PULMONARY EMBOLISM

Dr. Mehreen Saiyed Resident Med 4

Objectives
-Introduction -Clinical features -Diagnostic modalities -Diagnostic approach -Management

Introduction
In pulmonary embolism, a thrombus arises elsewhere in the body and migrates to the pulmonary vascular tree, where it causes obstruction. Nearly all pulmonary emboli derive from deep venous thrombosis.

Introduction

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Clinical features
SYMPTOMS IN PATIENTS WITH ANGIO PROVEN PTE Symptom Dyspnea Chest Pain, pleuritic Anxiety Cough Hemoptysis Sweating Chest Pain, nonpleuritic Syncope Percent 84 74 59 53 30 27 14 13

Clinical features
SIGNS WITH ANGIOGRAPHICALLY PROVEN PE Sign Tachypnea > 20/min Rales Accentuated S2 Tachycardia >100/min Fever > 37.8 Diaphoresis S3 or S4 gallop Thrombophebitis Lower extremity edema Percent 92 58 53 44 43 36 34 32 24

Clinical features
Diagnostic difficulties! Signs / symptoms non-specific Only 25% of suspected cases actually have pulmonary emboli1,2

1. Lee AY, Hirsh J. Diagnosis and treatment of venous thromboembolism. Annu Rev Med. 2002;53:15-33. 2. The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).JAMA. 1990;263:2753-2759.

Who do we work up?

- PRETEST PROBABILITY
Definition: The probability of the target disorder (PE) before a diagnostic test result is known.
Used to decide how to proceed with diagnostic testing and final disposition

Modified Wells pretest probability scoring

Diagnostic Modalities

ABG D-dimer Echocardiography

ECG
Chest X-ray Venous Ultrasonography Spiral/helical CT with IV contrast

Perfusion lung scanning Pulmonary angiography

ABG
The ABG/ A-a Gradient myth: You must do an arterial blood gas and calculate the alveolar-arterial gradient. Normal A-a gradient virtually rules out PE. Reality: The A-a gradient is a better measure of gas exchange than the pO2, but it is nonspecific and insensitive in ruling out PE.

ABG
-Characteristically reveal hypoxemia, hypocapnia, and respiratory alkalosis.

Data from the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) indicate that, contrary to classic teaching,. arterial blood gases lack diagnostic utility for PE..!!

D-dimer
-D-dimers are fibrinolytic products formed when the fibrin within a clot is proteolyzed by plasmin. -Highly nonspecific, but are highly associated with thrombosis and thrombolysis. - Negative ELISA has a >99% negative predictive value -Qualitative -Quantitative . (ELISA) Positive assay is > 500ng/ml

D-dimer
Combing Clinical Probability & D-Dimer
Christopher Study1 (n = 3,306) Dichotomized Wells score 4 D-Dimer 500 ng/ml Negative predictive value > 99.5% Useful in excluding PE in outpatients Safe to withhold treatment

1. Van Belle A, et al. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography. JAMA 2006;295(2):172-179

D-dimer

D-dimer

ECG
-About 70 percent of patients with acute PE have ECG abnormalities.

-The most common ECG abnormalities of pulmonary embolism are tachycardia and nonspecific ST-T wave abnormalities.
-The classic finding of right-sided heart strain demonstrated by an S1Q3-T3 pattern is observed in only 20% of patients with proven pulmonary embolism.

Chest X-ray
Chest X-Ray Myth: You have to do a chest x-ray so you can find Hamptons hump or a Westermark sign. Reality: Most chest x-rays in patients with PE are nonspecific and insensitive

Chest X-ray
CHEST RADIOGRAPH FINDINGS IN PATIENT WITH PULMONARY EMBOLISM Result Cardiomegaly Normal study Atelectasis Elevated Hemidiaphragm Pulmonary Artery Enlargement Pleural Effusion Parenchymal Pulmonary Infiltrate Percent 27% 24% 23% 20% 19% 18% 17%

Chest X-ray
CHEST X-RAY EPONYMS OF PE
Westermark's sign
A dilation of the pulmonary vessels proximal to the embolism along with collapse of distal vessels, sometimes with a sharp cutoff. Hamptons Hump A triangular or rounded pleural-based infiltrate with the apex toward the hilum, usually located adjacent to the hilum.

