Pulmonary Embolism

Pulmonary embolism after shoulder surgery: Is it a real threat?

Pulmonary embolism (PE) is a rare but devastating complication of shoulder surgery. Apart from increased morbidity and mortality rates, it may significantly impair postoperative recovery and functional outcome. Its frequency accounts for up to 5.7% of all shoulder surgery procedures with a higher occurrence in women and patients older than 70 years. It is most commonly associated with thrombophilia, diabetes mellitus, obesity, smoking, hypertension, and a history of malignancy. PE usually occurs secondary to upper or lower-extremity deep vein thrombosis (DVT). However, in rare cases, the source of the thrombi cannot be determined. Prophylaxis for PE following shoulder surgery remains a topic of debate, and the standard of care does not routinely require prophylactic medication for DVT prophylaxis. Early ambulation and elastic stockings are important preventative measures for DVT of the lower extremity and medical agents such as aspirin, low-molecular-weight heparin, and vitamin K antagonists are indicated for high-risk patients, long-lasting operations, or concomitant severe acute respiratory syndrome coronavirus 2 infection. The most common symptoms of PE include chest pain and shortness of breath, but PE can also be asymptomatic in patients with intrinsic tolerance of hypoxia. Patients with DVT may also present with swelling and pain of the respective extremity. The treatment of PE includes inpatient or outpatient anticoagulant therapy if the patient is hemodynamically unstable or stable, respectively. Hemodynamic instability may require transfer to the intensive care unit, and cardiovascular arrest can be implicated in fatal events. An important issue for patients with PE in the postoperative period after shoulder surgery is residual stiffness due to a delay in rehabilitation and a prolonged hospital stay. Early physiotherapy and range-of-motion exercises do not adversely affect the prognosis of PE and are highly recommended to preserve shoulder mobility and function.

Relationship between serum uric acid levels and pulmonary embolism: an age-based stratified analysis

BACKGROUND

The association between uric acid and pulmonary embolism(PE) remains controversial, and there has been limited investigation into how uric acid influences pulmonary embolism across different age groups. Our study aimed to elucidate the relationship between uric acid levels and pulmonary embolism, considering variations across age groups.

METHODS

A total of 368 patients who underwent computed tomography pulmonary angiography from July 2018 to May 2022 were included in the analysis. Subsequently, the cohort was stratified by age, with separate univariate and multivariate logistic regression analyses conducted for the elderly (aged ≥ 60 years) and non-elderly (aged < 60 years), respectively.

RESULTS

The study revealed that patients with PE exhibited higher uric acid levels compared to those without (325.11 ± 137.02 vs. 298.26 ± 110.54 (umol/l), p = 0.039). This disparity persisted even after adjusting for multiple confounders (OR = 1.002, 95% CI 1.000-1.005, p = 0.042). Additionally, a notable age difference was observed between PE and non-PE patients (65.7 ± 16.12 vs. 61.42 ± 15.03 (umol/l), p = 0.009). Subsequently, upon age stratification, significant differences (p < 0.05) in serum uric acid were noted between PE and non-PE patients in both elderly and non-elderly populations. However, elevated uric acid levels were independently associated with PE only in the elderly following adjustment for multiple confounders (OR = 1.003, 95% CI 1.001-1.005, p = 0.008).

CONCLUSION

High uric acid levels are an independent risk factor for pulmonary embolism in the elderly (≥ 60 years).

The Impact of Cardiovascular Disease Gene Polymorphism and Interaction with Homocysteine on Deep Vein Thrombosis

Deep vein thrombosis (DVT) affects vascular health and can even threaten life; however, its pathogenesis remains unclear. Cardiovascular disease (CVD) and DVT share common risk factors, such as dyslipidemia, aging, etc. We aimed to investigate the loci of published CVD susceptibility genes and their association with environmental factors that might be related to DVT. Genotyping by Kompetitive Allele Specific PCR (KASP), collection of lifestyle information, and determination of blood biochemical markers were performed in 165 DVT cases and 164 controls. The impact of six single nucleotide polymorphisms (SNPs) and additional potential variables on DVT morbidity was evaluated using unconditional logistic regression (ULR). To explore the high-order interactions related to genetics and the body's internal environment exposure that affect DVT, ULR, crossover analysis, and multifactor dimensionality reduction/generalized multifactor dimensionality reduction (MDR/GMDR) were employed. Sensitivity analyses were performed using the EpiR package. The polymorphisms of FGB rs1800790 and PLAT rs2020918 were significantly associated with DVT. The optimum GMDR interaction model for gene-gene (G × G) consisted of THBD rs1042579, PLAT rs2020918, and PON1 rs662. The PLAT rs2020918 and MTHFR rs1801133 polymorphisms together eliminated the maximum entropy by the MDR method. The optimum GMDR interaction model for gene-environment (G × E) consisted of MTHFR rs1801133, FGB rs1800790, PLAT rs2020918, PON1 rs662, and total homocysteine (tHcy). Those with high tHcy levels and three risk genotypes significantly increased the DVT risk. In conclusion, certain CVD-related SNPs and their interactions with tHcy may contribute to DVT. These have implications for investigating DVT etiology and developing preventive treatment plans.

Mir-150-5p distinguishes acute pulmonary embolism, predicts the occurrence of pulmonary arterial hypertension, and regulates ox-LDL-induced endothelial cell injury

BACKGROUND

Acute pulmonary embolism (APE) is a major type of venous thromboembolism (VTE) with a high risk of mortality and disability. There is a lack of biomarkers for APE to indicate deteriorating development and predict adverse outcomes. This study evaluated the significance of miR-150-5p in APE aiming to explore a novel potential biomarker for APE.

METHODS

The study enrolled APE (n = 137) and deep wein thrombosis (DVT, n = 67) patients and collected plasma samples from all study subjects. The expression of miR-150-5p was analyzed by PCR and its significance in screening APE and pulmonary arterial hypertension (PAH) was assessed by receiver operating curve (ROC) and logistic analyses. The study established oxidized low-density lipoprotein (ox-LDL)-induced human venous endothelial cells (HUVECs). Through cell transfection combined with cell counting kit-8 (CCK8), flow cytometry, and enzyme-linked immunosorbent assay (ELISA), the effect of miR-150-5p on ox-LDL-induced HUVEC injury was evaluated.

RESULTS

Significant downregulation of miR-150-5p was observed in the plasma of APE patients compared with DVT patients (P < 0.0001). The plasma miR-150-5p levels in APE patients occurred PAH was much lower than in patients without PAH (P < 0.0001). Reducing miR-150-5p distinguished APE patients from DVT patients (AUC = 0.912) and was identified as a risk factor for the occurrence of PAH in APE patients (OR = 0.385, P = 0.010). In HUVECs, oxidized low-density lipoprotein (ox-LDL) caused inhibited cell proliferation, enhanced apoptosis, increased pro-inflammatory cytokines, reactive oxygen species (ROS), malondialdehyde (MDA), and decreased superoxide dismutase (SOD). Overexpressing miR-150-5p could promote proliferation, inhibit apoptosis, and alleviate inflammation and oxidative stress of ox-LDL-treated HUVECs.

CONCLUSIONS

Downregulated plasma miR-150-5p served as a diagnostic biomarker for APE and predicted the predisposition of PAH in APE patients. Overexpressing miR-150-5p could alleviate ox-LDL-induced endothelial cell injury in HUVECs.

A Silent Threat: Deep Vein Thrombosis in Early-Stage Parkinson's Disease

Introduction

The primary clinical manifestation of venous thrombosis is discomfort in the lower extremities. Some early Parkinson's disease (PD) patients feel discomfort in the lower limbs. Venous thrombosis can risk lives by causing pulmonary embolism. This study examines the incidence of DVT in early PD patients and its correlation with different clinical and lab features.

Methods

A cross-sectional study was conducted on 117 patients with early-stage PD. Ultrasonography was employed to detect the presence of DVT. Factors such as age, gender, body mass index, lifestyle habits (smoking and drinking), medical history (hypertension, diabetes, atrial fibrillation, and tumor), and other lab tests linked to thrombosis were analyzed.

Results

In 117 patients, 11 (9.4%) had DVT, while 106 (90.6%) did not. There were no significant differences in gender, BMI, habits, medical history, or other thrombosis-related tests between both groups. However, DVT patients were older with higher d-dimer levels. They also showed an increased right substantia nigra ultrasound echo area, higher HY grades, higher UPDRS 3 scores, less improvement in UPDRS 3 scores and levodopa response.

Discussion

The primary risk factors for lower extremity venous thrombosis were found to be age, d-dimer levels, and low-dose levodopa. Therefore, for elderly patients with early-stage PD, it is crucial to conduct d-dimer and lower extremity vascular ultrasound tests. The prevention of venous thrombosis in the lower extremities of early PD patients is of utmost importance.

Accuracy of transthoracic lung ultrasound for diagnosing pulmonary embolism: An updated systematic review and meta-analysis

BACKGROUND

Computed tomography pulmonary angiography (CTPA) simplifies the diagnosis of pulmonary embolism (PE) but is not suitable for all patients. Transthoracic lung ultrasound (LUS) is a potential alternative; this meta-analysis evaluates its accuracy for diagnosing PE.

METHODS

We systematically searched PubMed, Embase and Cochrane Library from the inception of each database up to April 2024 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies guidelines. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool, and a bivariate random effects model was used to pool sensitivity and specificity.

