DVT&PE Final 1

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    PULMONARYEMBOLISM

    Dr. Mehreen SaiyedResident

    Med 4

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    -Introduction

    -Clinical features

    -Diagnostic modalities-Diagnostic approach

    -Management

    Objectives

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    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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    http://www.ceessentials.net/article12.html

    Introduction

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    SYMPTOMS IN PATIENTS WITH ANGIO PROVEN PTE

    Symptom Percent

    Dyspnea 84

    Chest Pain, pleuritic 74

    Anxiety 59

    Cough 53Hemoptysis 30

    Sweating 27

    Chest Pain, nonpleuritic 14

    Syncope 13

    Clinical features

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    SIGNS WITH ANGIOGRAPHICALLY PROVEN PE

    Sign Percent

    Tachypnea > 20/min 92Rales 58Accentuated S2 53Tachycardia >100/min 44

    Fever > 37.8 43Diaphoresis 36S3 or S4 gallop 34Thrombophebitis 32

    Lower extremity edema 24

    Clinical features

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    Diagnostic difficulties!

    Signs / symptoms non-specific

    Only 25% of suspected casesactually 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 PulmonaryEmbolism Diagnosis (PIOPED).JAMA. 1990;263:2753-2759.

    Clinical features

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    - PRETEST PROBABILITY

    Definition: The probability of the targetdisorder (PE) before a diagnostic test result is

    known.

    Used to decide how to proceed withdiagnostic testing and final disposition

    Who do we work up?

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    Modified Wells pretest probability scoring

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    Diagnostic Modalities

    ABG

    Spiral/helical CT with

    IV contrast

    Chest X-ray

    ECG

    D-dimer

    Venous Ultrasonography

    Pulmonary angiography

    Perfusion lung scanning

    Echocardiography

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    The ABG/ A-a Gradient myth:

    You must do an arterial blood gas and calculate thealveolar-arterial gradient. Normal A-a gradient virtually

    rules out PE.

    Reality:

    The A-a gradient is a better measure of gas exchange thanthe pO2, but it is nonspecific and insensitive in ruling outPE.

    ABG

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    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..!!

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    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

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    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 outpatientsSafe to withhold treatment

    1. Van Belle A, et al. Effectiveness of Managing Suspected Pulmonary Embolism

    Using an Algorithm Combining Clinical Probability, D-Dimer Testing, andCom uted Tomo ra h . JAMA 2006;295 2 :172-179

    D-dimer

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    D-dimer

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    D-dimer

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    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 S1-Q3-T3 pattern is observed in only 20% of patients with proven

    pulmonary embolism.

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    Chest X-ray

    Chest X-Ray Myth:

    You have to do a chest x-ray so you can find Hamptonshump or a Westermark sign.

    Reality:

    Most chest x-rays in patients with PE are nonspecific andinsensitive

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    CHEST RADIOGRAPH FINDINGS IN PATIENT WITHPULMONARY EMBOLISM

    Result Percent

    Cardiomegaly 27%Normal study 24%Atelectasis 23%Elevated Hemidiaphragm 20%

    Pulmonary Artery Enlargement 19%Pleural Effusion 18%Parenchymal Pulmonary Infiltrate 17%

    Chest X-ray

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    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 theapex toward the hilum, usually located adjacent to thehilum.

    Chest X-ray

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    Chest X-ray

    Westermark'ssign

    Hamptons

    Hump

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    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

    Echocardiography

    l / f

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    V/Q Scan

    Perfusion: Tc-99M

    Ventilation: Xenon

    Underperfusion ~ V/Q mismatch

    Ventilation/Perfusion Scan

    - V/Q Scan

    /

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    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.

    V/Q Scan

    l/h l l h

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    Spiral/helical CT with IV contrast

    -Technical advances in CT scanning, including thedevelopment 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 tobe nondiagnostic.

    i l/h li l i h

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    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

    S i l/h li l C i h IV

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    Spiral/helical CT with IV contrast

    Spiral computed tomography of the chest with contrast showing large

    clot (black arrow) obstructing right main pulmonary artery

    S i l/h li l CT i h IV

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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).

    http://www.ceessentials.net/article12.html

    Spiral/helical CT with IV contrast

    S i l/h li l CT i h IV

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    These two axial CT images show profound pulmonary emboli. On the left theembolus 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 lifethreatening and require immediate medical attention .

    http://www.ceessentials.net/article12.html

    Spiral/helical CT with IV contrast

    P l A i h

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    Pulmonary Angiography

    The clot appears as a filling defect (arrow)

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

    -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.

    P l A i h

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    Pulmonary Angiography

    Diagnostic: filling defects

    Secondary signs:

    Cut-off of vessels

    Segmental oligaemia

    Prolonged arterial phase, slow filling Tapering of vessels

    P l A i h

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

    filling defects

    Pulmonary Angiography

    E l ti f DVT

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    Duplex Doppler

    Compression Ultrasound

    Venogram (diagnostic dilemmas)

    MRI

    Helical CT Venography (CTV)

    Evaluation of DVT

    Di ti A h

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    Diagnostic Approach

    CT experienced institutions CT inexperienced institutions

    Modified Wells pretest probability scoring

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    Modified Wells pretest probability scoring

    Di ti A h

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    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 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 pulmonaryangiography or the diagnostic approach intended for institutions without experience

    in CT-PA can be used.

