How to Safely Prevent Venous Thromboembolism in Severe Trauma Patients

Venous thromboembolism (VTE) is a life-threatening complication after trauma. Several studies have reported VTE prophylaxis using low-molecular-weight heparin; however, there is no consensus for prophylaxis after trauma. This study aimed to assess the efficacy and safety of our new anticoagulation therapy protocol using unfractionated heparin (UFH) plus intermittent pneumatic compression (IPC) to prevent post-traumatic VTE in high-risk trauma patients.This study enrolled 70 trauma patients who were admitted to the emergency medical center of Nagasaki University Hospital and had Risk Assessment Profile (RAP) scores ≥ 5. After stopping bleeding at the trauma site, all patients received intravenous UFH (10,000 U/day) plus IPC, which was continued for 14 days or until the patients could walk. On days 7 and 14, all patients underwent lower extremity sonography for deep-vein thrombosis screening. VTE incidences between patients with the above intervention and historical controls with IPC alone were compared.No significant differences in age, sex, and the RAP score were observed between the 105 controls and intervention patients. VTE occurrence was fewer in patients with the intervention (14.3%) than in the controls (28.6%; P = 0.029). No hemorrhagic complications occurred after UFH administration. Multivariable logistic analysis revealed a significant association between the intervention and low incidence of VTE (odds ratio: 0.390; 95% confidence interval: 0.163-0.913; P = 0.030).Routine UFH administration with IPC may prevent post-traumatic VTE without adverse events.

[Quantitative measurement of cross-sectional area of small pulmonary vessels in pulmonary embolism]

Objective: The relationship between the percentage of total cross-sectional area (% CSA) of small pulmonary vessels for the lung area in CTPA and the right ventricular function parameters in patients with pulmonary embolism. Methods: 120 patients with PE and 72 healthy subjects underwent CTPA and all date were analyzed Retrospectively. The main pulmonary artery diameter (mPA), the ratio of the main pulmonary artery to the ascending aorta diameter (rPA), right ventricle/left ventricular diameter ratio (RVd/LVd), and the pulmonary artery obstruction index (PAOI) in the PE group were measured for all subjects. The %CSA<5 mm(2) and 5-10 mm(2) for the lung area (%CSA(<5) and %CSA(5-10)) of small pulmonary vessels were measured with Image J image-processing program. According to the risk stratification of the 2018 Guidelines for the Diagnosis and Treatment of Pulmonary Thromboembolism, PE patients were divided into medium-high risk group (RVd/LVd>1) and low-risk group (RVd/LVd<1). The indexes of PE in medium-high risk group, low risk group and control group were compared by ANOVA, and the indexes among PE subgroups were compared by independent sample t-test. Spearman correlation method was used to analyze the correlation between %CSA and right ventricular function parameters of PE patients. Results: %CSA(<5) of medium-high risk group, low-risk group and control group were (0.69±0.19)%, (0.95±0.27)% and (0.99±0.30)% (P<0.01), respectively. %CSA(5-10) of three groups were (0.63±0.15)%, (0.84±0.18)%, and (0.85±0.25)% (P<0.01), respectively; %CSA(<5) and %CSA(5-10) of medium-high risk group were lower than low-risk group and control group. %CSA(<5) and %CSA(5-10) in PE patients correlated negatively with RVd/LVd, rPA and mPA (r=-0.545/-0.549, -0.235/-0.352, -0.239/-0.298, respectively). Conclusion: The measurement of % CSA<(5) and %CSA (5-10) in CTPA were negatively correlated with RVd/LVd in patients with pulmonary embolism, which indirectly reflected the severity of the pulmonary embolism patients.

ETNA-VTE Europe: Benefits and risks of venous thromboembolism treatment using edoxaban in the first 3 months

INTRODUCTION

Edoxaban had a positive risk-benefit ratio for the treatment of venous thromboembolism (VTE) compared to conventional therapy with warfarin. The objective of this analysis of the ongoing ETNA-VTE Europe study was to assess the real-world benefits and risks of edoxaban during the first 3 months of treatment, the highest risk period for further VTE events.

METHODS

ETNA-VTE Europe is a prospective, non-interventional, post-authorization study, conducted in eight European countries. Participants had initial or recurrent acute VTE (deep vein thrombosis [DVT] and/or pulmonary embolism [PE]) that occurred ≤2 weeks prior to enrolment and received edoxaban therapy.

RESULTS

The analysis set included 2672 patients (PE ± DVT, n = 1117; DVT only, n = 1555); mean age 62.9 ± 16.0 years, bodyweight 81.9 ± 17.4 kg, estimated glomerular filtration rate 95.4 ± 42.8 mL/min; 46.4% were female. Overall, 66.4% of patients (PE ± DVT, 68.5%; DVT-only, 64.8%) received heparin lead-in treatment for at least 5 days. Most patients (87.7%) received edoxaban at a dose of 60 mg once daily. Event rates at 3 months were: recurrent VTE 0.34% (n = 9), major bleeding 0.97% (n = 26), all-cause mortality 0.79% (n = 21). Rates were numerically higher in the PE ± DVT group compared with the DVT-only group (recurrent VTE, 0.45% (n = 5) versus 0.26% (n = 4); major bleeding, 1.34% (n = 15) versus 0.71% (n = 11); and all-cause mortality 1.16% (n = 13) versus 0.51% (n = 8)).