RESULTS

A total of 18 studies with 2158 patients were analyzed. Lung ultrasound showed a sensitivity of 0.80 (95 %, confidence interval (CI): 0.71-0.86; I2 = 85.2 %) and specificity of 0.87 (95 %, CI: 0.81-0.92; I2 = 87.3 %). The diagnostic score was 3.27 (95 %, CI: 2.75-3.78; I2 = 61.9 %), and the diagnostic odds ratio was 26 (95 %, CI: 16-44; I2 = 100.0 %). The pooled positive likelihood ratio was 6.2 (95 %, CI: 4.2-9.1; I2 = 79.2 %), and the negative likelihood ratio was 0.24 (95 %, CI: 0.16-0.34; I2 = 83.7 %). The summary area under the curve was 0.91 (95 %, CI: 0.88-0.93). Significant heterogeneity was observed, which may impact the generalisability of the results, and no publication bias was detected.

CONCLUSION

Transthoracic LUS shows potential as an alternative to CTPA for PE diagnosis, but further research is needed to improve its accuracy and establish standardised diagnostic criteria. The observed heterogeneity highlights the need for a cautious interpretation of the results.

Thrombosis and Thrombotic Risk in Athletes

The hemostatic system is characterized by a delicate balance between pro- and anticoagulant forces, and the smallest alteration can cause serious events such as hemorrhages or thrombosis. Although exercise has been shown to play a protective role in athletes, several factors may increase the risk of developing venous thromboembolism (VTE), including hemoconcentration induced by exertion, immobilization following sports injuries, frequent long-distance flights, dehydration, and the use of oral contraceptives in female athletes. Biomarkers such as D-dimer, Factor VIII, thrombin generation, inflammatory cytokines, and leukocyte count are involved in the diagnosis of deep vein thrombosis (DVT), although their interpretation is complex and may indicate the presence of other conditions such as infections, inflammation, and heart disease. Therefore, the identification of biomarkers with high sensitivity and specificity is needed for the screening and early diagnosis of thromboembolism. Recent evidence about the correlation between the intensity of physical activity and VTE is divergent, whereas the repeated gestures in sports such as baseball, hockey, volleyball, swimming, wrestling, or, on the other hand, soccer players, runners, and martial art training represent a risk factor predisposing to the onset of upper and lower DVT. Anticoagulant therapy is the gold standard, reducing the risk of serious complications such as pulmonary embolism. The aim of this review is to provide a general overview about the interplay between physical exercise and the risk of thromboembolism in athletes, focusing on the main causes of thrombosis in professional athletes and underlying the need to identify new markers and therapies that can represent a valid tool for safeguarding the athlete's health.

Pulmonary thromboembolism: a case report and misdiagnosis analysis of a 63-year-old female patient

This paper presents a case of a 63-year-old female patient who was initially misdiagnosed with mycoplasma pneumonia due to symptoms such as chest pain, hemoptysis, and fever, but was later confirmed to have pulmonary thromboembolism (PTE) through further examination. This case highlights the similarities between PTE and pneumonia in terms of symptoms, as well as the complexity of PTE diagnosis. The article provides a detailed description of the patient's medical history, symptoms, examination process, and treatment outcomes. Furthermore, it discusses the possible reasons for the misdiagnosis, including insufficient awareness of PTE among physicians, lack of in-depth investigation into the causes of abnormally elevated D-dimer levels, the non-specific clinical manifestations of PTE, and the concerns of the patient's family regarding pulmonary artery CTA examination. Additionally, the article emphasizes the importance of clinicians in improving their ability to differentiate and diagnose PTE, rationally utilizing clinical examination methods, and ensuring timely diagnosis and treatment of PTE.

No Genetic Causality between Tobacco Smoking and Venous Thromboembolism: A Two-Sample Mendelian Randomization Study

BACKGROUND

 Given the current debate in clinical research about the relationship between tobacco smoking and the risk of venous thromboembolism (VTE), a Mendelian randomization (MR) study was conducted aimed at elucidating the causal associations of current and past tobacco smoking with the risk of VTE, from the perspective of genetics.

METHODS

 Two-sample univariate and multivariable MR analyses were designed, using summary-level data from large genome-wide association studies involving European individuals. Causality was primarily assessed using multiplicative fixed-effects or random-effects model and inverse variance weighting, supplemented by MR-Egger regression, MR-PRESSO, Cochran's Q test, and leave-one-out for sensitivity analysis to test the reliability of the results.

RESULTS

 In the univariate MR analysis, no significant causal effects were found between current tobacco smoking and the risk of VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE). Similarly, no significant causal effects were found between past smoking and VTE, DVT, and PE. As for the multivariable MR analysis, results were consistent with univariate MR analysis, with no significant causal effect of either current or past tobacco smoking on the risk of VTE, DVT, and PE.

CONCLUSION

 Evidence from both univariate and multivariable MR analyses demonstrated no significant causal relationships between current and past tobacco smoking and VTE, DVT, and PE. This contradicts positive correlations reported in some previous observational studies, which may be explained by other confounding factors. This provided genetic evidence for the conclusion reported in other observational studies that smoking did not affect VTE risk.

Outcomes of Mechanical Thrombectomy Compared With Systemic Thrombolysis in Pulmonary Embolism: A Comprehensive Evaluation From the National Inpatient Sample Database

BACKGROUND

Systemic thrombolysis (ST) may not be ideal for many patients with acute pulmonary embolism (PE) due to bleeding risk. In this analysis, we evaluated the safety and effectiveness of mechanical thrombectomy (MT) as an alternative to ST for acute PE.

METHODS

Patients aged ≥18 years who underwent MT and/or ST for PE were identified from the National Inpatient Sample database from 2016 to 2017. Patients who underwent catheter-directed thrombolysis were excluded. We compared in-hospital outcomes of both groups in this retrospective study.

RESULTS

Of 16 890 patients who received an intervention for acute PE, 1380 (8.2%) received MT and 15 510 (91.8%) received ST. There was no difference in age between both groups. In-hospital mortality was significantly lower in patients who received MT than that in those who received ST (11.9% vs 20.6%, odds ratio [OR]: 0.52, 95% confidence interval [CI]: 0.29-0.93, p=0.028). There was no statistically significant difference in terms of periprocedural bleeding, intracranial hemorrhage, and acute kidney injury between the 2 groups (p≥0.608 for all). Patients who received MT had a higher rate of respiratory complications (19.0% vs 11.6%, OR: 1.79, 95% CI: 1.06-3.03, p=0.030) and discharge to an outside facility (34.1% vs 19.2%, OR: 2.18, 95% CI: 1.41-3.37, p<0.001) than those who received ST.

CONCLUSION

Mortality was significantly lower with MT than that with ST, but larger randomized studies are needed to validate this. The use of MT should be individualized on the basis of the patients' clinical presentation, risk profile, and local resources.

CLINICAL IMPACT

In this study, we utilized the National Inpatient Sample database to study the in-hospital outcomes of pulmonary embolism patients who underwent mechanical thrombectomy compared to those who underwent systemic thrombolysis. We found that the patients who were diagnosed with pulmonary embolism and underwent mechanical thrombectomy had significantly lower mortality compared to those who were treated using systemic thrombolysis. This study was the first of its kind, utilizing the national inpatient sample database for evaluation of mechanical thrombectomy in comparison with the standard of care. These result would direct further randomized controlled trials for better evaluation of the utilization of mechanical thrombectomy in the correct clinical context. Furthermore, our study demonstrated comparable peri-operative complications between the mechanical thrombectomy group and the systemic thrombolysis group. These results would direct clinicians to consider mechanical thrombectomy if clinically indicated given the promising results.

Calf deep veins are safe and feasible accesses for the endovascular treatment of acute lower extremity deep vein thrombosis

This study was designed to assess the optimal access route for the endovascular treatment of acute lower extremity deep vein thrombosis. This was a retrospective analysis of patients with acute lower extremity deep venous thrombosis who underwent endovascular treatment from February 2009 to December 2020. Patients underwent non-direct calf deep vein puncture (NDCDVP) from February 2009 to December 2011 and direct calf deep vein puncture (DCDVP) from January 2012 to December 2020. Catheter directed thrombolysis (CDT) was used to treat all patients in the NDCDVP group, whereas patients in the DCDVP group were treated with CDT or the AngioJet rhyolitic thrombectomy system. In patients exhibiting iliac vein compression syndrome, the iliac vein was dilated and implanted with a stent. Technical success rates and perioperative complication rates were compared between these two treatment groups. The NDCDVP group included 83 patients (40 males, 43 females) with a mean age of 55 ± 16 years, while the DCDVP group included 487 patients (231 males. 256 females) with a mean age of 56 ± 15 years. No significant differences were observed between these groups with respect to any analyzed clinical characteristics. The technical success rates in the NDCDVP and DCDVP groups were 96.4 and 98.2%, respectively (P > 0.05). In the NDCDVP group, the small saphenous vein (SSV)or great saphenous vein (GSV)were the most common access routes (77.1%, 64/83), whereas the anterior tibial vein (ATV) was the most common access route in the DCDVP group (78.0%, 380/487), followed by the posterior tibial vein (PTV) and peroneal vein (PV)(15.6% and 6.4%, respectively). Relative to the NDCDVP group, more patients in the DCDVP group underwent the removal of deep vein clots below the knee (7.2% [6/83] vs. 24.2% [118/487], P < 0.001). Moreover, relative to the NDCDVP group, significantly lower complication rates were evident in the DCDVP group (local infection: 10.8% vs. 0.4%, P < 0.001; local hematoma: 15.7% vs. 1.0%, P < 0.001). The position change rate was also significantly lower in the DCDVP group relative to the NDCDVP group (0% [0/487] vs. 60.2% [50/83], P < 0.001). The calf deep veins (CDVs) represent a feasible and safe access route for the endovascular treatment of lower extremity deep vein thrombosis.

