1
|
Henkin S, Ujueta F, Sato A, Piazza G. Acute Pulmonary Embolism: Evidence, Innovation, and Horizons. Curr Cardiol Rep 2024:10.1007/s11886-024-02128-0. [PMID: 39215952 DOI: 10.1007/s11886-024-02128-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE OF REVIEW Pulmonary embolism (PE) is the third most common cause of cardiovascular morbidity and mortality. The goal of this review is to discuss the most up-to-date literature on epidemiology, diagnosis, risk stratification, and management of acute PE. RECENT FINDINGS Despite an increase in annual incidence rate of PE in the United States and development of multiple advanced therapies for treatment of acute PE, PE-related mortality is not consistently decreasing across populations. Although multiple risk stratification schemes have been developed, it is still unclear which advanced therapy should be used for the individual patient and optimal timing. Fortunately, multiple randomized clinical trials are underway to answer these questions. Nevertheless, up to 50% of patients have persistent reduced quality of life 6 months after acute PE, termed post-PE syndrome. Despite advances in therapeutic options for management of acute PE, many questions remain unanswered, including optimal risk stratification and management of acute PE.
Collapse
Affiliation(s)
- Stanislav Henkin
- Gonda Vascular Center, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Francisco Ujueta
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alyssa Sato
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
2
|
In Situ Pulmonary Arterial Thrombosis-Literature Review and Clinical Significance of a Distinct Entity. AJR Am J Roentgenol 2023:1-12. [PMID: 36856299 DOI: 10.2214/ajr.23.28996] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Filling defects identified in the pulmonary arterial tree are commonly presumed to represent an embolic phenomenon originating from thrombi formed in remote veins, particularly lower-extremity deep venous thrombosis (DVT). However, accumulating evidence supports an underappreciated cause for pulmonary arterial thrombosis (PAT), namely, de novo thrombogenesis-where thrombosis arises within the pulmonary arteries in the absence of DVT. Although historically underrecognized, in situ PAT has become of heightened importance with the emergence of SARS-CoV-2 infection. In situ PAT is attributed to endothelial dysfunction, systemic inflammation, and acute lung injury, and has been described in a range of conditions including COVID-19, trauma, acute chest syndrome in sickle cell disease, pulmonary infections, and severe pulmonary arterial hypertension. The distinction between pulmonary embolus and in situ PAT may have important implications regarding management decisions and clinical outcomes. In this review, we summarize the pathophysiology, imaging appearances, and management of in situ PAT in various clinical situations. This understanding will promote optimal tailored treatment strategies for this increasingly recognized entity.
Collapse
|
3
|
Mirijello A, Santoliquido M, Piscitelli P, Borelli C, Serviddio G, Simeone A, Grandone E, De Cosmo S. Pulmonary Artery Stump Thrombosis: To Treat or Not to Treat? The Question Is Still Open. Description of a Case and Review of the Literature. Front Cardiovasc Med 2021; 8:714826. [PMID: 34671651 PMCID: PMC8520941 DOI: 10.3389/fcvm.2021.714826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022] Open
Abstract
Pulmonary artery stump thrombosis (PAST) represents a possible complication after lung surgery. We report the case of a 59-year-old man who presented with dyspnoea about 4 years after right pneumonectomy due to squamous cell lung cancer. A CT-scan showed the presence of pulmonary artery stump thrombosis. Although there was no evidence of pulmonary embolism, given the clinical features and radiological shape of the thrombus, anticoagulation treatment with low-molecular-weight heparin was started with improvement of symptoms. The patient was discharged on anticoagulant treatment and a pulmonary CT-scan performed 4 months later showed an almost complete resolution of the PAST. Pathophysiological mechanisms of PAST are still unknown, although several hypotheses have been proposed. However, the decision to treat PAST with anticoagulants is still controversial. A review of literature will be provided in order to discuss risk factors, possible etiologies and to highlight clinical and radiological characteristics that could suggest to treat this condition, in particular when there is an increased risk of complications.