CONCLUSIONS

The results support the safety and effectiveness of edoxaban in a general VTE population during the most critical time period, the first 3 months. The outcomes of this study extend the principal efficacy and safety data on edoxaban into the routine clinical practice setting.

Pulmonary artery thrombi are co-located with opacifications in SARS-CoV2 induced ARDS

Purpose

Patients hospitalized for infection with SARS-CoV-2 typically present with pneumonia. The respiratory failure is frequently complicated by pulmonary embolism in segmental pulmonary arteries. The distribution of pulmonary embolism in regard to lung parenchymal opacifications has not been investigated yet.

Methods

All patients with COVID-19 treated at a medical intensive care unit between March 8th and April 15th, 2020 undergoing computed tomography pulmonary angiography (CTPA) were included. All CTPA were assessed by two radiologists independently in respect to parenchymal changes and pulmonary embolism on a lung segment basis.

Results

Out of 22 patients with severe COVID-19 treated within the observed time period, 16 (age 60.4 ± 10.2 years, 6 female SAPS2 score 49.2 ± 13.9) underwent CT. A total of 288 lung segment were analyzed. Thrombi were detectable in 9/16 (56.3%) patients, with 4.4 ± 2.9 segments occluded per patient and 40/288 (13.9%) segments affected in the whole cohort. Patients with thrombi had significantly worse segmental opacifications in CT (p < 0.05) and all thrombi were located in opacitated segments. There was no correlation between d-dimer level and number of occluded segmental arteries.

Conclusions

Thrombi in segmental pulmonary arteries are common in COVID-19 and are located in opacitated lung segments. This might suggest local clot formation.

Pulmonary embolism treatment. Detection of chronic thromboembolic pulmonary hypertension

The correct stratification of pulmonary embolism risk (PE) is essential for decision-making, regarding treatment and defining the patient's place of admission. In high-risk PE, urgent re-establishment of pulmonary circulation and admission to a critical unit is required. The reperfusion treatment of choice is systemic thrombolysis, although in certain situations, especially when there is a contraindication for it, we will evaluate a surgical embolectomy or one of the catheter-guided therapies. In the rest of PE, the treatment of choice will be anticoagulation. Currently, direct oral anticoagulants have become the treatment of choice for the treatment of PE, due to their better safety profile. However, low molecular weight heparins and subsequently antivitamins K, remain the most used treatment, because they are funded by the public system. In cases of PE with cardiorespiratory arrest and / or cardiogenic shock, whenever available at our center, we must consider the indication of extracorporeal membrane oxygenation. The recent creation of PE response teams (PERT team), have meant an improvement in the care of patients with intermediate-high and high risk PE. During the follow-up of patients with PE, it is essential to perform a correct screening of chronic thromboembolic pulmonary hypertension, in order to perform a correct diagnostic and therapeutic approach.

Managing acute pulmonary embolism in primary care in a patient declining emergency department transfer: a case report

Background

For patients with acute pulmonary embolism (PE) diagnosed in the primary care setting, transfer to a higher level of care, like the emergency department, has long been the convention. Evidence is growing that outpatient management, that is, care without hospitalization, is safe, effective, and feasible for selected low-risk patients with acute PE. Whether outpatient care can be provided entirely in the primary care setting has not been well-studied. We report a case of outpatient management of a low-risk patient with acute PE without emergency department transfer.

Case summary

A 74-year-old woman with a history of recent surgery and immobilization presented to a primary care physician with 10 days of mild, non-exertional pleuritic chest pain. Her D-dimer concentration was elevated. Computed tomography pulmonary angiography identified a lobar embolus without right ventricular dysfunction. She declined emergency department transfer but was classified as low risk (class II) on the PE Severity Index and met the criteria of the European Society of Cardiology (ESC) for outpatient care. Her physician provided comprehensive clinic-based PE management, discharging her to home with education, anticoagulation, and close follow-up. She completed her 3-month treatment course without complication.

Discussion

This case describes patient-centred, comprehensive, outpatient PE management in the primary care setting for a woman meeting explicit ESC outpatient criteria. This case illustrates the elements of care that clinics can put in place to facilitate PE management without having to transfer eligible low-risk patients to a higher level of care.

Right atrial thrombus in a patient with COVID-19 pneumonia: a case report

Background

Significant coagulopathy and hyperinflammation are found in patients with coronavirus disease 2019 (COVID-19). Expert consensus has recommended prophylactic anticoagulation in COVID-19 patients due to the risk of thrombo-embolism. However, the use of therapeutic anticoagulation in these patients is still a matter of debate.

