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Baumgartner C, Tritschler T, Aujesky D. Subsegmental Pulmonary Embolism. Hamostaseologie 2024; 44:197-205. [PMID: 37871632 DOI: 10.1055/a-2163-3111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
Subsegmental pulmonary embolism (SSPE) is increasingly diagnosed with the growing use and technological advancements of multidetector computed tomography pulmonary angiography. Its diagnosis is challenging, and some presumed SSPE may actually represent imaging artifacts. Indirect evidence and results from small observational studies suggest that SSPE may be more benign than more proximal pulmonary embolism, and may thus not always require treatment. Therefore, guidelines suggest to consider a management strategy without anticoagulation in selected patients with SSPE at low risk of recurrent venous thromboembolism (VTE), in whom proximal deep vein thrombosis is excluded. Recently, a large prospective study among low-risk patients with SSPE who were left untreated showed a higher VTE recurrence risk than initially deemed acceptable by the investigators, and thus was prematurely interrupted after recruitment of 97% of the target population. However, the risk-benefit ratio of anticoagulation for low-risk patients with SSPE remains unclear, and results from randomized trials are needed to answer the question about their optimal management.
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Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Le Gal G, Kovacs MJ, Bertoletti L, Couturaud F, Dennie C, Hirsch AM, Huisman MV, Klok FA, Kraaijpoel N, Mallick R, Pecarskie A, Pena E, Phillips P, Pichon I, Ramsay T, Righini M, Rodger MA, Roy PM, Sanchez O, Schmidt J, Schulman S, Shivakumar S, Trinh-Duc A, Verdet R, Vinsonneau U, Wells P, Wu C, Yeo E, Carrier M. Risk for Recurrent Venous Thromboembolism in Patients With Subsegmental Pulmonary Embolism Managed Without Anticoagulation : A Multicenter Prospective Cohort Study. Ann Intern Med 2022; 175:29-35. [PMID: 34807722 DOI: 10.7326/m21-2981] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The incidence of pulmonary embolism has been increasing, but its case-fatality rate is decreasing, suggesting a lesser severity of illness. The clinical importance of patients with pulmonary embolism isolated to the subsegmental vessels is unknown. OBJECTIVE To determine the rate of recurrent venous thromboembolism in patients with subsegmental pulmonary embolism managed without anticoagulation. DESIGN Multicenter prospective cohort study. (ClinicalTrials.gov: NCT01455818). SETTING Eighteen sites between February 2011 and February 2021. PATIENTS Patients with isolated subsegmental pulmonary embolism. INTERVENTION At diagnosis, patients underwent bilateral lower-extremity venous ultrasonography, which was repeated 1 week later if results were negative. Patients without deep venous thrombosis did not receive anticoagulant therapy. MEASUREMENTS The primary outcome was recurrent venous thromboembolism during the 90-day follow-up period. RESULTS Recruitment was stopped prematurely because the predefined stopping rule was met after 292 of a projected 300 patients were enrolled. Of the 266 patients included in the primary analysis, the primary outcome occurred in 8 patients, for a cumulative incidence of 3.1% (95% CI, 1.6% to 6.1%) over the 90-day follow-up. The incidence of recurrent venous thromboembolism was 2.1% (CI, 0.8% to 5.5%) and 5.7% (CI, 2.2% to 14.4%) over the 90-day follow-up in patients with single and multiple isolated subsegmental pulmonary embolism, respectively. No patients had a fatal recurrent pulmonary embolism. LIMITATION The study was restricted to patients with low-risk subsegmental pulmonary embolism. CONCLUSION Overall, patients with subsegmental pulmonary embolism who did not have proximal deep venous thrombosis had a higher-than-expected rate of recurrent venous thromboembolism. PRIMARY FUNDING SOURCE Heart and Stroke Foundation of Canada and French Ministry of Health Programme Hospitalier de Recherche Clinique.
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Affiliation(s)
- Grégoire Le Gal
- Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, Brest, France, and Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.L.)
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (M.J.K.)
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Hôpital Nord, CHU de St-Etienne, INSERM, SAINBIOSE, U1059, Dysfonction Vasculaire et Hémostase et Université Jean-Monnet, CIC1408, F- 42055 Saint-Etienne, Réseau français F-CRIN INNOVTE, Saint-Etienne, France (L.B.)
| | - Francis Couturaud
- Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, and Département de médecine interne, médecine vasculaire et pneumologie, Hôpital de la Cavale Blanche, EA3878-GETBO, Univ Brest, Réseau français F-CRIN INNOVTE, CHRU Brest, Brest, France (F.C.)
| | - Carole Dennie
- Department of Radiology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (C.D., E.P.)
| | - Andrew M Hirsch
- Department of Medicine, McGill University, Jewish General Hospital, Montreal, Quebec, Canada (A.M.H.)
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Dutch Thrombosis Network, Leiden, the Netherlands (M.V.H., F.A.K.)
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Dutch Thrombosis Network, Leiden, the Netherlands (M.V.H., F.A.K.)
