Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

27

Tim Daskivich Gillian Lieberman, MD

When in Doubt, Suck it

Guidewire to site of blockage.

6 Out

A Percutaneous Pulmonary Thrombectomy was then performed.

Telescope guiding catheter over the guidewire. Telescope suction catheter over the guiding catheter. Advance the suction catheter over the guiding catheter to the clot. Apply suction by attaching a 30mL syringe to the guiding catheter and suck it out.

28

Tim Daskivich Gillian Lieberman, MD

Angio: RL, Post-Embolectomy

Before

After
Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

29

Tim Daskivich Gillian Lieberman, MD

Angio: Post-Embolectomy

30
Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

Tim Daskivich Gillian Lieberman, MD

CXR, AP: 7 Hours postEmbolectomy

Return of vessel shadows in right middle and upper lobes

Left lower lobe partial collapse, evidenced by focal opacity of the left lower lobe region and deviation of the mediastinum to the left 31
Image Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

Tim Daskivich Gillian Lieberman, MD

Two months later

32
Images Courtesy of Dr. Elvira Lang, BIDMC, Boston, MA

Tim Daskivich Gillian Lieberman, MD

Conclusions
Diagnosis of PE is not easily done clinically, even with the help of biochemical tests Failure to be diagnosed is the greatest threat to patients with PE.1 Utilization of CXR, V/Q scan, CT Angiography, and Conventional Angiography are extremely helpful in diagnosis Burn the algorithm into your cerebri

33

Tim Daskivich Gillian Lieberman, MD

References

1.Sadosty, AT. Pulmonary embolism. Emerg Med Clin North Am. 01-MAY-2003; 21(2): 36384. 2.Carmen T., Deitcher, S. Advances in Diagnosing and Excluding Pulmonary Embolism: Spiral CT and D-dimer Measurement. Cleveland Clinic Journal of Medicine. September 2002; 69 (9): pp. 721-9. 3.Garg K. CT of Pulmonary Thromboembolic Disease. Radiol Clin North Am. 01-Jan-2002; 40(1): 111-22, ix. 4.http://www.ohsu.edu/ps-DiagRadiol/kojima/vq.htm 5.Worsley, DF. Radionuclide imaging of acute pulmonary embolism. Radiol Clin North Am. 01SEP-2001; 39(5): 1035-52. General Reference: Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th Ed., Copyright 2001 Churchill Livingstone, Inc.

34

Tim Daskivich Gillian Lieberman, MD

Acknowledgements
I would like to thank: Dr. Elvira Lang for her assistance in obtaining and explaining the shown images. Larry Barbaras Gillian Lieberman, MD Pamela Lepkowski
35