Case summary

We describe a patient with COVID-19 pneumonia and a clinical hyperinflammatory state. He developed early respiratory depression and required ventilation, and he subsequently developed haemodynamic instability. Point-of-care echocardiography demonstrated a right atrial thrombus and right ventricular dysfunction suggestive of acute massive pulmonary embolism. He was managed with veno-arterial extracorporeal membrane oxygenation and local thrombolysis.

Discussion

Critical cases of COVID-19 pneumonia are associated with hypercoagulation, and these patients should be monitored closely for complications. Therapeutic anticoagulation may play a role in the management and prevention of thrombo-embolism.

First Multi-Detector Computed Tomography Evidence of Transcatheter Pacing System Migration and Embolization into the Pulmonary Vasculature

Transcatheter leadless pacemaker dislodgment is a rare and potentially fatal complication of leadless device implantation. We present the first case of multidetector computed tomography images of leadless pacemaker migration and embolization in the pulmonary middle lobe artery. The patient was managed by percutaneous retrieval of the dislodged device and re-implantation in the appropriate position.

How to screen and diagnose deep venous thrombosis (DVT) in patients hospitalized for or suspected of COVID-19 infection, outside the intensive care units

Introduction

The Coronavirus disease-2019 outbreak (COVID-19) has been declared a pandemic by the World Health Organization. Studies report both a severe inflammatory syndrome and a procoagulant state in severe COVID-19 cases, with an increase of venous thromboembolism, including pulmonary embolism (PE) and deep vein thrombosis (DVT). In this context, we discuss the use of doppler ultrasonography (DUS) in the screening and diagnosis of DVT in ambulatory and hospitalized patients with, or suspected of having, COVID-19, outside the intensive care unit (ICU).

Material and methods

Non-systematic review of the literature.

Results

In patients hospitalized for or suspected of COVID-19 infection with the presence of either (a) DVT clinical symptoms, (b) a strong DVT clinical probability (Wells score > 2) or (c) elevated D-dimer levels without DVT clinical symptoms and without PE on lung CT angio-scan, DVT should be investigated with DUS. In the presence of PE diagnosed clinically and/or radiologically, additional systematic DVT screening using DUS is not recommended during the COVID-19 pandemic. The use of 4-points compression DUS for DVT screen and diagnosis is the most appropriate method in this context.

Discussion

Systematic DUS for DVT screening in asymptomatic COVID patients is not recommended unless the patient is in the ICU. This would increase the risk of unnecessarily exposing medical staff to SARS-CoV-2 and monopolizing limited resources during this period.

Preoperative and intraoperative predictors of deep venous thrombosis in adult patients undergoing craniotomy for brain tumors: A Chinese single-center, retrospective study

PURPOSE

Brain tumor resection by craniotomy is associated with a high risk of deep vein thrombosis (DVT). This study evaluated the incidence and preoperative and intraoperative risk factors for DVT within 30 days of surgery.

METHODS

The analysis included: 1) basic clinical variables (patient age, sex, body mass index [BMI], tumor location, and tumor histology); 2) blood test results before operation, such as leukocytes, platelets, and coagulation parameters; and 3) surgical factors (total amount of blood lost, anesthesia mode, and surgery duration).

RESULTS

Of the 1670 patients, 206 (12.34%) had DVT and nine (0.54%) had both DVT and pulmonary embolism (PE) after surgery. Preoperative and intraoperative factors independently associated with DVT/PE were: older age 46-55 years (odds ratio [OR]: 2.87; 95% confidence interval [CI]: 1.83-4.50; P < 0.001), age 56-65 years (OR: 5.24; 95% CI: 3.27-8.40; P < 0.001), age > 65 years (OR: 6.00; 95% CI: 3.45-10.45; P < 0.001), BMI (OR: 1.03; 95% CI: 1.00-1.05; P = 0.029), activated partial thromboplastin time [APTT] (OR: 0.91; 95% CI: 0.86-0.95; P = 0.000), D-dimer (OR: 1.69; 95% CI: 1.23-2.34; P = 0.001), high-grade glioma (OR: 2.09; 95% CI: 1.28-3.40; P = 0.003), glio-neuronal (OR: 3.30; 95% CI: 1.28-8.47; P = 0.013), craniopharyngioma (OR: 2.16; 95% CI: 1.13-4.10; P = 0.019), and surgery duration (OR: 1.82; 95% CI: 1.27-2.60; P = 0.001).

CONCLUSIONS

Older age, BMI, preoperative APTT, D-dimer, tumor histology, and surgery duration independently increased the risk of developing postoperative DVT/PE. These findings provide prognostic information that will guide therapies aimed at minimizing the development of DVT/PE during hospitalization.

SARS-CoV-2 and pulmonary embolism: who stole the platelets?