Collapse
Affiliation(s)
- Antonio Mirijello
- Internal Medicine Unit, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Mariateresa Santoliquido
- Internal Medicine Unit, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy.,Geriatrics Residency School, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Pamela Piscitelli
- Internal Medicine Unit, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Cristina Borelli
- Radiology Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Gaetano Serviddio
- Geriatrics Residency School, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Anna Simeone
- Radiology Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Elvira Grandone
- Thrombosis and Haemostasis Research Unit, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| | - Salvatore De Cosmo
- Internal Medicine Unit, Department of Medical Sciences, Fondazione IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy
| |
Collapse
|
4
|
Shargall Y, Brunelli A, Murthy S, Schneider L, Minervini F, Bertolaccini L, Agzarian J, Linkins LA, Kestenholz P, Li H, Rocco G, Girard P, Venuta F, Samama M, Scarci M, Anraku M, Falcoz PE, Kirk A, Solli P, Hofstetter W, Okumura M, Douketis J, Litle V. Venous thromboembolism prophylaxis in thoracic surgery patients: an international survey. Eur J Cardiothorac Surg 2021; 57:331-337. [PMID: 31363740 DOI: 10.1093/ejcts/ezz191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/22/2019] [Accepted: 05/30/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Venous thromboembolic events (VTE) after thoracic surgery (TS) can be prevented with mechanical and chemical prophylaxis. Unlike other surgical specialties, TS lacks evidence-based guidelines. In the process of developing these guidelines, an understanding of the current prophylaxis methods practiced internationally is necessary and is described in this article. METHODS A 26-item survey was distributed to members of the European Society of Thoracic Surgeons (ESTS), American Association of Thoracic Surgery (AATS), Japanese Association for Chest Surgery (JACS) and Chinese Society for Thoracic and Cardiovascular Surgery (CSTCS) electronically or in person. Participants were asked to report their current prophylaxis selection, timing of initiation and duration of prophylaxis, perceived risk factors and the presence and adherence to institutional VTE guidelines for patients undergoing TS for malignancies. RESULTS In total, 1613 surgeons anonymously completed the survey with an overall 36% response rate. Respondents were senior surgeons working in large academic hospitals (≥70%, respectively). More than 83.5% of ESTS, AATS and JACS respondents report formal TS thromboprophylaxis protocols in their institutions, but 53% of CSTCS members report not having such a protocol. The regions varied in the approaches utilized for VTE prophylaxis, the timing of initiation perioperatively and the use and type of extended prophylaxis. Respondents reported that multiple risk factors and sources of information impact their VTE prophylaxis decision-making processes, and these factors vastly diverge regionally. CONCLUSIONS There is little agreement internationally on the optimal approach to thromboprophylaxis in the TS population, and guidelines will be helpful and vastly welcomed.
Collapse
Affiliation(s)
- Yaron Shargall
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Laura Schneider
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Fabrizio Minervini
- Department of Thoracic Surgery, Kantonsspital Luzern, Lucerne, Switzerland
| | | | - John Agzarian
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Lori-Ann Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Peter Kestenholz
- Department of Thoracic Surgery, Kantonsspital Luzern, Lucerne, Switzerland
| | - Hui Li
- Department of Thoracic Surgery, Capital Medical University, Beijing, China
| | - Gaetano Rocco
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Girard
- Thoracic Department, Institut Mutualiste Montsouris, Paris, France
| | - Federico Venuta
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc Samama
- Department of Anaesthesia and Intensive Care Medicine, Cochin and Hôtel-Dieu University Hospitals, Paris, France
| | - Marco Scarci
- Department of Thoracic Surgery, San Gerardo Hospital, Monza, Italy
| | - Masaki Anraku
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | | | - Alan Kirk
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | | | - Wayne Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Meinoshin Okumura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Virginia Litle
- Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
5
|
Shargall Y, Litle VR. European perspectives in Thoracic Surgery, the ESTS venous thromboembolism (VTE) working group. J Thorac Dis 2018; 10:S963-S968. [PMID: 29744223 DOI: 10.21037/jtd.2018.04.70] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Venous thromboembolism (VTE), composed of deep vein thrombosis (DVT) and PE is a well-recognized cause for significant perioperative morbidity and mortality. While in orthopedic surgery and general oncology surgery there are well established guidelines regarding VTE prophylaxis, based on carefully conducted high level studies, in thoracic surgery the level of evidence and overall knowledge in the field is still lacking, The European Society of Thoracic Surgeons have established an international working group in 2016, whose task was the define contemporary best practice, coordinate research efforts and eventually define best practice guidelines. This collaboration has matured into a multi-organizational effort, with participation of the American Association for Thoracic Surgery, the International Society on Thrombosis and Haemostasis and Chinese and Japanese thoracic societies. Two major projects (International practice survey and an expert group Delphi process re best practice and VTE risk factors) have been completed so far. For 2018, the working group goals will be to establish VTE prophylaxis guidance in Thoracic Surgery.
