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D Bima

Purwaamidjaja

Jakarta 2019
EMBOLI PARU KRONIK :
Diagnostik dan Pengelolaan
RS KEPRESIDENAN RSPAD GATOT SOEBROTO JAKARTA
31 Agustus 2019
Pulmonary embolism (PE) is caused by
emboli, which have from venous
thrombi, travelling to and occluding the
arteries of the lung.

PE is the most dangerous form of venous


thromboembolism, and undiagnosed or
untreated PE can be fatal.

Huisman MV, Barco S, Cannegieter SC. Pulmonary Embolism. Nature


Reviews Disease Primers 2018;4:18028.
Acute PE is associated with right ventricular
dysfunction  which can lead to arrhythmia,
haemodynamic collapse and shock.

Survive PE  post-PE syndrome : chronic


thrombotic remains in the pulmonary arteries,
persistent right ventricular dysfunction,
decreased quality of life and/or chronic
functional limitations.

Huisman MV, Barco S, Cannegieter SC. Pulmonary Embolism. Nature Reviews Disease
Primers 2018;4:18028.
Several important improvements have been made in
the diagnostic and therapeutic management of
acute PE.

Future research should aim to address novel


treatment options (for example, fibrinolysis
enhancers) and improved methods for predicting
long-term complications and defining optimal
anticoagulant therapy parameters in individual
patients, and to gain a greater understanding of
post-PE syndrome.
Huisman MV, Barco S, Cannegieter SC. Pulmonary Embolism. Nature Reviews
Disease Primers 2018;4:18028.
Pulmonary embolism (PE) is the third most
common acute cardiovascular disease,
after myocardial infarction and stroke, and is
a major public health problem. (Goldhaber SZ.
Pulmonary embolism. Lancet 2004; 363:1295–1305)

Accurate diagnosis of PE is important


because the consequences of a false-positive or
false negative diagnosis can be rapidly fatal.

Witram C et all. Acute and chronic pulmonary emboli : Angiography –


CT correlation. AJR 2006;186:S421-S429
CT and angiography have complementary
roles in the accurate diagnosis of acute and
chronic thromboembolic disease.

Conventional angiography should be


used as a problem-solving technique after CT
angiography has been performed because CT
angiography is less invasive.
Witram C et all. Acute and chronic pulmonary emboli :
Angiography – CT correlation. AJR 2006;186:S421-S429
Abstract
Niels B. Phlebotomy 2017;24(2):97-104

In the last century, deep vein thrombosis (DVT) plus pulmonary embolism was one of the
most frequent causes of death in hospitalized patients. However, the incidence of DVT
alone has been difficult to calculate from the entity of venous thromboembolism because
the incidence of DVT is provided as either DVT without pulmonary embolism or pulmonary
embolism + DVT, where the latter group does not provide the precise rate of DVT.
Therefore, our epidemiological review will focus on the first group, with an emphasis on
first-time DVT. In the western world, the incidence of DVT (without pulmonary
embolism) is currently around 50 to 80 per 100 000 per year, which increases during
the winter, and the incidence increases with age and in females >60-65 years.
Until recently, terms, such as distal and proximal DVT, have been used widely, now with
suggestions of the anatomical descriptions for proximal DVT. Above-knee DVT is 2- to 3-
fold more frequent than is calf-vein DVT, and left-sided DVT is the most frequent. The
results from studies and lifetime risk estimates show that more emphasis needs to be
placed on prophylaxis with risk assessments in the daily work environment. Prospective,
large-scale, epidemiologic studies of patients with DVT verified by ultrasonography are
needed with a clear presentation of location and extension. This basic information may
reveal location-related rates of postthrombotic syndrome based on well-defined follow-
up regimens.
UEDVT :

upper-extremity deep vein


thrombosis

???
Owen CA et all. Pulmonary Embolism from Upper Extremity Deep Vein Thrombosis
and the Role of Superior Vena Cava Filters: A Review of the Literature. JVIR
2010;21(6):779-787.
Respirology(2018)23(Suppl. 2), 90–334

upper-extremity deep vein thrombosis


The placement of superior vena cava (SVC) filters
 prevent pulmonary emboli (PE) from upper-extremity
deep vein thrombosis (UEDVT) : although controversial,
has been reported.