Background

Patients infected with SARS-CoV-2 often develop venous and arterial thrombosis. The high patient mortality is partly attributed to thrombotic events. An emerging trend is the presence of immunological phenomena including antiphospholipid antibodies which may promote thrombosis. The mechanism for these observations is not clear though many patients with SARS-CoV-2 develop thrombocytopenia.

Case presentation

We describe a patient with SARS-CoV-2 pneumonitis who presented with intermediate risk pulmonary embolism (PE). Careful attention to his daily platelet count suggested the possibility of immune mediated heparin-induced thrombocytopenia (HIT) which was confirmed by laboratory testing and resolved when anticoagulation was switched to a direct thrombin inhibitor.

Conclusions

Since excessive platelet activation and in situ thrombosis occur in HIT, this case underscores the need to consider that thrombocytopenia in patients with SARS-CoV-2—most of whom receive heparinoids—may be unrecognized HIT. A central role for the platelet in the etiology of thrombosis during the COVID-19 pandemic should be explored.

Coagulopathie associée au COVID-19 : les éléments essentiels pour l’anesthésiste-réanimateur

Coagulation disorders are commonly reported in patients suffering from COVID-19 pneumonia. These are associated to an increase incidence of thrombotic disorders associated with an increase mortality rate. D-Dimers concentrations > 3 μg/L, fibrinogen > 8 g/L and decreased platelets count are associated with an increased thrombotic risk. These biological markers have to be closely monitored during ICU stay. The diagnosis of pulmonary embolism could be difficult in this setting. However, it has to be evoked in case of worsening hypoxemia unexplained by other reason and/or right ventricular failure. The thrombotic risk can be scored to adapt the thromboprophylactic treatment, impaired renal function and overweight making it even more difficult.

The "Survived Lung:" An Ultrasound Sign of "Bubbly Consolidation" Pulmonary Infarction

Since the presence of "bubbly consolidation" (central lucencies) on a multi-slice computed tomography pulmonary angiography (MCTPA) is one of the highly specific imaging appearances of infarct secondary to pulmonary embolism, we investigated the ultrasound characteristics of these infarctions. In this study, 118 patients with MCTPA diagnosis of acute pulmonary embolism were enrolled. Pulmonary infarctions were detected in 21 patients (17.7%), of which 10 (47.6%) showed the typical appearance of bubbly consolidation on MCTPA. Lung ultrasound (LUS) was performed to evaluate the characteristics of the infarcts highlighted by MCTPA. The bubbly consolidations showed a very peculiar echographic aspect represented by a triangular hypoechoic consolidation with sharp margins, the absence of air bronchograms and a mostly central roundish hyperechoic area. Air lucencies within a pulmonary infarct is hypothesized to represent the coexistence of aerated non-infarcted lung with the infarcted lung in the same lobule. The ultrasound appearance confirms this hypothesis, so we named the roundish hyperechoic area the "survived lung." This picture was found in all patients with a diagnosis of bubbly consolidation on MCTPA (100%). Χ² between MCTPA and LUS regarding the bubbly consolidation diagnosis is 17.18 (df = 1; p value = 0.00003). Bubbly consolidations show a very typical appearance on LUS. Their detection suggests further investigations (MCTPA or point-of-care multi-organ ultrasonography).

Clinical and computed tomography characteristics of COVID-19 associated acute pulmonary embolism: A different phenotype of thrombotic disease?

INTRODUCTION

COVID-19 infections are associated with a high prevalence of venous thromboembolism, particularly pulmonary embolism (PE). It is suggested that COVID-19 associated PE represents in situ immunothrombosis rather than venous thromboembolism, although the origin of thrombotic lesions in COVID-19 patients remains largely unknown.

METHODS

In this study, we assessed the clinical and computed tomography (CT) characteristics of PE in 23 consecutive patients with COVID-19 pneumonia and compared these to those of 100 consecutive control patients diagnosed with acute PE before the COVID-19 outbreak. Specifically, RV/LV diameter ratio, pulmonary artery trunk diameter and total thrombus load (according to Qanadli score) were measured and compared.

RESULTS

We observed that all thrombotic lesions in COVID-19 patients were found to be in lung parenchyma affected by COVID-19. Also, the thrombus load was lower in COVID-19 patients (Qanadli score -8%, 95% confidence interval [95%CI] -16 to -0.36%) as was the prevalence of the most proximal PE in the main/lobar pulmonary artery (17% versus 47%; -30%, 95%CI -44% to -8.2). Moreover, the mean RV/LV ratio (mean difference -0.23, 95%CI -0.39 to -0.07) and the prevalence of RV/LV ratio >1.0 (prevalence difference -23%, 95%CI -41 to -0.86%) were lower in the COVID-19 patients.

CONCLUSION

Our findings therefore suggest that the phenotype of COVID-19 associated PE indeed differs from PE in patients without COVID-19, fuelling the discussion on its pathophysiology.