Collapse
Affiliation(s)
- Yaron Shargall
- Division of Thoracic Surgery, McMaster University, St. Joseph's Healthcare, Hamilton, Canada
| | - Virginia R Litle
- Division of Thoracic Surgery, Department of Surgery, Boston University, Boston, MA, USA
| |
Collapse
|
6
|
|
7
|
Postdischarge venous thromboembolic complications following pulmonary oncologic resection: An underdetected problem. J Thorac Cardiovasc Surg 2016; 151:992-9. [DOI: 10.1016/j.jtcvs.2015.11.038] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/27/2015] [Accepted: 11/21/2015] [Indexed: 11/20/2022]
|
8
|
Varona Porres D, Andreu Soriano J, Pallisa Núñez E, Persiva Morenza O, Roque Pérez A. Patología vascular torácica en pacientes oncológicos. RADIOLOGIA 2011; 53:335-48. [DOI: 10.1016/j.rx.2011.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 01/28/2011] [Accepted: 01/31/2011] [Indexed: 11/15/2022]
|
9
|
Varona Porres D, Andreu Soriano J, Pallisa Núñez E, Persiva Morenza O, Roque Pérez A. Thoracic vascular disease in oncologic patients. RADIOLOGIA 2011. [DOI: 10.1016/j.rxeng.2011.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
10
|
Abstract
Venous thromboembolic disease is composed of two disease entities: pulmonary thromboembolism/pulmonary embolism and deep venous thrombosis. Clinical signs and symptoms of venous thromboembolic disease often are nonspecific and, as a result, the diagnosis may be difficult. If left untreated, pulmonary embolism can lead to a potentially fatal outcome. This article focuses on CT angiography as the diagnostic modality for thromboembolic pulmonary embolism and briefly discusses nonthromboembolic pulmonary embolism.
Collapse
Affiliation(s)
- Wael E A Saad
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
| | | |
Collapse
|
11
|
Thomas PA, Doddoli C, Barlési F, Reynaud-Gaubert M, Giudicelli R, Fuentes P. Late pulmonary artery stump thrombosis with post embolic pulmonary hypertension after pneumonectomy. Thorax 2006; 61:177-8. [PMID: 16443709 PMCID: PMC2104576 DOI: 10.1136/thx.2004.028480] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Ten years after right pneumonectomy for primary lung cancer, a 51 year old man developed a pulmonary artery stump thrombosis which produced microemboli in the remaining lung and, in turn, led to chronic pulmonary hypertension. This case strongly suggests that prolonged postoperative thromboembolic prophylaxis should be considered in patients undergoing right pneumonectomy.
Collapse
Affiliation(s)
- P A Thomas
- Service de Chirurgie Thoracique, Hôpital Sainte Marguerite, 274 Bvd Ste Marguerite, 13274 Marseille Cédex 09, France.
| | | | | | | | | | | |
Collapse
|
12
|
Kwek BH, Wittram C. Postpneumonectomy Pulmonary Artery Stump Thrombosis: CT Features and Imaging Follow-up. Radiology 2005; 237:338-41. [PMID: 16126932 DOI: 10.1148/radiol.2371041686] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To retrospectively evaluate the computed tomographic (CT) features of pulmonary artery stump thrombosis at initial and follow-up CT. MATERIALS AND METHODS The study was approved by institutional review board, which waived informed consent, and was HIPPA compliant. All patients who had undergone pneumonectomy and CT from January 2001 to August 2003, as identified with data search system, were included. Eighty-nine patients (49 men, 40 women; mean age, 60 years) were studied. Thrombus identification, categorization (concave or convex), and stump and thrombus measurements were made by two radiologists in consensus. The use of anticoagulation therapy was determined from patients' charts. The t test was used. RESULTS Initial CT scans were obtained 34 months +/- 67 (standard deviation) after pneumonectomy; multiple CT scans were obtained in 58 patients during follow-up of 25.1 months +/- 24.8. Eleven (12.4%) of 89 patients had stump thrombi with near equal frequency on either side. Five concave and six convex thrombi were initially identified. Anticoagulation was not commenced for stump thrombosis. The mean length of the right stump (31 mm +/- 10) was greater than that of the left stump (13 mm +/- 7) (P < .01). After a right and left pneumonectomy, there was a significant difference between the length of the stump in patients with (right, 40 mm +/- 14; left, 21 mm +/- 11) and patients without thrombosis (right, 30 mm +/- 9; left, 12 mm +/- 6) (P = .027 and P < .01, respectively). Follow-up CT scans were not available in four cases. CT findings demonstrated a reduction in thrombus size in four patients (one received anticoagulation therapy for concomitant pulmonary embolism). Two patients had stable concave thrombi, one with an initial concave thrombus developed convex thrombus, and one with an initial convex thrombus developed concave thrombus. No thrombi propagated outside of the stump. CONCLUSION There is a relationship between stump length and the development of in situ thrombosis. The data suggest a rather benign natural history.