The role of echocardiography in pulmonary embolism for the prediction of in-hospital mortality: a retrospective study

PURPOSE

Pulmonary Embolism (PE) is the third leading cause of cardiovascular death, following myocardial infarction and stroke. The latest European Society of Cardiology (ESC) guidelines on PE recommend short-term prognostic stratification based on right ventricular (RV) overload detected by transthoracic echocardiography (TTE) or contrast-enhanced chest CT. The aim of the study is to find out which of the signs of right ventricular dysfunction best predicts in-hospital mortality (IHM).

METHODS

This is a monocentric, retrospective study including adult patients admitted from the emergency department with a c-e cCT confirmed diagnosis of PE between January 2018 and December 2022 who underwent a TTE within 48 h.

RESULTS

509 patients (median age 76 years [IQR 67-84]) were included, with 7.1% IHM. At univariate analysis, RV/LV ratio > 1 (OR 2.23, 95% CI 1.1-4.5), TAPSE < 17 mm (OR 4.73, 95% CI 2.3-9.8), the D-shape (OR 3.73, 95% CI 1.71-8.14), and LVEF < 35% (OR 5.78, 95% CI 1.72-19.47) resulted significantly correlated with IHM. However, at multivariate analysis including also haemodynamic instability, PESI class > II, and abnormal hs-cTnI levels, only LVEF < 35% (OR 5.46, 95% CI 1.32-22.61) resulted an independent predictor of IHM.

CONCLUSION

Despite the recognised role of TTE in the early management of patients with circulatory shock and suspected PE, signs of RV dysfunction have been shown to be poor predictors of IHM, whereas severely reduced LVEF is an independent risk factor for in-hospital death.

Shock Index and Physiological Stress Index for reestratifying patients with intermediate-high risk pulmonary embolism

OBJECTIVE

Study and Evaluation of Two Scores: Shock Index (SI) and Physiological Stress Index (PSI) as discriminators for proactive treatment (reperfusion before decompensated shock) in a population of intermediate-high risk pulmonary embolism (PE).

DESIGN

Using a database from a retrospective cohort with clinical variables and the outcome variable of "proactive treatment", a comparison of the populations was conducted. Optimal cut-off for "proactive treatment" points were obtained according to the SI and PSI. Comparisons were carried out based on the cut-off points of both indices.

SETTING

Patients admitted to a mixed ICU for PE.

PARTICIPANTS

Patients >18 years old admitted to the ICU with intermediate-high risk PE recruited from January 2015 to October 2022.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Population comparison and metrics regarding predictive capacity when determining proactive treatment.

RESULTS

SI and PSI independently have a substandard predictive capacity for discriminating patients who may benefit from an early reperfusion therapy. However, their combined use improves detection of sicker intermediate-high risk PE patients (Sensitivity = 0.66) in whom an early reperfusion therapy may improve outcomes (Specificity = 0.9).

CONCLUSIONS

The use of the SI and PSI in patients with intermediate-high risk PE could be useful for selecting patients who would benefit from proactive treatment.

Pulmonary Embolism in a Young African American Male: A Diagnostic Challenge

This case report highlights the diagnostic challenges posed by pulmonary embolism (PE) in a young, otherwise healthy 33-year-old African American male with no apparent risk factors. The patient presented with penile pain, swelling, hematuria, flank pain, and rash, and was admitted for balanoposthitis and acute urinary retention. Despite prophylactic heparin, he suffered two cardiac arrests secondary to PE on the fifth day of hospitalization. Prompt thrombolytic therapy and heparin infusion were initiated, but his course was complicated by anuric acute kidney injury requiring hemodialysis, shock liver, and gastrointestinal bleeding. Imaging revealed a substantial thrombus burden in the pulmonary arteries. Notably, a hypercoagulable workup was negative. The absence of typical risk factors, negative hypercoagulable workup, and occurrence of PE despite prophylaxis underscore the importance of vigilance in recognizing atypical presentations. This case emphasizes the need for a high index of suspicion and comprehensive evaluation to diagnose PE in young patients without clear predisposing factors.

Inferior Vena Cava Filters: An Overview

For patients with existing venous thromboembolisms (VTEs), anticoagulation remains the standard of care recommended across multiple professional organizations. However, for patients who developed a deep venous thrombosis (DVT) and/or a pulmonary embolism and cannot tolerate anticoagulation, inferior vena cava (IVC) filters must be considered among other alternative treatments. Although placement of a filter is considered a low-risk intervention, there are important factors and techniques that surgeons and interventionalists should be aware of and prepared to discuss. This overview covers the basics regarding the history of filters, indications for placement, associated risks, and techniques for difficult removal.

The genetic causal relationship between type 2 diabetes, glycemic traits and venous thromboembolism, deep vein thrombosis, pulmonary embolism: a two-sample Mendelian randomization study

OBJECTIVE

To investigate the genetic underpinnings of the association between type 2 diabetes (T2D), glycemic indicators such as fasting glucose (FG), fasting insulin (FI), and glycated hemoglobin (GH), and venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), thereby contributing novel insights to the scholarly discourse within this domain.

METHODS

Genome-wide association study (GWAS) summary data pertaining to exposures (T2D, FG, FI, GH) and outcomes (VTE, DVT, PE) were acquired from the IEU Open GWAS database, encompassing participants of European descent, including both male and female individuals. Two-sample Mendelian randomization (MR) analyses were conducted utilizing the TwoSampleMR and MRPRESSO packages within the R programming environment. The primary analytical approach employed was the random-effects inverse variance weighted (IVW) method. Heterogeneity was assessed via Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger. Horizontal pleiotropy was evaluated using the intercept test of MR Egger and MR pleiotropy residual sum and outlier (MR-PRESSO) analysis, with the latter also employed for outlier detection. Additionally, a "Leave one out" analysis was conducted to ascertain the influence of individual single nucleotide polymorphisms (SNPs) on MR results.

RESULTS

The random-effects IVW analysis revealed a negative genetic causal association between T2D) and VTE (P = 0.008, Odds Ratio [OR] 95% confidence interval [CI] = 0.896 [0.827-0.972]), as well as between FG and VTE (P = 0.002, OR 95% CI = 0.655 [0.503-0.853]), GH and VTE (P = 0.010, OR 95% CI = 0.604 [0.412-0.884]), and GH and DVT (P = 0.002, OR 95% CI = 0.413 [0.235-0.725]). Conversely, the random-effects IVW analysis did not detect a genetic causal relationship between FI and VTE (P > 0.05), nor between T2D, FG, or FI and DVT (P > 0.05), or between T2D, FG, FI, or GH and PE (P > 0.05). Both the Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger indicated no significant heterogeneity (P > 0.05). Moreover, the intercept tests of MR Egger and MR-PRESSO suggested the absence of horizontal pleiotropy (P > 0.05). MR-PRESSO analysis identified no outliers, while the "Leave one out" analysis underscored that the MR analysis was not influenced by any single SNP.

CONCLUSION

Our investigation revealed that T2D, FG, and GH exhibit negative genetic causal relationships with VTE at the genetic level, while GH demonstrates a negative genetic causal relationship with DVT at the genetic level. These findings furnish genetic-level evidence warranting further examination of VTE, DVT, and PE, thereby making a contribution to the advancement of related research domains.

Effectiveness, reach, uptake and feasibility of digital health interventions for adults with venous thromboembolism: protocol of a systematic review and meta-analysis

INTRODUCTION

Prevention of recurrence after an episode of venous thromboembolism (VTE), and also the post-thrombotic syndrome (PTS), is still a recognised challenge. In this meta-analysis, we will summarise existing evidence to compare intelligent system follow-up and routine follow-up for patients with VTE.

METHODS AND ANALYSIS

Relevant randomised controlled trials (RCTs) and cohort studies will be included from the following databases: MEDLINE/PubMed, Web of Science and the Cochrane Library. The last search time will be 31 March 2024. Two reviewers will independently identify RCTs and cohort studies according to eligibility and exclusion criteria. The risk of bias of included cohort studies will be assessed with the Newcastle-Ottawa Scale, Methodological Index of Non-Randomised Studies, and the risk of bias of RCTs will be assessed with and Cochrane Collaboration's tool. The primary outcomes include overall survival rate and PTS incidence rate. The Grades of Recommendations, Assessment, Development and Evaluation tool will be used to assess the level of evidence for outcome from RCTs. RevMan V.5.4 software will be used to pool outcomes.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine Science Research Ethics Committee (SH9H-2023-T466-1). The findings will be disseminated to the public through conference presentations and publication in peer-reviewed scientific journals.

PROSPERO REGISTRATION NUMBER

CRD42023410644.

Expression level of neutrophil extracellular traps in peripheral blood of patients with chronic heart failure complicated with venous thrombosis and its clinical significance

OBJECTIVE

Previous studies have reported that neutrophil extracellular traps (NETs) have been identified to be involved in thrombosis, but the clinical value in chronic heart failure (CHF) patients with venous thrombosis is unclear. This study focused on the expression level of NETs in the peripheral blood of patients with CHF complicated with venous thrombosis and its clinical value.