Management of acute pulmonary embolism 2019: what is new in the updated European guidelines?

Pulmonary embolism (PE) is the third most frequent acute cardiovascular syndrome. Annual PE incidence and PE-related mortality rates rise exponentially with age, and consequently, the disease burden imposed by PE on the society continues to rise as the population ages worldwide. Recently published landmark trials provided the basis for new or changed recommendations included in the 2019 update of the European Society of Cardiology Guidelines (developed in cooperation with the European Respiratory Society). Refinements in diagnostic algorithms were proposed and validated, increasing the specificity of pre-test clinical probability and D-dimer testing, and thus helping to avoid unnecessary pulmonary angiograms. Improved diagnostic strategies were also successfully tested in pregnant women with suspected PE. Non-vitamin K antagonist oral anticoagulants (NOACs) are now the preferred agents for treating the majority of patients with PE, both in the acute phase (with or without a brief lead-in period of parenteral heparin or fondaparinux) and over the long term. Primary reperfusion is reserved for haemodynamically unstable patients. Besides, the 2019 Guidelines endorse multidisciplinary teams for coordinating the acute-phase management of high-risk and (in selected cases) intermediate-risk PE. For normotensive patients, physicians are advised to include the assessment of the right ventricle on top of clinical severity scores in further risk stratification, especially if early discharge of the patient is envisaged. Further important updates include guidance (1) on extended anticoagulation after PE, taking into account the improved safety profile of NOACs; and (2) on the overall care and follow-up of patients who have suffered PE, with the aim to prevent, detect and treat late sequelae of venous thromboembolism.

D-dimer can help differentiate suspected pulmonary embolism patients that require anti-coagulation

Objectives

Determine whether D-dimer concentration in the absence of imaging can differentiate patients that require anti-coagulation from patients who do not require anti-coagulation.

Methods

Data was obtained retrospectively from 366 hemodynamically stable adult ED patients with suspected pulmonary embolism (PE).

Patients were categorized by largest occluded artery and aggregated into: ‘Require anti-coagulation’ (main, lobar, and segmental PE), ‘Does not require anti-coagulation’ (sub-segmental and No PE), ‘High risk of deterioration’ (main and lobar PE), and ‘Not high risk of deterioration’ (segmental, sub-segmental, and No PE) groups.

Wilcoxon rank-sum test was used for 2 sample comparisons of median D-dimer concentrations. Receiver operating characteristic (ROC) curve analysis was utilized to determine a D-dimer cut-off that could differentiate ‘Require anti-coagulation’ from ‘Does not require anti-coagulation’ and ‘High risk of deterioration’ from ‘Low risk of deterioration’ groups.

Results

The ‘Require anti-coagulation’ group had a maximum area under the curve (AUC) of 0.92 at an age-adjusted D-dimer cut-off of 1540 with a specificity of 86% (95% CI, 81–91%), and sensitivity of 84% (79–90%). The ‘High risk of deterioration’ group had a maximum AUC of 0.93 at an age-adjusted D-dimer cut-off of 2500 with a specificity of 90% (85–93%) and sensitivity of 83% (77–90%).

Conclusions

An age-adjusted D-dimer cut-off of 1540 ng/mL differentiates suspected PE patients requiring anti-coagulation from those not requiring anti-coagulation. A cut-off of 2500 differentiates those with high risk of clinical deterioration from those not at high risk of deterioration. When correlated with clinical outcomes, these cut-offs can provide an objective method for clinical decision making when imaging is unavailable.

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ED providers are faced with risks and benefits when empirically administering anti-coagulation for suspected PE patients.

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We show that D-dimer concentration can be used as a clinical decision making tool to minimize these risks.

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A D-dimer cut-off of 1540 ng/mL can be used to minimize unnecessary anti-coagulation exposure in patients who do not need it.

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Using a 2500 ng/mL D-dimer cut-off minimizes the risk of withholding treatment for those at risk of clinical deterioration.

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Both cut-offs along with clinical gestalt are an objective measure weighing the risks & benefits of empiric anti-coagulation.

Clinical and imaging profiles of pulmonary embolism: a single-institution experience

BACKGROUND

Pulmonary embolism (PE) is a common life-threatening condition with non-specific clinical presentations. The diagnosis of PE depends highly on imaging studies, which may also provide prognostic information. This study aimed to describe the clinical and imaging profiles of patients with PE, emphasizing the differences between central and peripheral PE.

METHODS

After ethics review board approval, this retrospective observational study examined the non-negative results in adult patients who underwent computed tomography pulmonary angiography (CT-PA) at our hospital between May 2016 and December 2019. Demographic and clinical information and imaging findings were collected from the electronic medical records.

