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PubMedDate not supplied

[Interruption of the inferior vena cava in the prevention of pulmonary embolism].

Pulmonary thromboembolism constitutes the third cause of death after cardiovascular accidents and malignant tumours. Prevention is regarded as the most appropriate and effective therapeutic option. Medical antithrombotic therapy is the most common approach, but when antithrombotic therapy with heparin cannot be performed, vena cava filters are necessary devices in many patients and situations. Over the period from 1995 to 2003, 72 patients were admitted to the Surgical Sciences, Orthopaedics, Trauma and Emergency and Biomorphological and Functional Sciences Departments of the Federico II University of Naples. On the basis of their clinical condition and thrombus characteristics, different filters were applied (definitive, temporary, tempofilter). Thorough clinical and imaging follow-up examinations showed the efficacy of vena cava interruption in the prevention of pulmonary embolism, as well as a low complication rate and convenient risk-benefit ratio. Tempofilter, which allows partial interruption of the vena cava for more than 6 weeks, would appear to be the best filtration device. It is effective in the prevention of pulmonary thromboembolism, is durable and does not entail any significant increase in recurrent venous thrombosis, as is the case with definitive vena cava filters.

Aged↗

PubMed1988

Diagnosis of pulmonary embolism.

Pulmonary embolism (PE) is often unrecognized or misdiagnosed because of the lack of specificity of clinical signs and symptoms. PE shares many of the clinical features of pneumonia and is therefore often unrecognized in elderly patients who present with low-grade fever, modest leukocytosis, and pulmonary infiltrates. Assessment of clinical risk factors increases the usefulness of diagnostic tests. The accuracy of diagnosis is improved if specific tests are performed. Ventilation-perfusion lung scans, noninvasive or contrast venography, and pulmonary angiography increase the likelihood of correct diagnosis. Since pulmonary angiography is a relatively low-risk procedure, it should be performed in most patients suspected of having PE who have nondiagnostic lung scans and negative lower extremity venous studies.

Adult↗

PubMed2003

Computed tomography of acute pulmonary embolism.

Pulmonary embolism (PE) is a common condition in which diagnostic and therapeutic delays contribute to substantial morbidity and mortality. Advances in spiral computed tomography (CT) scanner technology over the past 10 years have been paralleled by progressive improvement in the ability to identify and accurately evaluate the pulmonary arteries for acute PE using CT pulmonary angiography (CTPA). Preliminary studies indicate multi-detector CT (MDCT) scanners offer improved accuracy for distal segmental and subsegmental PE. The ability to directly visualize emboli using CTPA has led to its widespread implementation. Published studies using optimal techniques have found sensitivity and specificity of approximately 90%. Clinical signs and symptoms are nonspecific. Only 20% to 30% of those patients evaluated for acute PE are found to harbor emboli. Previous imaging algorithms offered limited diagnostic value for the remaining 70% to 80% of patients who proved not to have PE. It has been shown that spiral CT identifies an alternate diagnosis in approximately 70% of these patients, which, along with its rapid and widespread availability, largely accounts for its popularity with referring clinicians. It is noted that meta-analysis studies of the existing data regarding spiral CT in acute PE have shown deficiencies in study designs, indicating that further research is required. However, at this time, spiral CT is being widely employed in the diagnostic work-up of patients with suspected acute PE. This review will discuss the use of spiral CT for acute PE, including scan acquisition parameters, radiation dose, diagnostic findings, interpretive pitfalls and the role of leg vein studies.

Acute Disease↗

PubMed1991

[Old and new aspects in the diagnosis of pulmonary embolism].

Pulmonary embolism remains a common complication of deep venous thrombosis. The diagnosis is often difficult, since symptoms and clinical signs are sensitive but unspecific. ECG, chest X-ray and blood chemistry serve to rule out other diseases. A normal lung perfusion scan excludes clinically relevant recent pulmonary emboli; multiple segmental perfusion defects support this diagnosis. Other scintigraphic findings have to be interpreted cautiously. Pulmonary angiography remains the diagnostic gold standard.

Angiography↗

PubMed2005

Venous thromboembolism: diagnosis and management of pulmonary embolism.