Collapse
Affiliation(s)
- Boon Han Kwek
- Department of Radiology, Division of Thoracic Radiology, FND 202, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, USA
| | | |
Collapse
|
13
|
Kim SY, Seo JB, Chae EJ, Do KH, Lee JS, Song JW, Song KS, Lim TH. Filling Defect in a Pulmonary Arterial Stump on CT After Pneumonectomy: Radiologic and Clinical Significance. AJR Am J Roentgenol 2005; 185:985-8. [PMID: 16177420 DOI: 10.2214/ajr.04.1515] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objectives of our study were to determine the incidence of filling defects in pulmonary arterial stumps on CT after pneumonectomy and to evaluate their radiologic and clinical significance. MATERIALS AND METHODS We retrospectively reviewed 401 contrast-enhanced chest CT scans of 147 consecutive patients (male-female ratio, 123:24; mean age, 60 years) who underwent pneumonectomy (right, 60; left, 87) from 1996 to 2002 in our institution. CT findings were analyzed for the presence or absence of a filling defect in the vascular stump and its size, shape, and interval change on follow-up CT. CT findings were also evaluated for the length of the vascular stump and the presence of embolism in the contralateral pulmonary arteries, pneumonia, bronchopleural fistula, and bronchiolitis obliterans with organizing pneumonia. Intrathoracic or stump recurrence was also assessed in patients with lung cancer. The medical records of lung cancer patients were reviewed for the cause of pneumonectomy and stage and cell type of cancer at surgery. Statistical tests were performed to determine the relationship between the filling defect and other radiologic and clinical findings. RESULTS A filling defect in the vascular stump was seen on CT scans of 18 patients after pneumonectomy (12%), and all had undergone the surgery for lung cancer. It was more frequently found in the right-sided stump (23.3%) than in the left-sided stump (4.6%) (p = 0.001). The vascular stump was longer in patients with a filling defect (37.2 +/- 6.8 [1 SD] mm) than those without this finding (25.0 +/- 12.5 mm) (p < 0.001). Other radiologic and clinical findings were not significantly related to the presence of the filling defect in the vascular stump. CONCLUSION A filling defect in the pulmonary arterial stump seen on CT after pneumonectomy is thought to be an in situ thrombus caused by stasis of blood flow and is not related to pulmonary embolism, tumor recurrence, or other complications after pneumonectomy.
Collapse
Affiliation(s)
- So Yeon Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap-2dong, Songpa-gu, Seoul 138-736, South Korea
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Wittram C, Maher MM, Yoo AJ, Kalra MK, Shepard JAO, McLoud TC. CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis. Radiographics 2005; 24:1219-38. [PMID: 15371604 DOI: 10.1148/rg.245045008] [Citation(s) in RCA: 209] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Computed tomographic (CT) pulmonary angiography is becoming the standard of care at many institutions for the evaluation of patients with suspected pulmonary embolism. This pathologic condition, whether acute or chronic, causes both partial and complete intraluminal filling defects, which should have a sharp interface with intravascular contrast material. In acute pulmonary embolism that manifests as complete arterial occlusion, the affected artery may be enlarged. Partial filling defects due to acute pulmonary embolism are often centrally located, but when eccentrically located they form acute angles with the vessel wall. Chronic pulmonary embolism can manifest as complete occlusive disease in vessels that are smaller than adjacent patent vessels. Other CT pulmonary angiographic findings in chronic pulmonary embolism include evidence of recanalization, webs or flaps, and partial filling defects that form obtuse angles with the vessel wall. Factors that cause misdiagnosis of pulmonary embolism may be patient related, technical, anatomic, or pathologic. The radiologist needs to determine the quality of a CT pulmonary angiographic study and whether pulmonary embolism is present. If the quality of the study is poor, the radiologist should identify which pulmonary arteries have been rendered indeterminate and whether additional imaging is necessary.
Collapse
Affiliation(s)
- Conrad Wittram
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Founders Building 202, 55 Fruit St, Boston, MA 02114, USA.
| | | | | | | | | | | |
Collapse
|