METHODS

80 patients with CHF were included and divided into 2 groups according to the occurrence of venous thrombosis, and the expression levels of NETs in peripheral venous blood and lesion veins of the patients were detected through fluorescent staining. Myeloperoxidase-DNA (MPO-DNA) and citrullinated histone H3 (CitH3), markers of NETs, were detected by enzyme linked immunosorbent assay kit. The receiver operating characteristic (ROC) curve was used to analyze the value of peripheral venous blood NETs in the diagnosis of venous thrombosis in CHF patients, while the relationship between NETs in peripheral and lesion veins was analyzed by a unitary linear regression model.

RESULTS

The results showed that the concentration of NETs, MPO-DNA, and CitH3 in CHF patients combined with venous thrombosis was markedly higher than that in patients without venous thrombosis, and the concentration of NETs, MPO-DNA, and CitH3 in lesion venous blood was notably higher than that in peripheral venous blood. Binary logistics regression analysis showed that NETs in peripheral venous blood were an independent risk factor for venous thrombosis in patients with heart failure. The unitary linear regression model fitted well, indicating a notable positive correlation between NETs concentrations in peripheral and lesion veins. The area under the ROC curve for diagnosing venous thrombosis was 0.85, indicating that peripheral blood NETs concentration levels could effectively predict venous thrombosis in CHF patients.

CONCLUSION

The expression level of NETs was high in the peripheral blood of CHF patients combined with venous thrombosis and was the highest in lesion venous blood. NETs levels in peripheral blood had the value of diagnosing venous thrombosis in CHF patients, and the concentrations of NETs in peripheral and lesion veins are markedly positively correlated.

Development and validation of a novel model to predict pulmonary embolism in cardiology suspected patients: A 10-year retrospective analysis

As there are no predictive models for pulmonary embolism (PE) in patients with suspected PE at cardiology department. This study developed a predictive model for the probability of PE development in these patients. This retrospective analysis evaluated data from 995 patients with suspected PE at the cardiology department from January 2012 to December 2021. Patients were randomly divided into the training and validation cohorts (7:3 ratio). Using least absolute shrinkage and selection operator regression, optimal predictive features were selected, and the model was established using multivariate logistic regression. The features used in the final model included clinical and laboratory factors. A nomogram was developed, and its performance was assessed and validated by discrimination, calibration, and clinical utility. Our predictive model showed that six PE-associated variables (age, pulse, systolic pressure, syncope, D-dimer, and coronary heart disease). The area under the curve - receiver operating characteristic curves of the model were 0.721 and 0.709 (95% confidence interval: 0.676-0.766 and 0.633-0.784), respectively, in both cohorts. We also found good consistency between the predictions and real observations in both cohorts. In decision curve analysis, the numerical model had a good net clinical benefit. This novel model can predict the probability of PE development in patients with suspected PE at cardiology department.

Detection and severity quantification of pulmonary embolism with 3D CT data using an automated deep learning-based artificial solution

PURPOSE

The purpose of this study was to propose a deep learning-based approach to detect pulmonary embolism and quantify its severity using the Qanadli score and the right-to-left ventricle diameter (RV/LV) ratio on three-dimensional (3D) computed tomography pulmonary angiography (CTPA) examinations with limited annotations.

MATERIALS AND METHODS

Using a database of 3D CTPA examinations of 1268 patients with image-level annotations, and two other public datasets of CTPA examinations from 91 (CAD-PE) and 35 (FUME-PE) patients with pixel-level annotations, a pipeline consisting of: (i), detecting blood clots; (ii), performing PE-positive versus negative classification; (iii), estimating the Qanadli score; and (iv), predicting RV/LV diameter ratio was followed. The method was evaluated on a test set including 378 patients. The performance of PE classification and severity quantification was quantitatively assessed using an area under the curve (AUC) analysis for PE classification and a coefficient of determination (R²) for the Qanadli score and the RV/LV diameter ratio.

RESULTS

Quantitative evaluation led to an overall AUC of 0.870 (95% confidence interval [CI]: 0.850-0.900) for PE classification task on the training set and an AUC of 0.852 (95% CI: 0.810-0.890) on the test set. Regression analysis yielded R² value of 0.717 (95% CI: 0.668-0.760) and of 0.723 (95% CI: 0.668-0.766) for the Qanadli score and the RV/LV diameter ratio estimation, respectively on the test set.

CONCLUSION

This study shows the feasibility of utilizing AI-based assistance tools in detecting blood clots and estimating PE severity scores with 3D CTPA examinations. This is achieved by leveraging blood clots and cardiac segmentations. Further studies are needed to assess the effectiveness of these tools in clinical practice.

A new nomogram prediction model for pulmonary embolism in older hospitalized patients

Purpose

Diagnosing pulmonary embolism (PE) in older adults is relatively difficult because of the atypical clinical symptoms of PE in older adults accompanied by multiple complications. This study aimed to establish a nomogram model to better predict the occurrence of PE in older adults.

Methods

Data were collected from older patients (≥65 years old) with suspected PE who were hospitalized between January 2012 and July 2021 and received confirmatory tests (computed tomographic pulmonary angiography or ventilation/perfusion scanning). The PE group and non-PE (control) group were compared using univariable and multivariable analyses to identify independent risk factors. A nomogram prediction model was constructed with independent risk factors and verified internally. The effectiveness of the nomogram model, Wells score, and revised Geneva score was assessed using the area under the receiver operating characteristic curve (AUC).

Results

In total, 447 eligible older patients (290 PE patients and 157 non-PE patients) were enrolled. Logistic regression analysis revealed nine independent risk factors: smoking, inflammation, dyspnea, syncope, mean corpuscular hemoglobin concentration, indirect bilirubin, uric acid, left atrial diameter, and internal diameter of the pulmonary artery. The AUC, sensitivity, and specificity of the nomogram prediction model were 0.763 (95 % confidence interval, 0.721-0.802), 74.48 %, and 67.52 %, respectively. The nomogram showed superior AUC compared to the Wells score (0.763 vs. 0.539, P < 0.0001) and the revised Geneva score (0.763 vs. 0.605, P < 0.0001).

Conclusions

This novel nomogram may be a useful tool to better recognize PE in hospitalized older adults.

Postoperative Coagulation State Predicts Deep Vein Thrombosis After Cesarean Section in Elderly Pregnant Women

Introduction

We aimed to evaluate the risk factors for the development of deep vein thrombosis (DVT) within one month after delivery in pregnant women of advanced maternal age undergoing cesarean section and explore the predictive value of fasting coagulation indicators in relation to the development of DVT.

Methods

A total of 176 eligible postpartum women were included in this study. Sixty-seven cases developed DVT within one month after delivery (DVT group), while 109 cases did not experience DVT (NDVT group). Within 24 hours after cesarean section, fasting coagulation indicators are measured. Coagulation system analysis was performed using the STA-R Evolution fully automated coagulation analyzer.

Results

The women who developed DVT were found to be older, had a higher proportion of women with previous childbirth experiences, and had a higher proportion of women with comorbidities. Our results revealed significant differences in the levels of activated partial thromboplastin time and prothrombin time between the NDVT group and the DVT group. In contrast, the DVT group displayed significantly higher levels of D-dimer, plasma fibrinogen and platelet count when compared to the NDVT group. The AUC for the combined test model was substantially higher compared to individual parameters.

Discussion

Multiple parameters of the postoperative coagulation state in the combined test model provided a more accurate prediction of DVT occurrence in elderly pregnant women after cesarean section.

Factors associated with thrombotic disease in dogs with renal proteinuria: A retrospective of 150 cases

BACKGROUND

Knowledge of additional risk factors for thrombotic disease (TD) among dogs with renal proteinuria is limited; these might differ for TD affecting the systemic arterial (AT), systemic venous (VT), and pulmonary circulation (PT).

HYPOTHESIS/OBJECTIVES

To compare signalment and clinicopathological data between dogs with renal proteinuria with or without TD, and between dogs with AT, VT, and PT.

ANIMALS

One hundred fifty client-owned dogs with renal proteinuria, 50 of which had TD.

METHODS

Retrospective case-controlled study. A database search (2004-2021) identified proteinuric dogs (UPC > 2) with and without TD. Clinicopathological data were obtained from the records. TD and non-TD (NTD) groups were compared by binary logistic regression, and AT, VT, and PT groups by multinomial regression. Normal data presented as mean ± SD, non-normal data presented as median [25th, 75th percentiles].

RESULTS

Cavalier King Charles Spaniels were overrepresented in the TD group (OR = 98.8, 95% CI 2.09-4671, P = .02). Compared to NTD cases, TD cases had higher concentration of neutrophils (11.06 [8.92, 16.58] × 109 /L vs 7.31 [5.63, 11.06] × 109 /L, P = .02), and lower concentration of eosinophils (0 [0, 0.21] × 109 /L vs 0.17 [0.04, 0.41] × 109 /L, P = .002) in blood, and lower serum albumin (2.45 ± 0.73 g/dL vs 2.83 ± 0.73 g/dL, P = .04). AT cases had higher serum albumin concentrations than VT cases (2.73 ± 0.48 g/dL vs 2.17 ± 0.49 g/dL, P = .03) and were older than PT cases (10.6 ± 2.6 years vs 7.0 ± 4.3 years, P = .008). VT cases were older (9.1 ± 4.2 years vs 7.0 ± 4.3 years, P = .008) and had higher serum cholesterol concentration (398 [309-692 mg/dL] vs 255 [155-402 mg/dL], P = .03) than PT cases.

CONCLUSIONS AND CLINICAL IMPORTANCE

Differences between thrombus locations could reflect differences in pathogenesis.