RESULTS

The study included 85 cases that were identified after re-interpreting the 103 non-negative CT-PA scans. Six cases were excluded for incomplete data and 12 cases were false-positive. Central PE was found in 63.5% of the cases. Obesity was the most common risk factor seen in 37.6% of the cases. Furthermore, 9.4% of the patients had sickle cell disease, which tended to be associated with peripheral PE. There was no difference between the peripheral and central PE in most clinical and imaging parameters evaluated (P > 0.05). However, patients with isolated subsegmental PE were more likely to develop hemoptysis (P = 0.04).

CONCLUSION

This study suggests that patients with obesity and sickle cell disease constitute an important proportion of all PE cases. Furthermore, the clinical and imaging profiles in patients with peripheral PE are similar to those in patients with central PE. Future research should focus on the clinical value of peripheral PE in patients with sickle cell disease.

Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over age 65

TITLE

Comparison of the Wells score and the revised Geneva score as a tool to predict pulmonary embolism in outpatients over 65 years of age.

INTRODUCTION

The incidence and mortality of pulmonary embolism (PE) is high in the elderly. The Wells score (SW) and the revised Geneva score (RGS) have been validated in patient populations with a large age range. The aim of this study was to compare the predictive accuracy of these two scores in diagnosis of PE in patients over 65 years of age.

METHOD

A prospective multicentre study (nine French and three Belgian centres) was conducted at the same time as the PERCEPIC study. A total of 1757 patients admitted with suspected PE were included and divided into two groups according to age (≥65 years or <65 years). The pre-test probability of PE was assessed prospectively for the RGS. The SW was calculated retrospectively. The predictive accuracy of the two scores was compared by the area under the curve (AUC) of the ROC curves.

RESULTS

The overall prevalence of PE was 11.3%. The prevalence among patients aged ≥65 in the low, moderate and high pre-test probability groups, evaluated using the WS and was respectively 13.5% (CI 95%: CI 9.9-17.3), 28.2% (CI 22.1-34.3), 50% (CI 26-74) and 8.1% (CI 3.2-12.9), 22.3% (CI 18.2-26.3), 43.7% (CI 25.6-61.9) using the RGS. The AUC for the WS and RGS for patients aged ≥65 was 0.632 (CI 0.574-0.691) and 0.610 (CI 0.555-0.666). The difference between the AUCs was not statistically significant (p = .441).

CONCLUSION

In the population for this study, the WS and RGS have the same PE diagnostic accuracy in patients over age 65. This result should be validated in a prospective study that directly compares these scores.

Lung and kidney perfusion deficits diagnosed by dual-energy computed tomography in patients with COVID-19-related systemic microangiopathy

Objectives

There is increasing evidence that thrombotic events occur in patients with coronavirus disease (COVID-19). We evaluated lung and kidney perfusion abnormalities in patients with COVID-19 by dual-energy computed tomography (DECT) and investigated the role of perfusion abnormalities on disease severity as a sign of microvascular obstruction.

Methods

Thirty-one patients with COVID-19 who underwent pulmonary DECT angiography and were suspected of having pulmonary thromboembolism were included. Pulmonary and kidney images were reviewed. Patient characteristics and laboratory findings were compared between those with and without lung perfusion deficits (PDs).

Results

DECT images showed PDs in eight patients (25.8%), which were not overlapping with areas of ground-glass opacity or consolidation. Among these patients, two had pulmonary thromboembolism confirmed by CT angiography. Patients with PDs had a longer hospital stay (p = 0.14), higher intensive care unit admission rates (p = 0.02), and more severe disease (p = 0.01). In the PD group, serum ferritin, aspartate aminotransferase, fibrinogen, D-dimer, C-reactive protein, and troponin levels were significantly higher, whereas albumin level was lower (p < 0.05). D-dimer levels ≥ 0.485 μg/L predicted PD with 100% specificity and 87% sensitivity. Renal iodine maps showed heterogeneous enhancement consistent with perfusion abnormalities in 13 patients (50%) with lower sodium levels (p = 0.03).

Conclusions

We found that a large proportion of patients with mild-to-moderate COVID-19 had PDs in their lungs and kidneys, which may be suggestive of the presence of systemic microangiopathy with micro-thrombosis. These findings help in understanding the physiology of hypoxemia and may have implications in the management of patients with COVID-19, such as early indications of thromboprophylaxis or anticoagulants and optimizing oxygenation strategies.

Key Points

• Pulmonary perfusion abnormalities in COVID-19 patients, associated with disease severity, can be detected by pulmonary DECT.

• A cutoff value of 0.485 μg/L for D-dimer plasma levels predicted lung perfusion deficits with 100% specificity and 87% sensitivity (AUROC, 0.957).

• Perfusion abnormalities in the kidney are suggestive of a subclinical systemic microvascular obstruction in these patients.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07155-3) contains supplementary material, which is available to authorized users.