    Diagnostic Approach

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    CT-based diagnostic strategy used in patients with suspected pulmonary embolism

    CT experienced institutions:

    Diagnostic Approach

    Diagnostic Approach

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    CT inexperienced institutions:-The Wells criteria are initially applied to determine whether the clinical probability

    of PE is low (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

    Diagnostic Approach

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    CT inexperienced institutions:

    Diagnostic Approach

    VQ-based diagnostic strategy used in patients with suspected pulmonary embolism

    Management

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    Supportive care

    Anticoagulation

    Thrombolysis

    Catheter based interventions

    Surgical embolectomy

    Inferior vena cava filters

    Management

    AHA definitions

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    Massive PE: Acute PEwith

    sustained hypotension (SBP

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    Submassive PE: AcutePE without systemic

    hypotension (systolic blood pressure 90mm

    Hg) but with either RV dysfunction or

    myocardial necrosis.

    Low-risk PE: Acute PEand the absence of the

    clinical markers of adverse prognosisthat

    define massive or submassive PE.

    AHA definitions

    Anticoagulation

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    -Is the mainstay of treatment.

    Anticoagulation

    AHA Recommendations for Initial Anticoagulation for Acute PE

    Therapeutic anticoagulation with subcutaneous LMWH, IVor SC

    UFH with monitoring, unmonitored weight-based

    SC UFH, orsubcutaneous fondaparinux should be givento patients withobjectively confirmed PE and no contraindicationstoanticoagulation

    Therapeuticanticoagulation during the diagnostic workupshouldbe givento patients with intermediate or high clinicalprobabilityofPE and no contraindications to anticoagulation

    Anticoagulants

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    Anticoagulants

    Unfractionated heparin therapy

    Low-molecular-weight heparin therapy

    Fondaparinux

    Warfarin therapy

    Target INR = 2 - 3

    Thrombolytic Therapy

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    Thrombolytic Therapy

    AHA Recommendations for Fibrinolysis for Acute PE

    Fibrinolysis is reasonable for patients with massive acute PEandacceptable risk of bleeding complications

    Fibrinolysis may be considered for patientswith submassiveacute PEjudged to have clinical evidence ofadverse prognosis(newhemodynamic instability, worsening respiratoryinsufficiency,severe RVdysfunction, or major myocardial necrosis)and lowrisk of bleeding

    complications

    Thrombolytic Therapy

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    Thrombolytic Therapy

    orrisk PE-with lowrecommended for patientsnotFibrinolysis issubmassiveacute PE withminor RV dysfunction, minor myocardialnecrosis,and no clinical worsening .

    arrestrecommended for undifferentiated cardiacnotFibrinolysis is

    Thrombolytic Therapy

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    Contraindications for thrombolytic therapy

    Thrombolytic Therapy

    Thrombolytic Therapy

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    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).

    Thrombolytic Therapy

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    Catheter-Based Interventions

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    Percutaneous techniques to recanalize complete

    and partial occlusionsin the pulmonary trunk or

    major pulmonary arteries are potentiallylife-saving

    in selected patients with massive or submassivePE.

    In general, mechanical thrombectomy should be

    limited to themain and lobar pulmonary arterialbranches

    Catheter-Based Interventions

    Surgical Embolectomy

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    Emergency surgical embolectomy with

    cardiopulmonary bypass hasreemerged as an

    effective strategy for managing patients

    withmassive PE or submassive PE with RVdysfunction when contraindicationspreclude

    thrombolysis.

    Surgical Embolectomy

    Recommendations for Catheter

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    Either catheter embolectomy and

    fragmentation or surgical embolectomyis reasonable for

    patientswith massive PE and contraindications to fibrinolysis

    patients with massivePE who remain unstableafter receiving

    fibrinolysis

    patientswith submassive acute PE judged to have clinicalevidence

    ofadverse prognosis (new hemodynamic instability,worsening

    respiratoryfailure, severe RV dysfunction, or majormyocardial necrosis)

    Catheter embolectomy andsurgical thrombectomy are not

    recommendedfor patients withlow-risk PE or submassive acute PE with

    minorRV dysfunction,minor myocardial necrosis, and no clinical

    worsening.

    Recommendations for Catheter

    Embolectomy and Fragmentation

    Inferior Vena Cava Filters

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    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

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    Inferior Vena Cava Filters

    Recommendations on IVC Filters in the

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    Recommendations on IVC Filters in the

    Setting of Acute PE

    Adult patients with any confirmed acute PE (or proximal DVT)withcontraindications to anticoagulation or with active

    bleedingcomplication

    Anticoagulation should be resumed in patients

    with an IVCfilteronce contraindications to anticoagulationor active

    bleedingcomplications have resolved .

    For patients with recurrent acute PE despite

    therapeuticanticoagulation, it is reasonable to place an IVC filter

    For DVT or PE patients who willrequire permanent IVC filtration(eg,

    those with a long-termcontraindication to anticoagulation),it is

    reasonable to selecta permanent IVC filter device

    Recommendations on IVC Filters in the

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    For DVT or PE patients with a time-limited indicationfor

    anIVC filter (eg, those with a short-term

    contraindicationtoanticoagulation therapy), it is reasonable

    to select a retrievableIVC filter device

    Placementof an IVC filter may be considered for patients

    withacute PEand very poor cardiopulmonary reserve,

    including thosewithmassive PE

    An IVC filtershould not be used routinelyas an adjuvant

    toanticoagulationand systemic fibrinolysis in the treatment

    ofacute PE

    Recommendations on IVC Filters in the

    Setting of Acute PE

    Resources

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    Resources http://emedicine.medscape.com/article/4623

    90-overview

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    Thank You