Pulmonary embolism (PE) affects 0.5-1 per 1000 people in the general population each year, and is one of the most common preventable causes of death among hospitalised patients. The clinical diagnosis of PE is unreliable and must be confirmed objectively with ventilation perfusion scanning or computed tomography pulmonary angiography. The diagnosis of PE can be reliably excluded, without the need for diagnostic imaging, if the clinical pretest probability for PE is low and the D-dimer assay result is negative. The initial treatment of PE is low-molecular-weight heparin or unfractionated heparin for at least 5 days, followed by warfarin (target international normalised ratio [INR], 2.0-3.0) for at least 3-6 months. Patients with a high clinical pretest probability of PE should commence treatment immediately while awaiting the results of the diagnostic work-up. Thrombolysis is indicated for patients with objectively confirmed PE who are haemodynamically unstable. Percutaneous transcatheter or surgical embolectomy may be life-saving in patients ineligible for, or unresponsive to, thrombolytic therapy. Unresolved issues in the management of venous thromboembolism include the roles of thrombophilia testing, thrombolysis for the treatment of stable PE patients who present with right ventricular dysfunction, and new anticoagulants; and the duration of anticoagulation for first unprovoked venous thromboembolism.

Angiography↗

PubMed1994

The clinical impact of risk factor analysis and prophylaxis on pulmonary embolism.

Pulmonary emboli cause 50,000 deaths annually despite recognized risk factors and methods of prophylaxis. To determine the impact of risk factor analysis and the use of prophylaxis, a retrospective chart review of patients suffering pulmonary embolism (PE) at Georgetown University Hospital was performed. During a fifty-month period, 25,000 surgical and 36,000 nonsurgical admissions included 171 cases of PE. The incidence of PE among surgical patients was 0.24% (n = 61) and was 0.30% (n = 110) among nonsurgical patients as confirmed in 82% by pulmonary angiography or high-probability ventilation/perfusion scans. PE prophylaxis included pneumatic stockings, low-dose heparin, combination low-dose heparin/stockings, and coumarin. However, prophylactic measures were absent in 23% of the surgical and in all the nonsurgical patients suffering PE. On the basis of established criteria (SVS/ISCVS), 57% of surgical patients suffering PE were considered at high risk as compared with 13% of nonsurgical patients. Conversely, 54% of nonsurgical patients suffering a PE were considered to be at low risk. Standard treatment modalities were instituted after nonfatal PE: anticoagulation (61%), inferior vena cava filter (14%), and anticoagulation/filter (6%). While risk factor analysis identifies high-risk surgical patients, it may be less effective in identifying nonsurgical patients at increased risk for PE.

Adult↗

PubMedDate not supplied

Using the ECG to identify pulmonary embolism.

Pulmonary embolism is frequently unrecognized in postoperative and medical patients. In this article, the author describes how to recognize this "great imitator" and protect patients from potentially fatal complications.

Diagnosis, Differential↗

PubMed1991

[Reflections on the management of suspected recent pulmonary embolism].

Pulmonary Embolism (EP) remains a major challenge for the physician, despite increasingly sophisticated investigations and efficient therapeutic programs. Many reasons explain persistent difficulties: the disorder crosses all specialties. A wide variety of clinical presentations has to be considered according to the size of the thrombus, the coexisting conditions ("predisposing factors") and the prior cardio pulmonary status. Major investigations include perfusion and ventilation lung scans, pulmonary angiography, invasive and non invasive investigations of the deep venous system. But obvious practical limitations exist; selection of the most suitable test includes severity of the present patient condition and risk of an early recurrence of EP; risk of the contemplated therapeutic procedure if the diagnosis of EP is confirmed; skillfulness required for the selected investigation. Angiography is mandatory if a substantial hemorrhagic risk exists, if massive EP is suspected, and if at risk treatment procedures are contemplated. In the other cases, and in the absence of significant pulmonary pathology, a lung perfusion scan is the advisable procedure; the diagnosis is excluded if the scan is normal. Previous or current significant pulmonary pathology requires angiography. However, proof of coexisting deep venous thrombosis is an alternative way to enhance the diagnosis in case of poor clinical conditions or other practical considerations.

Angiography, Digital Subtraction↗

PubMed2004

[New aspects in the diagnosis of pulmonary embolism].

Pulmonary embolism (PE) and deep venous thrombosis (DVT), venous thromboembolism (VTE) respectively, are relatively frequent diseases. Despite progress in early detection and treatment, the rates of mortality and recurrent PE, remain high. Clinical findings include oligosymptomatic conditions with unexplained chest discomfort or shortness of breath that cannot be recognized as PE, but also and massive embolism with hemodynamic colapse and sudden cardiac death (SCD). The time from the first symptoms, till PE diagnosis is the most important for prognosis. Diagnostic methods include non imaging methods as plasma d-dimer Elisa, electrocardiogram, and many imaging methods from roentgenography, echocardiography, lung scanning, spiral chest computed tomography, magnetic resonance imaging to pulmonary angiography as "the gold standard" for PE diagnosis. It is recommended integrated diagnostic approach and various algorithms according to medical equipment and staff skill of a hospital.