Cost-effectiveness of apixaban for prevention of venous thromboembolic events in patients after gynecologic cancer surgery

OBJECTIVE

The cost-effectiveness of apixaban was compared with enoxaparin for prevention of postoperative venothromboembolic events (VTE) in gynecologic oncology patients. Current guidelines recommend thromboprophylaxis with low molecular weight heparin for 28 days following gynecologic cancer surgery, but recent trials suggest that oral apixaban may be a safe, patient-preferred alternative. Apixaban was superior to enoxaparin in a Canadian cost-effectiveness analysis using orthopedics trial data.

METHODS

Medication costs, adherence rates, event rates, event costs, and utility decrements were estimated using prior clinical trial data and literature review for input into a short-term decision model to simulate outcomes in a hypothetical cohort of 1000 patients. Incremental cost-effectiveness ratios (ICERs) were calculated as net cost difference per quality-adjusted life year (QALY) gained. Input values at which net costs and QALYs were equivalent and ICERs at upper and lower bounds were evaluated.

RESULTS

Using aggregated costs, apixaban was less expensive and more effective than enoxaparin, and remained so or had high value in all scenarios on sensitivity analysis. Examining disaggregated ICERs, apixaban was cost-effective for deep venous thrombosis (DVT); of high value for clinically-relevant non-major bleeding (CRNMB) ($411); low value for major bleeding ($183,465), VTE-related death ($2,711,229), and all-cause mortality ($297,522); and not cost-effective for pulmonary embolism prevention.

CONCLUSIONS

Apixaban is more cost-effective than enoxaparin for the prevention of postoperative VTE in patients with gynecologic cancer. This appears to be driven largely by DVT and CRNMB prevention.

Incidence of deep vein thrombosis and pulmonary embolism in Asian patients after direct anterior total hip arthroplasty

Objective

Venous thromboembolism (VTE), comprising either deep vein thrombosis (DVT) and pulmonary embolism (PE), is one of the most significant complications after Total Hip Arthroplasty (THA). The incidence of VTE after Direct Anterior Approach (DAA) hip arthroplasty is not known. Preceding studies have shown that internal femoral rotation used in the posterior approach leads to "scissoring" of the femoral vein and complete occlusion of flow. In contrast, external femoral rotation, utilized in an anterior approach, does not lead to any limitation in venous flow. We hypothesize that the rate of VTE post-operatively after DAA THA is comparable, if not lower, to other conventional approaches.

Methods

Retrospective analysis of medical records was examined to identify the incidence of symptomatic DVT within 6 months post-surgery, yielding 196 cases of elective primary DAA after THAs between 2015 and 2019. Aspirin was administered post-operatively. Corresponding imaging was performed for cases with high clinical suspicion of either DVT or PE based on Well's criteria.

Results

There were no cases of symptomatic DVT or fatal PE within 1 year of THA. There was 1 case of non-fatal subsegmental pulmonary embolism, treated with warfarin, which made an uneventful recovery. The overall incidence of symptomatic DVT and PE after DAA THA was 0% and 0.5% respectively in our study population.

Conclusion

Cumulative rate of symptomatic DVT and PE was less than 1%, demonstrating that incidence of VTE after DAA THA is low. DAA is a viable approach in Asian patients undergoing THA, in view of lower incidence of post-operative VTE compared values cited in other conventional surgical approaches. Further large scale studies involving use of routine post-operative venography for assessment will further validate our results.

A case-report of widespread pulmonary embolism in a middle-aged male seven weeks after asymptomatic suspected COVID 19 infection

BACKGROUND

Pulmonary embolism (PE) is seen in high frequency in hospital-treated patients with Covid-19. We present a case of suspected Covid-19 with long-term dyspnea and widespread PE.

CASE PRESENTATION

A 51- year old male, with no prior medical history, no medication, and non-smoker arrived at the emergency department with exercise induced dyspnea during 4-5 weeks and for the last 48 h dyspnea at rest. Seven weeks before hospitalization, he felt difficulties taking deep breaths for some days but no other symptoms. Oxygen saturation at rest was 93%. Troponin T was 1200 mg/L (ref < 15 mg/L). CT angiography revealed widespread bilateral segmental pulmonary embolism. Additional findings were ground glass opacities that could match Covid-19. The patient tested negative for SARS -CoV-2. Full dose tinzaparin was given for 2 days in hospital, followed by apixaban for 6 months. Recovery has been uneventful so far.

CONCLUSIONS

Long-term breathing difficulties might be relatively common after non-hospitalized symptomatic Covid-19. The frequency of PE in this group is unknown. We report a case of suspected covid-19 with widespread PE and a long history of dyspnea but no other symptoms. In our case slight hypoxia and laboratory testing indicated significant disease, which was proven with contrast angiography. This case shows that PE is a differential diagnosis in non-hospitalized symptomatic Covid-19 with persisting breathing problems.