CXCL10 May Be Responsible for Susceptibility to Pulmonary Embolism in COVID-19 Patients

Background

Although the potential of coronavirus disease 2019 (COVID-19) patients to develop pulmonary embolism (PE) is widely recognized, the underlying mechanism has not been completely elucidated. This study aimed to identify genes common to COVID-19 and PE to reveal the underlying pathogenesis of susceptibility to PE in COVID-19 patients.

Methods

COVID-19 genes were obtained from the GEO database and the OMIM, CTD, GeneCards, and DisGeNET databases; PE genes were obtained from the OMIM, CTD, GeneCards, and DisGeNET databases. We overlapped the genes of COVID-19 and PE to obtain common genes for additional analysis, including functional enrichment, protein-protein interaction, and immune infiltration analysis. Hub genes were identified using cytoHubba, a plugin of Cytoscape, and validated using the independent datasets GSE167000 and GSE13535. The genes validated by the above datasets were further validated in clinical samples.

Results

We obtained 36 genes shared by PE and COVID-19. Functional enrichment and immune infiltration analyses revealed the involvement of cytokines and immune activation. Five genes (CCL2, CXCL10, ALB, EGF, and MKI67) were identified as hub genes common to COVID-19 and PE. CXCL10 was validated in both independent datasets (GSE167000 and GSE13535). Serum levels of CXCL10 in the COVID-19 group and the COVID-19 combined with PE group were significantly higher than those in the healthy control group (P<0.001). In addition, there were significant differences between the COVID-19 group and the COVID-19 combined with PE group (P<0.01).

Conclusion

Our study reveals common genes shared by PE and COVID-19 and identifies CXCL10 as a possible cause of susceptibility to PE in COVID-19 patients.

Photon Counting CT: Technical Principles, Clinical Applications, and Future Prospects

Photon-counting computed tomography (PCCT) is a new technique that utilizes photon-counting detectors to convert individual X-ray photons directly into an electrical signal, which can achieve higher spatial resolution, improved iodine signal, radiation dose reduction, artifact reduction, and multienergy imaging. This review introduces the technical principles of PCCT, and summarizes its first-in-human experience and current applications in clinical settings, and discusses the future prospects of PCCT.

Intrahepatic Gallbladder Rupture and Biloma Mimicking Pulmonary Embolism Following Orthopedic Surgery

In this case report, a 75-year-old male with a history of coronary artery disease, type 2 diabetes, hypertension, and benign prostate hypertrophy developed postoperative fever and chest pain following left knee arthroplasty. Upon admission to the emergency department, pulmonary embolism was considered highly probable, and the patient was treated with anticoagulation and antibiotics due to diagnostic uncertainty. However, further investigations revealed a complex condition involving an intraparenchymal gallbladder rupture resulting in a biloma secondary to choledocholithiasis. The patient's history of receiving spinal anesthesia with intrathecal morphine was identified as a potential causative factor to the sphincter of Oddi constriction, leading to increased biliary pressure and gallbladder rupture. This case highlights the importance of having a broad differential diagnosis in postoperative patients, especially when the clinical presentation is atypical. With the diagnosis being confirmed, the patient underwent successful treatment, including biliary stenting, drainage of the biloma, and ultimately cholecystectomy. This case underlines the need for vigilance and a multidisciplinary approach in managing complex postoperative complications, emphasizing that clinical presentations may sometimes deviate significantly from the expected, requiring further investigation and individualized treatment.

Investigation of the association of the RAN (rs14035) and XPO5 (rs11077) polymorphisms with venous thromboembolism

INTRODUCTION

Venous thromboembolism (VTE) is the third most common hemostatic disease worldwide. Studies have reported a role for microRNA (miRNA) in the homeostasis and development of VTE. The ras-related nuclear protein (RAN) and exportin 5 (XPO5) genes are involved in miRNA biogenesis, as both regulate the transport of pre-miRNA from the nucleus to the cytoplasm. Therefore, the aim of the current study is to examine the association between RAN (rs14035) and XPO5 (rs11077) single nucleotide polymorphisms (SNPs) and VTE.

METHODS

The study sample consisted of 300 subjects (150 patients and 150 age and sex matched controls). The polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and tetra-primer amplification refractory mutation system (T-ARMS) techniques were used to genotype rs14035 and rs11077, respectively.

RESULTS

The results showed that there was a significant association between the XPO5 rs11077 and the risk of VTE (P < 0.05). Subjects with AC (OR: 2.08, CI:1.26-3.44) and CC (OR: 1.77, CI: 0.88-3.55) genotypes were at increased risk of the developing VTE. Regarding RAN gene, no association was found between rs14035 and VTE (P > 0.05). In addition, no associations were found between XPO5 rs11077 and RAN rs14035 genotypes with blood cell parameters (P > 0.05). As for the demographic characteristics, the results indicated a strong association between family history and body mass index (BMI) with the risk of VTE (P < 0.01).

CONCLUSION

The XPO5 rs11077, BMI and family history might contribute to the development of VTE in Jordan.

Pulmonary arteries segmentation from CT images using PA-Net with attention module and contour loss

BACKGROUND

Pulmonary embolism is a kind of cardiovascular disease that threatens human life and health. Since pulmonary embolism exists in the pulmonary artery, improving the segmentation accuracy of pulmonary artery is the key to the diagnosis of pulmonary embolism. Traditional medical image segmentation methods have limited effectiveness in pulmonary artery segmentation. In recent years, deep learning methods have been gradually adopted to solve complex problems in the field of medical image segmentation.

PURPOSE

Due to the irregular shape of the pulmonary artery and the adjacent-complex tissues, the accuracy of the existing pulmonary artery segmentation methods based on deep learning needs to be improved. Therefore, the purpose of this paper is to develop a segmentation network, which can obtain higher segmentation accuracy and further improve the diagnosis effect.

METHODS

In this study, the pulmonary artery segmentation performance from the network model and loss function is improved, proposing a pulmonary artery segmentation network (PA-Net) to segment the pulmonary artery region from 2D CT images. Reverse Attention and edge attention are used to enhance the expression ability of the boundary. In addition, to better use feature information, the channel attention module is introduced in the decoder to highlight the important channel features and suppress the unimportant channels. Due to blurred boundaries, pixels near the boundaries of the pulmonary artery may be difficult to segment. Therefore, a new contour loss function based on the active contour model is proposed in this study to segment the target region by assigning dynamic weights to false positive and false negative regions and accurately predict the boundary structure.

RESULTS

The experimental results show that the segmentation accuracy of this proposed method is significantly improved in comparison with state-of-the-art segmentation methods, and the Dice coefficient is 0.938 ± 0.035, which is also confirmed from the 3D reconstruction results.

CONCLUSIONS

Our proposed method can accurately segment pulmonary artery structure. This new development will provide the possibility for further rapid diagnosis of pulmonary artery diseases such as pulmonary embolism. Code is available at https://github.com/Yuanyan19/PA-Net.

Diagnostic Yield of CT Pulmonary Angiogram in the Diagnosis of Pulmonary Embolism and Its Predictive Factors

Introduction Computed tomography pulmonary angiography (CTPA) is the reference investigation of choice to diagnose pulmonary embolism (PE). Nevertheless, the use of CTPA should be weighed against its risks, such as radiation and contrast-induced nephropathy. We aim to assess the yield of CTPA in diagnosing PE at a tertiary centre in Malaysia. We also identify predictive factors associated with the yield of CTPA in this cohort. Methods This was a cross-sectional study involving all patients who had had CTPA done at Hospital Tengku Ampuan Afzan, Kuantan, Malaysia, from January 1, 2021, to November 30, 2021. All patients' records were retrieved and reviewed. CTPA images were retrieved from the Radiology Information System (RIS) and Picture Archiving and Communication System (PACS). They were double-reviewed by the authors, with the initial reports redacted from reporting radiologists to prevent reporting bias. The predictive factors were determined using simple logistic regression and multiple logistic regression. Results A total of 351 CTPAs were reviewed, of which 93 were found to be positive for PE, giving rise to an overall CTPA yield of 26.5%. Upon simple logistic regression, factors such as gender, discipline, history of trauma, presence of COVID-19 infection, and pneumonia were found to be associated with positive CTPA. Upon multiple logistic regression, male patients were found to have a higher chance of positive CTPA results. On the other hand, patients with COVID-19 infection and pneumonia have a lower chance of positive results in CTPA. Conclusion The yield of CTPA in diagnosing PE at our institution was acceptable at 26.5%. Upon multiple logistic regression, patients with COVID-19 infection and pneumonia were more likely to have a negative CTPA result, highlighting the need for clinicians to be more prudent in requesting CTPAs in these patients.