Chest X-ray

Westermark's sign

Hamptons Hump

Echocardiography
Rapidly gaining importance (risk stratify) 40 % have abnormalities: RV pressure overload McConnel sign: Regional RV dysfunction Apical wall motion remains normal Hypokinesis of free wall

Ventilation/Perfusion Scan - V/Q Scan

V/Q Scan Perfusion: Tc-99M Ventilation: Xenon Underperfusion ~ V/Q mismatch

V/Q Scan
Greatest limiting factors: Structural lung disease Availability Often non-diagnostic (60%!)1

Still useful: peripheral small/multiple PEs

1. The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).JAMA. 1990;263:2753-2759.

Spiral/helical CT with IV contrast

-Technical advances in CT scanning, including the development of multidetector-array scanners, have led to the emergence of CT scanning as an important diagnostic technique in suspected PE.

-Contrast-enhanced CT scanning is increasingly used as the initial radiologic study in the diagnosis of pulmonary embolism, especially in patients with abnormal chest radiographs in whom scintigraphic results are more likely to be nondiagnostic.

Spiral/helical CT with IV contrast

Findings of Acute PE Intraluminal filling defect surrounded by contrast Ancillary findings that are suggestive: Expanded unopicified vessels Eccentric filling defects Peripheral wedge-shaped consolidation Oligaemia Pleural effusion

Spiral/helical CT with IV contrast

Spiral computed tomography of the chest with contrast showing large clot (black arrow) obstructing right main pulmonary artery

Spiral/helical CT with IV contrast

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The axial CT image (left) shows large pulmonary emboli bilaterally. The pulmonary arteries from this image are magnified on the right to show these emboli better (yellow arrows).

Spiral/helical CT with IV contrast

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These two axial CT images show profound pulmonary emboli. On the left the embolus almost completely blocks the right pulmonary artery (yellow arrow). Right image show an extensive saddle embolus forming in both pulmonary arteries and becoming extensive. Both of these types of pulmonary emboli are life threatening and require immediate medical attention .

Pulmonary Angiography
-Is the definitive technique or gold standard in the diagnosis of PE. -A filling defect or abrupt cutoff of a vessel is indicative of PE.

-Can detect emboli as small as 1 to 2 mm.

http://www.webmm.ahrq.gov/case.aspx?caseID=14

The clot appears as a filling defect (arrow)

Pulmonary Angiography
Diagnostic: filling defects

Secondary signs: Cut-off of vessels Segmental oligaemia Prolonged arterial phase, slow filling Tapering of vessels

Pulmonary Angiography

http://www.nci.cu.edu.eg/lectures/pulmonary%20Embolism.pdf

filling defects

Evaluation of DVT
Duplex Doppler Compression Ultrasound Venogram (diagnostic dilemmas) MRI Helical CT Venography (CTV)

Diagnostic Approach

CT experienced institutions

CT inexperienced institutions

Modified Wells pretest probability scoring

Diagnostic Approach
CT experienced institutions:
-When PE is suspected, the modified Wells criteria should be applied to determine if PE is unlikely (score 4) or likely (score >4). -Patients classified as PE unlikely should undergo D-dimer testing with a quantitative rapid ELISA assay or a semiquantitative latex agglutination assay. The diagnosis of PE can be excluded if the D-dimer level is <500 ng/mL or negative.

-Patients classified as PE likely and patients classified as PE unlikely who have a Ddimer level >500 ng/mL should undergo CT-PA. A positive CT-PA confirms the diagnosis of PE. Alternatively, a negative CT-PA excludes the diagnosis of PE.
-In those rare instances in which the CT-PA is inconclusive, either pulmonary angiography or the diagnostic approach intended for institutions without experience in CT-PA can be used.

Diagnostic Approach
CT experienced institutions:
CT-based diagnostic strategy used in patients with suspected pulmonary embolism

Diagnostic Approach
CT inexperienced institutions:
-The Wells criteria are initially applied to determine whether the clinical probability of PE is low (score <2), intermediate (score 2 to 6), or high (score >6). -A ventilation-perfusion (V/Q) scan is then performed, with the following combinations of outcomes possible. Normal V/Q scan plus any clinical probability excludes PE Low probability V/Q scan plus low clinical probability excludes PE High probability V/Q scan plus high clinical probability confirms PE. -Any other combination of V/Q scan result plus clinical probability should prompt either a pulmonary angiogram or serial lower extremity venous ultrasound exams. Only the pulmonary angiogram is able to diagnose PE.

Diagnostic Approach
CT inexperienced institutions:
VQ-based diagnostic strategy used in patients with suspected pulmonary embolism

Management
Supportive care Anticoagulation Thrombolysis Catheter based interventions Surgical embolectomy Inferior vena cava filters

AHA definitions
Massive PE: Acute PE with sustained hypotension (SBP<90 mm Hg for at least 15 mins or requiring inotropic support, not due to a cause other than PE, such as arrhythmia, hypovolemia, sepsis, or left ventricular [LV] dysfunction), pulselessness, or persistent profound bradycardia (heart rate <40 bpm with signs or symptoms of shock).

