Pulmonary Embolism

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Pulmonary Embolism

• Prof. Ahmed BaHammam, FRCP, FCCP
• Professor of Medicine
• College of Medicine
• King Saud University

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Phlegmasia cerulea dolens Venous
gangrene
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Color duplex scan of DVT
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Venogram shows DVT
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Patient with suspect symptomatic Acute lower
extremity DVT
negative
Venous duplex scan
Low clinical probability
observe
High clinical probability
positive
negative
Evaluate coagulogram /thrombophilia/ malignancy
Repeat scan / Venography
IVC filter
Anticoagulant therapy contraindication
yes
No
pregnancy
LMWH
OPD
LMWH
warfarin
hospitalisation
UFH
Compression treatment
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Thrombophilia screeningFactor V leiden, Prot C/S
deficiency Antithrombin III deficiency

• Idiopathic DVT lt 50 years
• Family history of DVT
• Thrombosis in an unusual site
• Recurrent DVT

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Recommendation for duration of warfarin

• 3-6 months first DVT with reversible risk factors
• At least 6 months for first idiopathic DVT
• 12 months to lifelong for recurrent DVT or first
  DVT with irreversible risk factors
• malignancy or thrombophilic state

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Catheter directed-thrombolysis

• Consider in Acutelt 10 days iliofemoral DVT.
• Long-term benefit in preventing
  post-phebitic syndrome is unknown.

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• 50,000 individuals die from PE each year in USA
• The incidence of PE in USA is 500,000 per year

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Incidence of Pulmonary Embolism Per Year in the
United States
Total Incidence 630,000
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Survival gt1hr 563,000
Death within 1 hr 67,000
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Dx not made 400,000
Dx made, therapy instituted 163,000
Progress in Cardiovascular Diseases, Vol. XVII,
No. 4 (Jan/Feb 1975)
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Survival 280,000
Death 120,000
Survival 150,000
Death 120,000
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Risk factor for venous thrombosis

• Stasis
• Injury to venous intima
• Alterations in the coagulation-fibrinolytic system

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Source of emboli

• Deep venous thrombosis (gt95)
• Other veins
• Renal
• Uterine
• Right cardiac chambers

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Risk factors for DVT

• General anesthesia
• Lower limb or pelvic injury or surgery
• Congestive heart failure
• Prolonged immobility
• Pregnancy
• Postpartum
• Oral contraceptive pills
• Malignancy
• Obesity
• Advanced age
• Coagulation problems

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Clinical features

• Sudden onset dyspnea
• Pleuritic chest pain
• Hemoptysis
• Clinical clues cannot make the diagnosis of PE
  their main value lies in suggesting the diagnosis

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Massive Pulmonary Embolism

• It is a catastrophic entity which often results
  in acute right ventricular failure and death
• Frequently undiscovered until autopsy
• Fatal PE typically leads to death within one to
  two hours of the event

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Pathophysiology

• Massive PE causes an increase in PVR ? right
  ventricular outflow obstruction ? decrease left
  ventricular preload ? Decrease CO
• In patients without cardiopulmonary disease,
  occlusion of 25-30 of the vascular bed ?
  increase in Pulmonary artery pressure (PAP)
• Hypoxemia ensues ? stimulating vasoconstriction
  ? increase in PAP

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Pathophysiology

• More than 50 of the vascular bed has to be
  occluded before PAP becomes substantially
  elevated
• When obstruction approaches 75, the RV must
  generate systolic pressure in excess of 50mmHg to
  preserve pulmonary circulation
• The normal RV is unable to accomplish this
  acutely and eventually fails

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Diagnosis

• CXR
• ABG
• ECG
• V/Q
• Spiral CT
• Echo
• Angio
• Fibrin Split Products/D-dimer

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S1 Q3 T3 Pattern
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T-wave inversion
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Rt. Bundle Branch Block
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Rt. Ventricular Strain
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Diagnosis

• The diagnosis of massive PE should be explored
  whenever oxygenation or hemodynamic parameters
  are severely compromised without explanation
• CXR
• ABG
• Significant hypoxemia is almost uniformly present
  when there is a hemodynamically significant PE
• V/Q
• Spiral CT
• Echo
• Angio

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Chest radiograph showing pulmonary infarct in
right lower lobe
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High-probability ventilation-perfusion scan
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High-probability ventilation-perfusion scan
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High-probability ventilation-perfusion scan
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Prospective Investigation of Pulmonary Embolism
Diagnosis (PIOPED) results
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Spiral CT
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Spiral CT
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Spiral CT
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Before
After
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Tomographic scan showing infarcted left lung,
large clot in right main pulmonary artery
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Before
After
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Pulmonary angiogram
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Pulmonary Angiogram
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MRA with contrast
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MRA Real Time
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PULMONARY EMBOLISM
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Sensitivity of spiral computed tomography,
magnetic resonance angiography, and real-time
magnetic resonance angiography, for detecting
pulmonary emboli
Reader 1 2 Mean K
CT 72.1 69.8 71.0 0.86
MRA 79.1 81.4 80.3 0.84
RT-MRA 97.7 97.7 97.7 1
Am J Respir Crit Care Med 2003
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Suggested diagnostic strategy for venous
thromboembolism
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Dosage and monitoring of anticoagulant therapy
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Approved thrombolytics for pulmonary embolism
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Contraindications

• Relative
• Recent surgery within last 10 d Previous
  arterial punctures within 10 d
• Neurosurgery within 6 mo Bleeding disorder
  (thrombocytopenia, renal failure, liver failure)
• Ophthalmologic surgery within 6 wk
• Hypertension gt200 mm Hg systolic or 110 mm Hg
  diastolic Placement of central venous catheter
  within 48 h
• Hypertensive retinopathy with hemorrhages or
  exudates Intracerebral aneurysm or malignancy
• Cardiopulmonary resuscitation within 2 wk
• Cerebrovascular disease
• Major internal bleeding within the last 6
  mo Pregnancy and the 1st 10 d postpartum
• Infectious endocarditis Severe trauma within 2
  mo
• Pericarditis
• Absolute
• Active internal bleeding

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Various inferior vena caval filters
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Indications for inferior vena caval (IVC) filters
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Conclusions

• PE is common and under-recognized serious medical
  problem
• Early diagnosis and treatment is essential for
  good outcome
• High index of suspicion is needed in high risk
  patients

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• http//faculty.ksu.edu.sa/ahmedbahammam