Incidence and Factors Associated With Pulmonary Embolism After Upper Extremity Trauma: A Tertiary Hospital Experience in Turkey

Introduction Venous thromboembolism (VTE), particularly pulmonary embolism (PE), is the third highest cause of death in trauma patients who survive beyond the first day. Musculoskeletal surgery is associated with several complications, some of which may be life-threatening, including deep vein thrombosis (DVT) and PE. Objective This research aims to describe risk variables for VTE after upper extremity (UE) fracture at a single institution and estimate the incidence of PE following UE fracture. Methods The writers accessed the database via their respective universities using the International Standard Classification (ICD) codes. The medical files of patients aged 18 and older who sought treatment at our emergency department for an injury to their UE and also sought treatment at the orthopedics and traumatology clinic between the years 2013 and 2021 were manually scanned. The patients who applied to the Chest Diseases Clinic within 30 days after the trauma and were diagnosed with PE in the ICD code scan were included in the study. Results UE trauma was the cause of admission to the emergency department for 3,265 patients, and 21 of those patients (0.64%) were found to have PE. Fifteen of the patients were male, and six were female. The median age was 59 years (IQR 17). There were no deaths associated with PE. One of the patients had a scaphoid fracture, seven patients had a humerus fracture, five patients had a distal radius fracture, two patients had an acromioclavicular joint injury, one patient had a shoulder dislocation, one patient had a finger fracture, four patients had wrist crush injury. Three patients had diabetes mellitus. Five patients were active smokers. JAK-2 gene V617F mutation was detected in one patient. One patient was diagnosed with prostate cancer, and one had gastric cancer. One patient had a central venous catheter. Two patients were being treated for hypothyroidism. Two patients had hypertension. Conclusion According to the findings of our research, the probability of developing PE in the days following of an injury to the UE was found to be 0.64%. Patients with UE injuries who are active smokers and who also have diabetes, hypertension, hypothyroidism, cancer, coagulation disorder (JAK2 gene V617F mutation), or a central venous catheter may benefit from anticoagulant prophylaxis. This is because these patients are at a higher risk of developing dangerous blood clots.

NET-(works) in arterial and venous thrombo-occlusive diseases

Formation of Neutrophil Extracellular Traps (NETosis), accompanied by the release of extracellular decondensed chromatin and pro-inflammatory as well as pro-thrombotic factors, is a pivotal element in the development and progression of thrombo-occlusive diseases. While the process of NETosis is based on complex intracellular signalling mechanisms, it impacts a wide variety of cells including platelets, leukocytes and endothelial cells. Consequently, although initially mainly associated with venous thromboembolism, NETs also affect and mediate atherothrombosis and its acute complications in the coronary, cerebral and peripheral arterial vasculature. In this context, besides deep vein thrombosis and pulmonary embolism, NETs in atherosclerosis and especially its acute complications such as myocardial infarction and ischemic stroke gained a lot of attention in the cardiovascular research field in the last decade. Thus, since the effect of NETosis on platelets and thrombosis in general is extensively discussed in other review articles, this review focusses on the translational and clinical relevance of NETosis research in cardiovascular thrombo-occlusive diseases. Consequently, after a brief summary of the neutrophil physiology and the cellular and molecular mechanisms underlying NETosis are presented, the role of NETosis in atherosclerotic and venous thrombo-occlusive diseases in chronic and acute settings are discussed. Finally, potential prevention and treatment strategies of NET-associated thrombo-occlusive diseases are considered.

Antipsychotic drugs as a contributing factor of pulmonary embolism: A report of 4 cases

Pulmonary embolism is the third leading cause of cardiovascular death in the world after stroke and heart attack; several factors have been identified, and it has been reported that antipsychotic drugs increase the risk of pulmonary embolism. It is a brief communication reporting the case of 4 patients under antipsychotic drugs, were hospitalized in the intensive care unit of cardiology in Mohammed VI hospital center for the management of pulmonary embolism. All the etiological investigations performed including SARS COV2 viral serologies with PCR, tumor markers, chest-abdomen-pelvis CT angiogram scan, phthisiology, thrombophilia tests, and lower limbs echo Doppler returned without any notable findings, and the evolution was positive after anticoagulation and stopping antipsychotics.

Evolving paradigm of thrombolysis in pulmonary embolism: Comprehensive review of clinical manifestations, indications, recent advances and guideline

Thrombolytic therapy has been the mainstay for patients with pulmonary embolism (PE). Despite being linked to a higher risk of significant bleeding, clinical trials demonstrate that thrombolytic therapy should be used in patients with moderate to high-risk PE, in addition to hemodynamic instability symptoms. This prevents the progression of right heart failure and impending hemodynamic collapse. Diagnosing PE can be challenging due to the variety of presentations; therefore, guidelines and scoring systems have been established to guide physicians to correctly identify and manage the condition. Traditionally, systemic thrombolysis has been utilized to lyse the emboli in PE. However, newer techniques for thrombolysis have been developed, such as endovascular ultrasound-assisted catheter-directed thrombolysis for massive and intermediate-high submassive risk groups. Additional newer techniques explored are the use of extracorporeal membrane oxygenation, direct aspiration, or fragmentation with aspiration. Because of the constantly changing therapeutic options and the scarcity of randomized controlled trials, choosing the best course of treatment for a given patient may be difficult. To help, the Pulmonary Embolism Reaction Team is a multidisciplinary, rapid response team that has been developed and is used at many institutions. Hence to bridge the knowledge gap, our review highlights various indications of thrombolysis in addition to the recent advances and management guidelines

Venous thromboembolism after arthroscopic shoulder surgery: a systematic review

PURPOSE

To summarize the incidence, risk factors, diagnosis methods, prophylaxis methods, and treatment of venous thromboembolism (VTE) following arthroscopic shoulder surgery.

METHODS

Literature on VTE after arthroscopic shoulder surgeries was summarized, and all primary full-text articles reporting at least 1 case of deep vein thrombosis (DVT) or pulmonary embolism (PE) after arthroscopic shoulder surgeries were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, diagnosis, prophylaxis, and management of VTE following arthroscopic shoulder surgeries.

RESULTS

This study included 42 articles in which the incidence of VTE ranges from 0 to 5.71% and the overall incidence was 0.26%. Most VTE events took place between the operation day and the 14th day after the operation (35/51). Possible risk factors included advanced age (> 70 years), obesity (BMI ≥ 30 kg/m²), diabetes mellitus, thrombophilia, history of VTE, prolonged operation time, hormone use, and immobilization after surgery. The most common prophylaxis method was mechanical prophylaxis (13/15). No statistical difference was detected when chemoprophylaxis was applied. The management included heparinization followed by oral warfarin, warfarin alone and rivaroxaban, a direct oral anticoagulant.

CONCLUSION

Based on the included studies, the incidence rate of VTE after arthroscopic shoulder surgeries is relatively low. The risk factors for VTE are still unclear. CT/CTA and ultrasound were the mainstream diagnosis methods for PE and DVT, respectively. Current evidence shows that chemical prophylaxis did not deliver significant benefits, since none of the existing studies reported statistically different results. High-quality studies focusing on the prophylaxis and management of VTE population undergoing arthroscopic shoulder surgeries should be done in the future.

Be aware of non-specific presentation of pulmonary embolism: a case report

BACKGROUND

The early diagnosis of non-specific presentation of pulmonary embolism (PE) is difficult because the symptoms are non-specific and varied.

CASE PRESENTATION

A 69-year-old female patient had syncope accompanied by gait disturbance, without obvious inducement. The patient was initially suspected to have cerebral infarction, but the symptoms did not improve and myocardial markers increased after two days of symptomatic treatment for myocardial infarction. Hence, PE was suspected and computed tomography pulmonary angiography (CTPA) examination confirmed the diagnosis. CTPA showed multiple emboli in pulmonary artery and its branches, so high-risk PE was diagnosed. Intravenous thrombolysis was administered, and pulmonary CTA showed a significant reduction of emboli in pulmonary artery and its left and right branches.

CONCLUSION

This case report highlights the importance of improving the clinical awareness about non-specific presentation of PE and avoiding misdiagnosis or missed diagnosis.

Independent risk factors for an increased incidence of thromboembolism after lung transplantation

BACKGROUND

Thromboembolism (TE) after lung transplantation (LTX) is associated with increased morbidity and mortality. The aim of this study is to analyze the incidence and outcome of venous and arterial thromboembolic complications and to identify independent risk factors.

PATIENTS AND METHODS

We retrospectively analyzed the medical records of 221 patients who underwent LTX at our institution between 2002 and 2021. Statistical analysis was performed using SPSS and GraphPad software.

RESULTS

74 LTX recipients (33%) developed TE. The 30-days incidence and 12-months incidence were 12% and 23%, respectively. Nearly half of the patients (48%) developed pulmonary embolism, 10% ischemic stroke. Arterial hypertension (p = 0.006), a body mass index (BMI) > 30 (p = 0.006) and diabetes mellitus (p = 0.041) were independent predictors for TE. Moreover, a BMI of > 25 at the time of transplantation was associated with an increased risk for TE (43% vs. 32%, p = 0.035). At the time of LTX, 65% of the patients were older than 55 years. An age > 55 years also correlated with the incidence of TE (p = 0.037) and these patients had reduced overall post-transplant survival when the event occurred within the first postoperative year (59% vs. 72%, p = 0.028).

CONCLUSIONS

The incidence of TE after LTX is high, especially in lung transplant recipients with a BMI > 25 and an age > 55 years as well as cardiovascular risk factors closely associated with the metabolic syndrome. As these patients comprise a growing recipient fraction, intensified research should focus on the risks and benefits of regular screening or a prolonged TE prophylaxis in these patients. Trial registration number DKRS: 00021501.

Keep the Right in Mind-A Focused Approach to Right Ventricle-Predominant Cardiogenic Shock

Cardiogenic shock (CS) remains a highly lethal condition despite many efforts and new interventions. Patients presenting with a rapid onset of hemodynamic instability and subsequent collapse require prompt and appropriate multimodality treatment. Multiple etiologies can lead to heart failure and subsequent shock. As the case prevalence of heart failure increases worldwide, it is of great importance to explore all manners and protocols of presentation and treatment present. With research primarily focusing on CS due to cardiac left-sided pathology, few assessments of right-sided pathology and the subsequent clinical state and treatment have been conducted. This review aims to present an in-depth assessment of the currently available literature, assessing the pathophysiology, presentation and management of CS patients due to right heart failure.