Humans↗

PubMed2002

Pulmonary embolism.

Pulmonary embolism (PE) is a common problem for which prompt diagnosis and treatment is essential to minimize mortality. The clinical presentation is more variable than sudden dyspnea and chest pain, especially in the critical care patient. Recognition of venous thromboembolic (VTE) risk factors can help develop a good clinical suspicion for PE. A wide range of diagnostic tests are available to the clinician. The ventilation/perfusion scan, pulmonary arteriogram, and lower extremity investigations are still important for diagnosis. Other noninvasive tests such as spiral CT with venography, echocardiography, and D-dimers are becoming more accepted. Heparin is the mainstay of PE therapy, but thrombolytic treatment may be lifesaving in the unstable patient. VTE prophylaxis should be considered in all post-operative or critical care patients.

Algorithms↗

PubMed1986

Pulmonary embolism.

Pulmonary embolism is a commonly seen emergency that presents many diagnostic and therapeutic challenges. In order to meet these challenges, clinicians must have an organized approach to work-up and management of this emergency.

Coumarins↗

PubMed2002

Imaging techniques in treatment algorithms of pulmonary embolism.

Pulmonary embolism (PE) is more often diagnosed post mortem by pathologists than in vivo by clinicians. The identification of practical diagnostic algorithms could reduce the rate of diagnoses first made at autopsy. The literature was reviewed for evidence-based approaches to PE diagnosis. Since the PE mortality rate greatly exceeds that of deep vein thrombosis (DVT), more emphasis was given to reports specifically dealing with PE diagnosis by objective pulmonary vascular imaging techniques than to those aimed at DVT detection. Several studies have shown that standardized clinical estimates can be effectively used to give a pretest probability to calculate, after appropriate objective testing, the post-test probability of PE. A prospective trial has shown that perfusion scanning, rather than ventilation/perfusion scanning, should be the imaging technique of first choice for the management of patients suspected of having PE. The clinical usefulness of spiral computed tomography has not as yet been firmly established. However, ongoing technological developments would probably render the technique accurate enough to replace conventional angiography. The authors propose a noninvasive diagnostic algorithm with high predictive accuracy (positive predictive value 96%; negative predictive value 98%) starting with a standardized assessment of clinical likelihood, followed by a perfusion scan and, eventually, spiral computed tomography in only a minority of patients (< 20%) with discordant clinical and scintigraphic findings.

Algorithms↗

PubMed2005

Performance of magnetic resonance angiography in suspected acute pulmonary embolism.

Pulmonary embolism (PE) is a common and potentially fatal disorder. Non-specific findings make the clinical diagnosis of PE difficult. To assess the diagnostic value and inter-observer agreement of magnetic resonance angiography (MRA) in a cohort of patients with suspected PE, we conducted a prospective clinical study. MRA was compared for sensitivity and specificity to a diagnostic strategy including clinical probability, D-dimer testing, spiral CT, ultrasound leg compression and pulmonary angiography. A total of 89 patients with clinically suspected PE were included: the clinical probability of PE was intermediate or high in 78, and low in the remaining 11. All patients underwent monoor multi-slice spiral CT and MRA with gadolinium injection (both within 24 hours of entry to the study). Anticoagulation was withheld in patients concerned about the strategy. All subjects were followed up for 3 months. MRA was read independently by two experienced teams of radiologists: one local and one from another university centre. Spiral CT was positive in 62 of 63 cases of confirmed PE. No patient with negative CT findings was positive ultrasonographically. Only one patient with a negative CT (and negative ultrasound) had a recurrent thromboembolic event. The first team diagnosed PE with MRA in 47 cases, with a sensitivity of 71% and a specificity of 92%; the second team obtained the diagnosis in 23 cases, with a sensitivity of 31% and a specificity of 85%. Inter-observer agreement between MRA reading was low: Kappa = 0.16 (-0.01 to 0.33); p = 0.07. In conclusion, compared with a non-invasive strategy based on spiral CT, the diagnostic value of MRA is limited by poor inter-observer agreement.

