Presenter Dr Sadaf Sultana Consultant in charge Dr S M Danish Qaseem Date of presentation 27042020 Definition Risk factors Natural history SymptomsSigns Investigations Diagnosis Management ID: 934001
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Slide1
Acute & Chronic Pulmonary Embolism
Presenter: Dr Sadaf Sultana
Consultant in charge : Dr S. M. Danish
Qaseem
Date of presentation: 27/04/2020
Slide2DefinitionRisk factorsNatural history
Symptoms/Signs
Investigations
Diagnosis
Management
Recommendations (ACCP Guidelines)
Slide3Definition Pulmonary embolism (PE) is a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism).
Slide4SourcesDVT & PE continuum of same diseaseMost common source- Thrombus extending into and above the
popliteal
vein
Deep veins of calf
Pelvic veins
Central venous catheters & cardiac devices
Blood borne parasites, Sickle cell disease
Slide5Virchow’s triadRudolf Virchow ; 19
th
century..
Stasis – immobility, bed rest, anesthesia, CCF, prior venous thrombosis
Hypercoagulability – malignancy, anti cardiolipin antibody, HIT, IBD, PNH, DIC, AT
lll
Protein C , Protein S deficiency
Vessel wall injury – trauma, surgery
Risk factors: (1) Acquired
(2) Inherited
Slide6Risk factors:INHERITED THROMBOPHILIA
AT
lll
Deficiency
Factor V Leiden mutation
Protein C deficiency
Protein S deficiency
ACQUIRED
Surgical procedure
Traumatic injuries – hip,
spine,head
NYHA
lll
-
lV
CCF, COPD, Sepsis
Stroke
Prolonged bed rest
Pregnancy, HRT
Obesity , Malignancy
APLA, PNH,
Polycythemia
Vera
Slide7PathophysiologyResults in – (1)Hemodynamic consequences
--(2) Gas exchange abnormalities
Emboli
Sys venous system Right cardiac chambers
Pulmonary arterial
system
Slide8Hemodynamic Changes
:
Reflex vasoconstriction
Serotonin
Slide9Gas exchange abnormalityMost common immediate effect- HypoxemiaV/Q inequality, intrapulmonary shunting and decrease in mixed venous oxygen level
Increase in alveolar dead space
Pulmonary infarction uncommon
Slide10Outcome:Outcome depends on (1) Size and location of embolus
(2) Cardiopulmonary disease
(3) Humoral mediator release
(4) Rate of resolution
Slide11DIAGNOSISClinical assessmentLab Investigation
ECG, ECHO
D DIMER
CXR
V/Q Scanning
CT- PA
MRI
Slide12Clinical assessment
Slide13Well’s Clinical Prediction Score
Slide14Revised GENEVA Clinical Prediction Score
Slide15Lab findingsRule out other causesModerate
leukocytosis
ABG – Hypoxemia
--
Hypercapnia
ECG:
Non specific changes
S1Q3T3 Pattern, Axis deviation,
Arrythymias
, Right ventricular dysfunction, RBBB
Slide16CXRR/O Pneumothorax
A normal CXR often occurs in PE
Normal CXR with unexplained a/c tachypnea, dyspnea, hypoxemia- suspect PE
Findings-
Cardiomegaly
Atelectasis
Pleural effusion
Pulmonary infiltrates
Elevated hemidiaphragm
Hampton’s hump
Westermark
sign
Slide17CXRHampton’s Hump (A peripheral wedged shaped opacity above the diaphragm)
-Aubrey Otis Hampton
-high sensitivity, less specificity
Westermark’s
Sign (Focal oligemia)
- PIOPED Trial - 10% of CXR; highest PPV
Fleishner
Sign
- Low sensitivity high specificity
Pallas Sign (An enlarged Rt descending PA)
Knuckle Sign
Melting ice cube Sign
Slide18Slide19Slide20Slide21Figure 1. Chest radiograph demonstrating focal
oligemia
in the right lung (area between white arrowheads) and a prominent right descending pulmonary artery (black arrow).
Slide22The patient’s chest x-ray at admission showing the Hampton’s hump (long arrow), the wedge-shaped opacity of the peripheral left lung field, and the
Palla’s
sign (short arrow), enlargement of the right descending pulmonary artery.