A bibliometric analysis of the theme trends and knowledge structures of pulmonary embolism from 2017 to 2021

Background

Pulmonary embolism (PE) is a popular area of research in the field of respiratory medicine. We performed a bibliometric analysis based on PubMed database to characterize the distribution pattern of literature and knowledge structures related to PE.

Methods

Literature pertaining to PE from January 1, 2017, to December 31, 2021, was retrieved from the PubMed database. Bibliographic information was generated using the Bibliographic Item Co-Occurrence Matrix Builder (BICOMB). The visualization matrix was established using gCLUTO software. Strategic diagram analysis was performed using GraphPad Prism 9 software. Social network analysis (SNA) was generated using Ucinet6.0 and NetDraw 2.084 software.

Results

Out of all the retrieved MeSH terms and subheadings, 52 MeSH terms/MeSH subheadings with a high frequency were found, and hot subjects were sorted into 6 clusters. The strategy diagram showed that the epidemiology, etiology, and drug therapy of PE were well advanced. In contrast, studies on diagnostic imaging, pathology, and complications of PE were still immature and offered potential research space. Social network analysis showed that marginal topics such as surgical treatment of pulmonary hypertension, prevention and control of postoperative complications, and metabolism and analysis of fibrin/fibrinogen degradation products were emerging research hotspots.

Conclusion

Objective analysis of the research developments in the field of PE can provide intuitive knowledge structure for researchers and clinicians. Analysis of the research hotspots related to PE is helpful for researchers and clinicians by highlighting future research directions.

Gadolinium Enhances Dual-energy Computed Tomography Scan of Pulmonary Artery

OBJECTIVE

To evaluate the feasibility of using gadopentetate dimeglumine (Gd-DTPA) for dual-energy computed tomography pulmonary angiography (CTPA).

METHODS

Sixty-six patients were randomly divided into three groups and underwent CTPA. Group A had a turbo flash scan using an iohexol injection, Group B had a turbo flash scan using Gd-DTPA, and Group C had a dual-energy scan using Gd-DTPA. The original images of Group C were linearly blended with a blending factor of 0.5 or reconstructed at 40, 50, 60, 70, 80, 90, 100, and 110 keV, respectively. The groups were compared in terms of pulmonary artery CT value, image quality, and radiation dose.

RESULTS

The pulmonary artery CT values were significantly higher in Group C_40keV than in Groups B and C, but lower than in Group A. There was no significant difference in the image noise of Groups C_40keV, B, and C. Moreover, Group A had the largest beam hardening artifacts of the superior vena cava (SVC), followed by Groups B and C. Group C_40keV showed better vascular branching than the other three groups, among which Group B was superior to Group A. The subjective score of the image quality of Groups A, B, and C showed no significant difference, but the score was significantly higher in Group C_40keV than in Groups A and B. The radiation dose was significantly lower in Group B than in Groups A and C.

CONCLUSION

Gd-CTPA is recommended to patients who are unsuitable for receiving an iodine-based CTPA. Furthermore, a turbo flash scan could surpass a dual-energy scan without consideration for virtual monoenergetic imaging.

Case report: AngioJet thrombectomy with extracorporeal membrane oxygenation support for acute massive pulmonary embolism in a severe multiple trauma patient

Acute massive pulmonary embolism (PE) is one of the main leading causes of high cardiovascular mortality, and the prognosis strongly varies, depending on the severity of pulmonary arterial obstruction and its impact on the RV function. Alternative therapy approaches comprise systemic thrombolysis, catheter-directed thrombolysis, catheter embolectomy, catheter-assisted fragmentation techniques, and surgical thrombectomy. The following case study explores a 72-year-old man with severe multiple trauma who suffered from a sudden massive pulmonary embolism and presented with an unstable hemodynamic status. Extracorporeal membrane oxygenation (ECMO) has amply proven its efficacy in supplying cardiopulmonary assistance for this patient shocked by a massive PE with contraindication for thrombolysis. AngioJet catheter embolectomy and ECMO were performed, which finally cleared the massive pulmonary embolism away and improved the patient's hemodynamic status. The use of ECMO was continued during the weaning program, on the fifth day after ECMO decannulation, the patient was extubated and transferred to a local hospital for further recuperation. This case highlights that the AngioJet thrombectomy with the combination use of ECMO may be a potential choice of treatment for unstable PE patients.

VA-ECMO-assisted aspiration thrombectomy in a patient presenting with acute massive PE with absolute contraindications to thrombolytics

Massive pulmonary embolism (PE) is a life-threatening complication of major surgery with a mortality rate up to 50%. First-line therapy for massive PE is systemic thrombolytics, but surgical patients are at high bleeding risk with absolute contraindications. As surgical thrombectomy carries a high burden of morbidity and mortality, endovascular interventions are becoming more common in these clinical scenarios. We report a case of a neurosurgical patient whose postoperative course was complicated by massive PE and subsequent cardiac arrest that required emergent venoarterial extracorporeal membrane oxygenation, followed by aspiration thrombectomy with the Inari FlowTriever Device (Inari Medical). The patient had immediate hemodynamic improvement with eventual recovery to baseline functional status.

Clinical Outcome After Discontinuation of Anticoagulation Therapy in Japanese Patients With Venous Thromboembolism ― Insights From the J’xactly Study ―

Background: Rivaroxaban, a direct oral anticoagulant, is used as first-line treatment to prevent venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). However, the frequency of rivaroxaban discontinuation and the subsequent clinical outcomes remain unclear.

Methods and Results: The study was a subanalysis of the prospective, multicenter, observational J’xactly study, conducted in Japan, and included patients who underwent anticoagulant discontinuation without major bleeding and recurrent VTE. The modified intention-to-treat population (n=1,016) included 579 patients (57%) who underwent anticoagulant discontinuation during a mean follow-up period of 20.2 months (mean [±SD] anticoagulation period 6.9±6.2 months). Patients were divided into 3 groups: those with active cancer, those without active cancer and a transient risk factor for VTE, and those without active cancer or a transient risk factor and/or with previous VTE (unprovoked group). After discontinuation, VTE recurrence occurred in 4.1% of patients, with an annual incidence of 4.6%/year and an increased tendency in the unprovoked group; major bleeding occurred in 8 patients (1.4%; annual incidence 1.1%/year), of whom half were in the cancer group.

Conclusions: This analysis of a real-world observational study provides data on VTE recurrence after rivaroxaban discontinuation, which will facilitate anticoagulant discontinuation according to individual risk-benefit considerations.

Antiphospholipid Syndrome-Related Pulmonary Embolism: Clinical Characteristics and Early Recognition

Background

Pulmonary thromboembolism is a common disease frequently encountered in the emergency room and has a high mortality rate. Antiphospholipid syndrome (APS) is a high-risk factor for recurrent pulmonary embolism (PE). It is critical to effectively administer anticoagulants to avoid the recurrence of thrombotic events. This study aims to identify the clinical characteristics of APS patients with PE (APS-PE) and to develop a risk score for determining the presence of APS in PE patients in the emergency situations.

Methods

We retrospectively enrolled 76 PE patients in this study, with 46 patients in the APS-PE group and 30 patients in the non-APS-PE group. We compared differences in demographics, laboratory parameters, and early mortality risk between the two groups. Risk factors for APS-PE were screened using logistic regression analysis. We also developed an early risk score using multivariate analysis weighted points proportional to the β- regression coefficient values and calculated the sensitivity and specificity for APS in PE patients.

Results

In the APS-PE group, we observed a higher proportion of males (43.6 vs. 20%), a higher proportion of low-risk patients (58.7 vs. 10%), lower levels of white blood cells and platelets (PLT), longer activated partial thromboplastin time (APTT), and a slight increase in D-dimer levels. Patients who were triple positive for antiphospholipid antibodies (aPLs) were younger. The APTT gradually increased as the number of positive aPLs increased. The risk factors for APS included male (OR = 5.565, 95% CI 1.176–26.341), decreased PLT (OR = 0.029, 95% CI 0.003–0.330), slightly increased D-dimer (OR = 0.089, 95% CI 0.019–0.426), and prolonged APTT (OR = 4.870, 95% CI 1.189–19.951). The risk score was named MPDA and included male, PLT, D-dimer and APTT, which can predict APS in PE patients with the AUC at 0.888 (95% CI 0.811–0.965).

Conclusion

The risk factors for APS in PE patients are male, low PLT, prolonged APTT and slightly increased D-dimer. The MPDA is a quantitative scoring system which is highly suggestive of APS in PE patients.

A retrospective study of the role of preoperative ultrasonography in the detection of deep vein thrombosis in 1750 patients with gastric and colorectal cancers

BACKGROUND

There has been a lack of research in the past on the prevalence and risk factors associated with deep vein thrombosis (DVT) in patients with resectable gastric and colorectal cancers. The purpose of this study was to review the anatomical distribution, prevalence and risk factors associated with lower limb DVT in 1750 patients with preoperative gastric and colorectal cancers and to evaluate the role of preoperative ultrasonography in the detection of DVT in preventing postoperative pulmonary thromboembolism (PTE) in patients with gastric and colorectal cancers.

METHODS

A total of 1750 patients with gastric and colorectal cancers who underwent preoperative venous ultrasonography of the lower limbs were retrospectively reviewed. The risk factors associated with preoperative DVT were identified using univariate and multivariate logistic regression analysis.