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands (N.K.)
| | - Ranjeeta Mallick
- Ottawa Methods Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.M.)
| | - Amanda Pecarskie
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Elena Pena
- Department of Radiology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (C.D., E.P.)
| | - Penny Phillips
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Isabelle Pichon
- Service de Recherche Clinique, Hôpital d'Instruction des Armées, Brest, France (I.P.)
| | - Tim Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (T.R.)
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland (M.R.)
| | - Marc A Rodger
- Department of Medicine, McGill University, McGill University Health Center, Montreal, Quebec, Canada (M.A.R.)
| | - Pierre-Marie Roy
- Univ Angers, MITOVASC, Equipe CarMe, Département de Médecine d'Urgence, Centre Hospitalier Universitaire d'Angers, Réseau français F-CRIN INNOVTE, Angers, France (P.R.)
| | - Olivier Sanchez
- Université de Paris, Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP.Centre - Université de Paris, INSERM UMR S 1140 Innovative therapies in hemostasis, Réseau français F-CRIN INNOVTE, Paris, France (O.S.)
| | - Jeannot Schmidt
- Département de Médecine d'Urgence, Centre Hospitalier Universitaire Gabriel Montpied, Réseau français F-CRIN INNOVTE, Clermont-Ferrand, France (J.S.)
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada, and Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia (S.S.)
| | - Sudeep Shivakumar
- Department of Medicine, Dalhousie University, Nova Scotia Health, Halifax, Nova Scotia, Canada (S.S.)
| | | | - Rachel Verdet
- Direction de la Recherche et de l'Innovation, Centre Hospitalier Régional Universitaire de Brest, Brest, France (R.V.)
| | - Ulric Vinsonneau
- Department of Cardiology, Clermont Tonnerre Hospital of Military Training, Brest, France (U.V.)
| | - Philip Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
| | - Cynthia Wu
- Department of Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada (C.W.)
| | - Erik Yeo
- Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada (E.Y.)
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (A.P., P.P., P.W., M.C.)
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Vinson DR, Isaacs DJ, Taye E, Balasubramanian MJ. Challenges in Managing Isolated Subsegmental Pulmonary Embolism. Perm J 2021; 25. [PMID: 35348105 DOI: 10.7812/tpp/21.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/20/2021] [Indexed: 12/14/2022]
Abstract
This commentary explores the clinical conundrums arising when caring for patients with acute pulmonary embolism isolated to the subsegmental pulmonary arteries. We discuss ways to confirm the radiologic diagnosis, how to distinguish patients for whom anticoagulation is indicated from those who are eligible for structured surveillance without anticoagulation, what surveillance entails, and why ensuring continuity of care matters. We report a case from our own experience that illustrates these decision-making crossroads and highlights the importance of cross-disciplinary collaboration. Because the evidence in the literature is currently weak and indirect, we draw on expert opinion in US and European guidelines, a recent statement from a multidisciplinary consensus panel, and several ongoing well-designed clinical trials. This discussion will help clinicians better manage the spectrum of patients who present with isolated subsegmental embolism.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA.,Kaiser Permanente Division of Research, Oakland, CA.,Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Dayna J Isaacs
- School of Medicine, University of California, Davis, Sacramento, CA.,Internal Medicine Residency Program, University of California Los Angeles Health, Los Angeles, CA
| | - Etsehiwot Taye
- The Permanente Medical Group, Oakland, CA.,Department of Adult and Family Medicine, Kaiser Permanente, Selma, CA
| | - Mahesh J Balasubramanian
- The Permanente Medical Group, Oakland, CA.,Department of Adult Hospital Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
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Derenoncourt PR, Felder GJ, Royal HD, Bhalla S, Lang JA, Matesan MC, Itani M. Ventilation-Perfusion Scan: A Primer for Practicing Radiologists. Radiographics 2021; 41:2047-2070. [PMID: 34678101 DOI: 10.1148/rg.2021210060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lung scintigraphy, or ventilation-perfusion (V/Q) scan, is one of the commonly performed studies in nuclear medicine. Owing to variability in clinical applications and different departmental workflows, many trainees are not comfortable interpreting the results of this study. This article provides a simplified overview of V/Q imaging, including a review of its technique, interpretation methods, and established and emerging clinical applications. The authors review the role of V/Q imaging in evaluation of acute and chronic pulmonary embolism, including the role of SPECT/CT and comparing V/Q scan with CT angiography. In addition, a variety of other applications of pulmonary scintigraphy are discussed, including congenital heart disease, pretreatment planning for lung cancer and emphysema, posttransplant imaging for bronchiolitis obliterans, and less common vascular and nonvascular pathologic conditions that may be detected with V/Q scan. This article will help radiologists and residents interpret the results of V/Q scans and understand the various potential clinical applications of this study. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Paul-Robert Derenoncourt
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Gabriel J Felder
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Henry D Royal
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Jordan A Lang
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Manuela C Matesan
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
| | - Malak Itani
- From the Mallinckrodt Institute of Radiology, Washington University in St Louis, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (P.R.D., H.D.R., S.B., J.A.L., M.I.); Department of Radiology, NYU Winthrop Hospital, Mineola, NY (G.J.F.); and Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.C.M.)
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