Slide23D-Dimer
- ELISA
- Negative predictive value
- False positive in elderly, pregnancy, trauma, infections, post op period, malignancy
inflammatory states
Slide24Echo
Indication- Risk assessment and treatment guidance , R/O other causes
Sensitivity of TTE – 50%
Sensitivity of TEE – 90%
(Proximal pulmonary trunk)
Mc Connell’s sign
Slide25Lower Extremity EvaluationLower extremity evualation
Duplex USG –
sens
& spec 95% in symptomatic
Look for:
-
Noncompressible
venous segment
-
Echogenic
material in the lumen
- Loss of
phasicity
with respiration
- No increase in diameter with
valsalva
- No augmentation of flow to calf
muscle compression
Slide26Slide27Slide28Slide29Slide30CT Venography
Sens
& Spec similar to USG
Contrast and radiation exposure
Advt
:
- Visualize pelvic veins and
venacava
- Combined CT PA and
Venography
Slide31MRA
PIOPED
lll
Trial
Sensitivity – 78%
Specificity – 99%
Advts
:
- Pregnancy
- IV Contrast allergy
Disadvt
:
- Gadolinium related
nephrogenic
sys fibrosis
Slide32Slide33Slide34Slide35Conventional Pulmonary Angiography
Diagnostic findings:
- Filling defect
- Abrupt cut off of vessel
Limitations:
- Expertise in interpretation
- Complications
PIOPED Trial
- Complication rate 1%
- Death rate 0.5%
- Non diagnostic in 3%
Evaluation of suspected chronic
thrombo
embolic disease
Slide36Slide37Slide38Slide39CT- PA
PIOPED Trial
ll
CT PA first line imaging test for PE
Sensitivity- 83%, Specificity – 96%
PPV- 86%, NPV- 97%
Excluding PE in low or I/M probability
Confirming PE in I/M and high probability pts
Slide40CTA anatomy
Slide41CTA anatomy
Slide42CTA ANATOMY
Slide43Cta anatomy
Slide44PATHOLOGY
Slide45CTA Diagnostic criteria for Pulmonary Embolism.
Slide46Slide47Acute Pulmonary Embolism
Slide48Acute Pulmonary Embolism
Slide49Acute Pulmonary Embolism
Slide50Acute Pulmonary Embolism
Slide51Slide52Slide53Slide54Slide55Slide56Slide57Chronic Pulmonary Embolism
Slide58Chronic Pulmonary Embolism
Slide59Chronic Pulmonary Embolism
Slide60Chronic Pulmonary Embolism
Slide61Chronic Pulmonary Embolism
Slide62Chronic Pulmonary Embolism
Slide63Chronic Pulmonary Embolism
Slide64Chronic Pulmonary Embolism
Slide65Chronic Pulmonary Embolism
Slide66Chronic Pulmonary Embolism
Slide67Slide68V/Q Scanning
Replaced by CT
PPV - 88 TO 96%
PIOPED l Trial
Advts
over CT:
-Renal dysfunction/ Severe contrast allergy
-Portable gamma scintillation camera
- Pregnancy
Slide69V/Q Scanning
Slide70V/Q Scanning
Slide71Current diagnostic strategies capable of confirming diagnosis of pulmonary embolism
Slide72Current diagnostic strategies capable of excluding diagnosis of pulmonary embolism
Slide73Interventional Radiologic Techniques:
Interventional thrombus fragmentation
- Catheter fragmentation along with local or systemic
thrombolysis
- Devices use either
pressurised
saline or rotating impeller to fragment central thrombi
- Fragments either aspirated through a separate port on the catheter or allowed to migrate distally
Limitation
Paradoxical embolism
esp
in Patent Foramen
Ovale
.
Slide74Venacava Interruption and Filter:
Permanent and Temporary filters
Indications:
- Contraindication to anticoagulants
- Prophylaxis
Disadvts
:
- Potential DVT formation
- Filter migration/ shift / thrombosis
- Post thrombotic syndrome
In patients with acute DVT or PE who are treated with
anticoagulants,recommendation
against the use of an inferior vena cava (IVC) filter
(Grade 1B)(ACCP 2016)
Slide75Thank you
Thank you