AHA definitions
Submassive PE: Acute PE without systemic hypotension (systolic blood pressure 90 mm Hg) but with either RV dysfunction or myocardial necrosis. Low-risk PE: Acute PE and the absence of the clinical markers of adverse prognosis that define massive or submassive PE.

Anticoagulation
-Is the mainstay of treatment.
AHA Recommendations for Initial Anticoagulation for Acute PE
Therapeutic anticoagulation with subcutaneous LMWH, IV or SC UFH with monitoring, unmonitored weight-based SC UFH, or subcutaneous fondaparinux should be given to patients with objectively confirmed PE and no contraindications to anticoagulation

Therapeutic anticoagulation during the diagnostic workup should be given to patients with intermediate or high clinical probability of PE and no contraindications to anticoagulation

Anticoagulants
Unfractionated heparin therapy Low-molecular-weight heparin therapy Fondaparinux Warfarin therapy

Target INR = 2 - 3

Thrombolytic Therapy
AHA Recommendations for Fibrinolysis for Acute PE

Fibrinolysis is reasonable for patients with massive acute PE and acceptable risk of bleeding complications

Fibrinolysis may be considered for patients with submassive acute PE judged to have clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory insufficiency,severe RV dysfunction, or major myocardial necrosis) and low risk of bleeding complications

Thrombolytic Therapy

Fibrinolysis is not recommended for patients with low-risk PE or submassive acute PE with minor RV dysfunction, minor myocardial necrosis, and no clinical worsening .

Fibrinolysis is not recommended for undifferentiated cardiac arrest

Thrombolytic Therapy
Contraindications for thrombolytic therapy

Thrombolytic Therapy

A computed tomographic angiogram shows a large saddle embolus at the bifurcation of the main pulmonary artery, with extension into the right and left pulmonary arteries (arrow in Panel A). Following treatment with intravenous tissue plasminogen activator, the patient's respiratory status dramatically improved over a period of several hours. Computed tomography obtained approximately 24 hours later demonstrates resolution of the saddle embolus (Panel B).

Catheter-Based Interventions
Percutaneous techniques to recanalize complete and partial occlusions in the pulmonary trunk or major pulmonary arteries are potentially life-saving in selected patients with massive or submassive PE. In general, mechanical thrombectomy should be limited to the main and lobar pulmonary arterial branches

Surgical Embolectomy
Emergency surgical embolectomy with cardiopulmonary bypass has reemerged as an effective strategy for managing patients with massive PE or submassive PE with RV dysfunction when contraindications preclude thrombolysis.

Recommendations for Catheter Embolectomy and Fragmentation

Either catheter embolectomy and fragmentation or surgical embolectomy is reasonable for patients with massive PE and contraindications to fibrinolysis patients with massive PE who remain unstable after receiving fibrinolysis patients with submassive acute PE judged to have clinical evidence of adverse prognosis (new hemodynamic instability, worsening respiratory failure, severe RV dysfunction, or major myocardial necrosis) Catheter embolectomy and surgical thrombectomy are not recommended for patients with low-risk PE or submassive acute PE with minor RV dysfunction, minor myocardial necrosis, and no clinical worsening .

Inferior Vena Cava Filters

An inferior vena cava filter, also IVC filter or Greenfield Filter a type of vascular filter, that is implanted by interventional radiologists or vascular surgeons into the inferior vena cava to prevent fatal pulmonary embolism (PEs).

Inferior Vena Cava Filters

Recommendations on IVC Filters in the Setting of Acute PE

Adult patients with any confirmed acute PE (or proximal DVT) with contraindications to anticoagulation or with active bleeding complication Anticoagulation should be resumed in patients with an IVC filter once contraindications to anticoagulation or active bleeding complications have resolved . For patients with recurrent acute PE despite therapeutic anticoagulation, it is reasonable to place an IVC filter For DVT or PE patients who will require permanent IVC filtration (eg, those with a long-term contraindication to anticoagulation), it is reasonable to select a permanent IVC filter device

Recommendations on IVC Filters in the Setting of Acute PE

For DVT or PE patients with a time-limited indication for an IVC filter (eg, those with a short-term contraindication to anticoagulation therapy), it is reasonable to select a retrievable IVC filter device

Placement of an IVC filter may be considered for patients with acute PE and very poor cardiopulmonary reserve, including those with massive PE An IVC filter should not be used routinely as an adjuvant to anticoagulation and systemic fibrinolysis in the treatment of acute PE

Resources
http://emedicine.medscape.com/article/4623 90-overview

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