RESULTS

Seventy-three of the 1750 patients with gastric and colorectal cancers had DVT detected by preoperative venous ultrasonography of the lower limb and the incidence of lower limb DVT was 4.17 % in 1750 patients with gastric and colorectal cancers. Univariate analysis showed a higher risk of DVT in patients who met the following criteria: aged ≥80 years, female sex, the performance status ≥1, stage IV, ASA class ≥ III/IV, and hypertension. Multivariate logistic regression analysis showed that female sex, stage IV and ASA class ≥ III/IV were significantly associated with DVT before gastric and colorectal cancer surgery.

CONCLUSIONS

Our study showed that female sex, stage IV and ASA class ≥ III/IV were significantly associated with DVT before gastric and colorectal cancer surgery. Routine venous ultrasonography for the lower limb can identify the risk of PTE, which is of great significance in the prevention and occurrence of PTE.

Risk factors of pulmonary embolism in the elderly patients: a retrospective study

AIM

We aimed to summarize the clinical feature and risk factors of patients suffering from pulmonary embolism (PE) in the elderly patients, and explore the change in D-dimer after anti-coagulant therapy.

METHODS

A total of 426 patients with PE admitted from August 2012 to January 2019 in the Cangzhou Central Hospital were analyzed in this retrospective study. A comparison of clinical features and risk factors was conducted between the elderly group and non-elderly groups. Blood levels of D-dimer, C-reactive protein (CRP), tumor necrosis factor-α and interferon-γ were measured before and 3 days after anti-coagulant therapy in two groups.

RESULTS

The most important risk factor for the elderly patients was stroke, while for non-elderly patients was deep vein thrombosis (DVT). After anti-coagulant therapy, the decreasing level of D-dimer and CRP showed statistically significant differences between the two groups. Between the elderly and non-elderly groups, the main clinical manifestations were similar. The risk factors of elderly patients were chronic obstructive pulmonary disease, malignant tumor, DVT and stroke. After anti-coagulant therapy, the content of D-dimer was lower than 3 days ago.

CONCLUSION

Blood levels of D-dimer and CRP may be potent screening markers for PE especially among elderly patients.

A Cohort Study of Rivaroxaban Combined with D-Dimer Dynamic Monitoring in the Prevention of Deep Venous Thrombosis after Knee Arthroplasty

Objective

To explore the cohort study of rivaroxaban combined with D-dimer dynamic monitoring in the prevention of deep venous thrombosis (DVT) after knee arthroplasty.

Methods

Eighty-four patients with knee osteoarthritis who went through total knee arthroplasty from June 2019 to June 2021 in our hospital were arbitrarily assigned into the study group and the control group. The patients in the control group were cured with rivaroxaban anticoagulation after operation, and the study group was cured with dynamic monitoring of D-dimer on the basis of the control group. The incidence of postoperative DVT, pulmonary embolism (PE), and bleeding complications (incision ecchymosis and bleeding events) were compared. The related indexes such as drainage volume and blood transfusion volume were compared. The levels of activated partial prothrombin time (APPT), prothrombin time (PT), and D-dimer were dynamically monitored before and after operation. Visual analogue scale (VAS) was adopted to assess the degree of postoperative incision pain, the level of limb swelling before and after operation was measured, the circumference difference of affected limb was calculated, the ecchymosis area was assessed in the form of nine-palace grid, and the scores were compared.

Results

According to the comparison of VAS score, there exhibited no remarkable difference before operation and on the first day after operation, but the VAS score decreased after operation, and the VAS score of the study group on the 3rd day, 7th day, and 14th day after operation was remarkably lower compared to the control group (P < 0.05). There exhibited no remarkable difference in drainage volume (P > 0.05), but the blood transfusion volume and total blood loss in the study group were remarkably lower (P < 0.05). There exhibited no remarkable difference in the level of PT on the 3rd day before operation and on the 3rd day after operation, but on the 7th day and 14th day after operation, the level of PT in the study group was remarkably higher (P < 0.05). The level of PT in the study group was remarkably higher (P < 0.05). There exhibited no remarkable difference in the level of APPT on the 3rd day before operation and on the 3rd day after operation, but on the 7th day and 14th day after operation, the level of APPT in the study group was remarkably higher (P < 0.05). The level of APPT in the study group was remarkably higher (P < 0.05). There exhibited no remarkable difference in the level of plasma D-dimer before operation (P > 0.05). The level of plasma D-dimer in the study group was lower (P < 0.05). In terms of the postoperative ecchymosis area score, the ecchymosis area score decreased remarkably after operation. Furthermore, the ecchymosis area score of the study group was remarkably lower (P < 0.05). In terms of the swelling degree of the affected limb, there exhibited no remarkable difference in thigh circumference and calf circumference before operation (P > 0.05), but after operation, the thigh circumference difference and calf circumference difference decreased, and the thigh circumference difference and calf circumference difference in the study group were lower (P < 0.05). The incidence of DVT in the study group was 16.67%, while that in the control group was 38.10%. No PE occurred in the two groups at the early stage after operation. There were 3 cases of incision ecchymosis, 1 case of bleeding event (incision oozing) in the study group, 11 cases of incisional ecchymosis, and 2 cases of bleeding event in the control group. In 3 patients with incisional bleeding, there were no obvious abnormalities in routine blood examination and blood coagulation indexes. The patients were given wound pressure bandaging and stopped using anticoagulants and changing wound dressings every day, all of which disappeared within 5 days. The incidence of early postoperative DVT and bleeding complications in the study group was lower (P < 0.05).

Conclusion

Rivaroxaban combined with D-dimer dynamic monitoring has high clinical value in preventing DVT after knee arthroplasty and can effectively reduce the amount of blood loss during operation and the incidence of postoperative DVT, PE, and bleeding complications, which is worth popularizing to reduce the area of ecchymosis and the degree of pain after operation and shorten the recovery process.

Characteristics and outcomes of cancer patients who develop pulmonary embolism: A cross‑sectional study

Pulmonary embolism (PE), along with deep vein thrombosis, are collectively known as venous thromboembolism (VTE). Predisposing factors for PE include post-operative conditions, pregnancy, cancer and an advanced age; of note, a number of genetic mutations have been found to be associated with an increased risk of PE. The association between cancer and VTE is well-established, and cancer patients present a higher risk of a thrombotic event compared to the general population. In addition, PE is a significant cause of morbidity and mortality among cancer patients. The aim of the present study was to illustrate the clinical characteristics, laboratory findings, radiology features and outcomes of cancer patients who developed PE, collected from an anticancer hospital. For this purpose, adult cancer patients diagnosed with PE by imaging with computed tomography pulmonary angiography were enrolled. The following data were recorded: Demographics, comorbidities, type of cancer, time interval between cancer diagnosis and PE occurrence, the type of therapy received and the presence of metastases, clinical signs and symptoms, predisposing factors for PE development, laboratory data, radiological findings, electrocardiography findings, and the type of therapy received for PE and outcomes in a follow-up period of 6 months. In total, 60 cancer patients were enrolled. The majority of the cancer patients were males. The most common type of cancer observed was lung cancer. The majority of cases of PE occurred within the first year from the time of cancer diagnosis, while the majority of patients had already developed metastases. In addition, the majority of cancer patients had received chemotherapy over the past month, while they were not receiving anticoagulants and had central obstruction. A large proportion of patients had asymptomatic PE. The in-hospital mortality rate was 13.3% and no relapse or mortality were observed during the follow-up period. The present study demonstrates that elevated levels of lactic acid and an increased platelet count, as well as low serum levels of carcinoembryonic antigen, albumin and D-dimer, may be potential biomarkers for asymptomatic PE among cancer patients.

How artificial intelligence improves radiological interpretation in suspected pulmonary embolism

Objectives

To evaluate and compare the diagnostic performances of a commercialized artificial intelligence (AI) algorithm for diagnosing pulmonary embolism (PE) on CT pulmonary angiogram (CTPA) with those of emergency radiologists in routine clinical practice.

Methods

This was an IRB-approved retrospective multicentric study including patients with suspected PE from September to December 2019 (i.e., during a preliminary evaluation period of an approved AI algorithm). CTPA quality and conclusions by emergency radiologists were retrieved from radiological reports. The gold standard was a retrospective review of CTPA, radiological and clinical reports, AI outputs, and patient outcomes. Diagnostic performance metrics for AI and radiologists were assessed in the entire cohort and depending on CTPA quality.

Results

Overall, 1202 patients were included (median age: 66.2 years). PE prevalence was 15.8% (190/1202). The AI algorithm detected 219 suspicious PEs, of which 176 were true PEs, including 19 true PEs missed by radiologists. In the cohort, the highest sensitivity and negative predictive values (NPVs) were obtained with AI (92.6% versus 90% and 98.6% versus 98.1%, respectively), while the highest specificity and positive predictive value (PPV) were found with radiologists (99.1% versus 95.8% and 95% versus 80.4%, respectively). Accuracy, specificity, and PPV were significantly higher for radiologists except in subcohorts with poor-to-average injection quality. Radiologists positively evaluated the AI algorithm to improve their diagnostic comfort (55/79 [69.6%]).

Conclusion

Instead of replacing radiologists, AI for PE detection appears to be a safety net in emergency radiology practice due to high sensitivity and NPV, thereby increasing the self-confidence of radiologists.

Key Points

• Both the AI algorithm and emergency radiologists showed excellent performance in diagnosing PE on CTPA (sensitivity and specificity ≥ 90%; accuracy ≥ 95%).

• The AI algorithm for PE detection can help increase the sensitivity and NPV of emergency radiologists in clinical practice, especially in cases of poor-to-moderate injection quality.

• Emergency radiologists recommended the use of AI for PE detection in satisfaction surveys to increase their confidence and comfort in their final diagnosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-022-08645-2.