Acute Disease↗

PubMed1994

Decision making in the surgical treatment of massive pulmonary embolism.

Pulmonary embolectomy in the treatment of acute massive pulmonary embolism (PE) is the subject of considerable controversy with regard to indication, technique of embolectomy and perioperative management. Since 1968 50 patients have undergone surgery for massive PE in our unit. Inflow occlusion technique and cardiopulmonary bypass were used in 33 and 17 patients, respectively. The overall operative mortality was 46%. Univariate analysis disclosed age (< 60 vs > 60), preoperative hemodynamics (cardiogenic shock vs cardiac arrest), location of emboli (peripheral vs central), duration of symptoms (hours vs days vs weeks) and number of episodes (first episode vs recurrent pulmonary emboli) as predictive factors of the post-operative outcome. The results of the retrospective analysis show that pulmonary embolectomy remains an acceptable procedure in patients with acute massive pulmonary emboli who are in refractory cardiogenic shock or who need intermittent resuscitation.

Cardiopulmonary Bypass↗

PubMed2004

[Epidemiology, diagnosis, and treatment of pulmonary embolism].

Pulmonary embolism (PE) is a frequent pathology, the mortality of which remains elevated despite the efficacy of anticoagulation. This is mainly due to diagnostic difficulty, resulting from the low sensibility and specificity of clinical signs and routine exams in PE. The best diagnostic approach relies on decision making algorithms based on the determination of a clinical probability, which in turn dictates the choice of specialized exams (C-scan/scintigraphy, venous duplex, angiography and D-dimers). Risk stratification, which is based on the presence of hemodynamic alterations (right ventricular dysfunction, shock) is essential to guide therapy. In case of shock (massive embolism), treatment relies on systemic thrombolysis. In the presence of right ventricular dysfunction without shock (sub-massive embolism), the advantage of thrombolysis over anticoagulation alone has not been clearly demonstrated. In all other cases, as long as no contraindication exists, therapeutic anticoagulation with heparin must be initiated as soon as PE is suspected, since the mortality of this condition is highest in the two first hours following presentation.

Algorithms↗

PubMed1988

Pulmonary embolism.

Pulmonary embolism remains a challenging problem in diagnosis and management for the emergency physician. Although its clinical presentation is protean and often ambiguous, risk stratification can be accomplished based on the predictive power of a limited number of physical and historical characteristics. Ventilation-perfusion lung scanning occupies a central position in the work-up of suspected PE; however, evidence exists that it may be misused by many physicians. A low probability V-Q scan does not exclude the diagnosis of PE. Patients with other than normal- or high-probability patterns of pulmonary ventilation and perfusion on lung scanning require further investigation. Noninvasive venous studies are useful when indicative of proximal deep venous thrombosis, but are normal in many patients with acute PE. Heparin remains the standard of treatment for most patients with PE. Vena cava filters effectively reduce the incidence of recurrent PE in patients with contraindications to anticoagulation. Thrombolytic therapy offers potential advantages in the treatment of patients with shock due to their PE. Case reports of PE treated with tissue-type plasminogen activator, a new thrombus-specific fibrinolytic agent, are encouraging but preliminary.

Algorithms↗

PubMed2001

Diagnosis of pulmonary embolism.

Pulmonary embolism (PE) is a common, lethal yet treatable disease. The clinical diagnosis of PE remains to be a problem due to the nonspecific presenting signs, symptoms, electrocardiographic findings, arterial blood gas abnormalities and chest X-ray changes. Despite these nonspecific clinical findings, clinicians are adept at assigning pretest probability using overall clinical assessment. Clinical models have been developed to improve the accuracy of pretest probability assessment. D-dimers are becoming a widely available clinical tool useful in the diagnostic management of suspected PE. The limitations of the imaging modalities for PE [ventilation-perfusion (V/Q) scanning, spiral computerised tomography, pulmonary angiography and venous leg imaging] necessitate the use of these tests in series and in combination with clinical pretest probability assessment and D-dimer in diagnostic management algorithms. These algorithms permit safe diagnostic management of patients with suspected PE while limiting invasiveness, inaccessibility and expense.

Algorithms↗

PubMed1987

Pulmonary oedema during pulmonary embolism.

Pulmonary oedema during angiographically proved massive pulmonary embolism without left ventricular failure is unusual. A few previous reports have used haemodynamic data obtained during the acute phase to rule out left ventricular failure. The following case, which we were able to observe for a period of 4 years has given further evidence of uninvolved left ventricular function.

Female↗