[Imaging findings of CT pulmonary angiography in patients with chronic thromboembolic pulmonary hypertension]

Objective: To investigate the imaging findings of CT pulmonary angiography (CTPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Methods: Consecutive CTEPH cases admitted to receive CTPA in China-Japan Friendship Hospital from December 2015 to December 2019 were enrolled with prospective data collected. The medical histories, imaging manifestation and hemodynamic parameters were analyzed. Patients were divided into proximal lesions group and distal lesions group according to the site of thrombus, and imaging findings were compared between these two groups. Results: In 135 cases of CTEPH, CTPA showed thrombus in both lungs in the majority of patients (133 cases, 98.5%) with location of thromboembolic disease in level Ⅰ, Ⅱ and Ⅲ for most patients, only 8 cases with level Ⅳ(7.3%) and no level 0 patients. The most common signs of chronic thrombus were vessel cutoffs (134 cases, 99.3%), eccentric wall-adherent filling defects (111 cases, 88.2%), web or bands (80 cases, 59.3%), stenosis (41 cases, 30.4%). Compared to patients with distal lesions, eccentric wall-adherent filling defects, irregular vessel wall were more common in patients with proximal lesions, stenosis was more common in distal lesions, all P<0.05. The most common lung parenchymal signs were mosaic attenuation (104 cases, 77.0%), and pulmonary infarction (79 cases, 58.5%). Pulmonary infarction included pleura-based consolidation opacity (35/79, 44.3%), linear opacities (23/79, 29.1%), or both (13/79, 16.5%). Pulmonary artery enlargement (132 cases, 97.8%) and right ventricular hypertrophy (130 cases, 96.3%) were common, other signs included contrast reflux into the inferior vena cava (70 cases, 51.9%), enlargement of bronchial arteries (68 cases, 50.3%). No differences were found for all the secondary signs between patients with proximal lesions and those with distal lesions, all P>0.05. Conclusions: Vessel cutoffs, eccentric wall-adherent filling defects, web or bands are the most common CTPA findings of chronic thrombus in CTEPH. Secondary signs include mosaic attenuation, pulmonary infarction, pulmonary artery enlargement, right ventricular hypertrophy and enlargement of bronchial arteries. Eccentric wall-adherent filling defects are more common in patients with proximal lesions than those with distal lesions.

[Risk factors associated with mortality in patient with non-high-risk pulmonary embolism and cancer and the prognostic value of Charlson comorbidity index]

Objective: To investigate the risk factors associated with mortality and the prognostic value of Charlson comorbidity index (CCI) for mortality in patients with non-high-risk pulmonary embolism complicated by caner. Methods: Patients diagnosed with non-high-risk pulmonary embolism and caner from the medical departments of West China Hospital of Sichuan University from May, 2015 to April, 2018 were included in this study. The patients were classified into death group and survival group according to whether they died during hospitalization. Clinical information was collected and univariate along with multivariate analysis were performed in order to identify the independent risk factor related to short-term mortality in these patients. Besides, all the patients were assessed the comorbidity burden using CCI score and thereby to evaluate the prognostic value of CCI for short-time mortality. Results: A total of 195 patients were included in this study, including 115 males and 80 females. In all, 32 patients died during hospitalization and the mortality rate was 16.4%. Univariate analysis showed that male (P=0.044), age ≥65y (P=0.008), staying in bed (P=0.001), chronic pulmonary diseases (P=0.030), central venous catheterization (P=0.015), stroke history within 1 month (P=0.015), pneumonia (P=0.017), respiratory failure (P=0.017), diabetes mellitus (P=0.005) and anemia (P=0.035) were related to short term mortality of these patients. As for laboratory examination results, levels of hemoglobin and sodium in death group were significantly lower than survival group (P<0.05). Multivariate logistic regression showed that age ≥65y (OR=3.01, 95%CI: 1.05-8.68, P=0.041), staying in bed (OR=4.15, 95%CI: 1.37-12.54, P=0.012), central venous catheterization (OR=16.10, 95%CI: 2.09-124.08, P=0.008), stroke history within 1 month (OR=6.56, 95%CI: 1.05-40.95, P=0.044) and hyponatremia (OR=2.75, 95%CI: 1.06-7.15, P=0.038) were independent risk factors of short term mortality in these patients. Besides, CCI score in death group was significantly higher than that in survival group (5.66±2.96 vs 4.13±2.74, P=0.005). Pulmonary embolism patients with CCI≥4 were associated with 4.25-fold increased risk of mortality compared with patients with CCI<4 (OR=4.25, 95%CI: 1.83-9.89, P=0.001), and the per additional 1-score increase of CCI after 4 was associated with 4.89-fold increased risk of mortality (OR=4.89, 95%CI: 2.07-11.55, P<0.001). Survival analysis showed that patients with CCI≥4 had lower survival rate than the patients with CCI<4 during hospitalization (P<0.001). Conclusions: Age ≥65y, staying in bed, central venous catheterization, stroke history within 1 month and hyponatremia are independent risk factor of short-term mortality in patients with non-high-risk pulmonary embolism and caner. CCI score has prognostic value of short term mortality in these patients, and the risk increases with the increase of comorbidities patients have.