A total of 21 publications were identified that reported 209


SVC filters and documented eight major filter-related
complications (3.8%) : four cardiac tamponades, two
aortic perforations, and one recurrent pneumothorax.

The in-hospital or 1-month mortality rate was 43.1%.


Owen CA et all. Pulmonary Embolism from Upper Extremity Deep Vein Thrombosis
and the Role of Superior Vena Cava Filters: A Review of the Literature. JVIR
2010;21(6):779-787.
Levin D et all. Triage for suspected acute Pulmonary Embolism: Think before
opening Pandora's Box. European Journal of Radiology 2015;84(6):1202-11.
Chronic pulmonary embolism
Chronic thromboembolic pulmonary hypertension (CTEPH) is a
complication of venous thromboembolic disease.

Differently from other causes of pulmonary hypertension, CTEPH is


potentially curable with surgery (thromboendarterectomy) or balloon
pulmonary angioplasty.

Imaging plays a central role in CTEPH diagnosis  Combination


techniques : lung scintigraphy, computed tomography and magnetic
resonance angiography provides non-invasive anatomic and functional
information.

Conventional pulmonary angiography (CPA) with right heart


catheterization (RHC) is considered the gold standard method for
diagnosing CTEPH.
Nishiyama KH et all, Chronic Pulmonary Embolism. Cardiovasc Diagn Ther
2018;8(3):253-271
CTEPH  Pulmonary Hipertension characterized by :
- Persistence of thromboembolic obstructing the pulmonary arteries as an
organized tissue and the presence of a variable small vessel arteriopathy.

-  Increase in pulmonary vascular resistance  progressive right heart


failure.

- CTEPH is classified as group IV pulmonary hypertension according to the


WHO classification of pulmonary hypertension.

- CTEPH is defined as precapillary pulmonary hypertension (mean


pulmonary artery pressure ≥ 25 mmHg with a pulmonary capillary wedge
pressure ≤ 15 mmHg) associated with mismatched perfusion defects on
ventilation-perfusion lung scan and signs of chronic thromboembolic
disease on computed tomography pulmonary angiogram and/or
conventional pulmonary angiography, in a patient who received at least 3
months of therapeutic anticoagulation.
O Connel et all. Chronic thromboembolic pulmonary hypertension. Press Media
2015;;44.
CTEPH should be considered in any patient with unexplained
PH.

Splenectomy, chronic inflammatory conditions such as


inflammatory bowel disease, indwelling catheters and cardiac
pacemakers have been identified as associated conditions
increasing the risk of CTEPH.

Ventilation-perfusion scan (V/Q) is the best test available for


establishing the thromboembolic nature of PH. When CTEPH is
suspected, patients should be referred to expert centres where
pulmonary angiography, right heart catheterization and high-
resolution CT scan will be performed to confirm the diagnosis
and to assess the operability.
O Connel et all. Chronic thromboembolic pulmonary hypertension. Press Media
2015;;44.
Pulmonary endarterectomy (PEA) remains the gold
standard treatment for CTEPH when organized
thrombi involve the main, lobar or segmental arteries.
This operation should only be performed by
experienced surgeons in specialized centres. For
inoperable patients, current ESC/ERS guidelines for
the diagnosis and treatment of pulmonary
hypertension recommend the use of riociguat and say
that off-label use of drugs approved for PAH and
pulmonary angioplasty may be considered in expert
centres.
O Connel et all. Chronic thromboembolic pulmonary hypertension. Press Media
2015;;44.
CRITICALLY ILL PATIENTS : LIMITED
COMPENSATION ORGANS

PULMONARY EMBOLY  CHRONIC


 ACUTE MASIVE  FATAL

EARLY DETECTION + EARLY TREATMENT


 LOWER MORBIDITY AND MORTALITY

PULMONARY EMBOLISM IN CRITICALLY ILL PATIENTS


 NEW ERA  INDONESIA ???
RS Kepresidenan RSPAD
Gatot Soebroto bersama
RSCM.

IACA 2018.

Diagnosis PE dengan
pendekatan standar masih
sulit.

Deteksi dini dan


pengelolaan dini turunkan
mortalitas.

DSA salah satu diagnostik


spesifik dilanjutkan
pengelolaan (mechanical
and pharmacological
combination therapy
TERIMAKASIH