Non-invasive diagnosis of pulmonary embolism, anno 2005

Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but no longer for subsegmental PE, because the inter-observer agreement for angiographically documented subsegmental PE is only 60%. Two non-invasive tools exclude PE with a negative predictive value of >99% : a normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test. The positive predictive value is 85 to 88% for a high probability ventilation-perfusion lung scan (VP-scan) and >95% for helical spiral CT. The prevalence of PE in management studies of symptomatic patients with a non-diagnostic VP-scan is 20 to 24%. Helical spiral CT detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic VP-scan or a high probability VP-scan. Single-slice helical CT as the primary diagnostic test in patients with suspected PE in three retrospective studies and in two prospective management study indicate that the negative predictive value of a normal helical spiral CT, a negative compression ultrasonography of the legs (CUS) together with a low or intermediate pre-test clinical probability is >99%. Therefore, helical spiral CT can replace both the VP-scan and pulmonary angiography to safely rule in and out PE. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer followed by CUS will reduce the need for helical spiral CT by 40 to 50%.     

Non-Invasive Diagnosis of Pulmonary Embolism,Anno 2005

Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but no longer for sub-segmental PE, because the inter-observer agreement for angiographically documented subsegmental PE is only 60%. Two non-invasive tools exclude PE with a negative predictive value of > 99%: a normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test. The positive predictive value is 85 to 88% for a high probability ventilation-perfusion lung scan (VP-scan) and > 95% for helical spiral CT. The prevalence of PE in management studies of symptomatic patients with a non-diagnostic VP-scan is 20 to 24%. Helical spiral CT detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic VP-scan or a high probability VP-scan. Single-slice helical CT as the primary diagnostic test in patients with suspected PE in three retrospective studies and in two prospective management study indicate that the negative predictive value of a normal helical spiral CT, a negative compression ultrasonography of the legs (CUS) together with a low or intermediate pre-test clinical probability is > 99%. Therefore, helical spiral Ct can replace both the VP-scan and pulmonary angiography to safely rule in and out PE. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer followed by CUS will reduce the need for helical spiral CT by 40 to 50%.     

Normal D-dimer levels do not exclude thrombotic complications in trauma patients

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are common complications in trauma patients. These diagnoses can be difficult and expensive to make. Recent studies report that a negative D-dimer test excludes thrombotic complications. We questioned the predictive value of a D-dimer test to exclude DVT and PE. METHODS: Adult trauma patients admitted March 1999 to March 2001, with an Injury Severity Score > or =9 and expected length of stay >3 days, were approached for enrollment. Bilateral lower extremity duplex ultrasounds and d-dimer levels were performed within 36 hours of admission, day 3-4, day 7, and weekly until discharge. RESULTS: Twenty-three patients were diagnosed with DVTs, with 18 DVTs detected within the first week of admission. Five DVT patients had normal D-dimer levels. One of three PE patients tested had a normal D-dimer level. The false negative rate for DVT by d-dimer assay was 24%, and the sensitivity was 76%. The negative predictive value for D-dimers was 92%. All false negative d-dimer tests occurred in patients diagnosed with DVT or PE within the 4 days after admission. CONCLUSION: In the early postinjury phase, a negative d-dimer test does not exclude DVT or PE. However, the negative predictive value of a D-dimer test after the first 4 days from admission rose to 100%. Patients with clinical signs and symptoms of DVT or PE in the immediate postinjury phase should undergo further screening to exclude thromboembolic complications.     

Current diagnostic techniques for pulmonary embolism

The diagnosis of venous thromboembolism (VTE) includes deep venous thrombosis (DVT) and pulmonary embolism (PE) and requires objective testing. The clinician uses a combination of risk factors and nonspecific clinical findings to identify patients who warrant such an evaluation. The recommended approach begins with ventilation/perfusion (V/Q) lung scans or lower extremity noninvasive studies by compression ultrasonography. Nondiagnostic V/Q scans or negative noninvasive studies require further testing. A high-probability V/Q scan or a positive noninvasive study warrant treatment. A normal V/Q scan excludes the diagnosis of PE. Helical computed tomography (CT) can diagnose PE of major vessels but is not sufficiently sensitive to exclude PE because of its poor sensitivity for subsegmental pulmonary vessels. Newer D-dimer assays have a high negative predictive value, but results vary with the specific assay and do not perform well in patients with cancer. Future studies are needed to validate magnetic resonance imaging (MRI) or magnetic resonance angiography (MRA).     

Usefulness of D-dimer, blood gas, and respiratory rate measurements for excluding pulmonary embolism

BACKGROUND: A study was undertaken to assess the usefulness of the SimpliRED D-dimer test, arterial oxygen tension, and respiratory rate measurement for excluding pulmonary embolism (PE) and venous thromboembolism (VTE). METHODS: Lung scans were performed in 517 consecutive medical inpatients with suspected acute PE over a one year period. Predetermined end points for objectively diagnosed PE in order of precedence were (1) a post mortem diagnosis, (2) a positive pulmonary angiogram, (3) a high probability ventilation perfusion lung scan when the pretest probability was also high, and (4) the unanimous opinion of an adjudication committee. Deep vein thrombosis (DVT) was diagnosed by standard ultrasound and venography. RESULTS: A total of 40 cases of PE and 37 cases of DVT were objectively diagnosed. The predictive value of a negative SimpliRED test for excluding objectively diagnosed PE was 0.99 (error rate 2/249), that of PaO2 of > or = 80 mm Hg (10.7 kPa) was 0.97 (error rate 5/160), and that of a respiratory rate of < or = 20/min was 0.95 (error rate 14/308). The best combination of findings for excluding PE was a negative SimpliRED test and PaO2 > or = 80 mm Hg, which gave a predictive value of 1.0 (error rate 0/93). The predictive value of a negative SimpliRED test for excluding VTE was 0.98 (error rate 5/249). CONCLUSIONS: All three of these observations are helpful in excluding PE. When any two parameters were normal, PE was very unlikely. In patients with a negative SimpliRED test and PaO2 of > or = 80 mm Hg a lung scan is usually unnecessary. Application of this approach for triage in the preliminary assessment of suspected PE could lead to a reduced rate of false positive diagnoses and considerable resource savings.     

Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty

We evaluated a total of 473 knees (264 patients) to determine the prevalence of deep vein thrombosis and pulmonary embolism (PE) in those who were not given thromboprophylaxis after total knee arthroplasty (TKA). Deep vein thrombosis was diagnosed by roentgenographic venography, and PE was diagnosed by perfusion lung scanning. In patients with bilateral TKA, 47 (11%) of 418 venograms showed positive findings for thrombi, whereas in patients with unilateral TKA, 11 (20%) of 55 venograms showed positive findings for thrombi (P = .758). No patient had symptoms of PE, and findings for the perfusion lung scans were negative in all patients. We neither treat our patients for deep vein thrombosis and PE prophylactically nor therapeutically unless patient has a symptomatic PE.     

D-dimer and calf circumference in the evaluation of outpatient deep venous thrombosis

OBJECTIVE: Duplex ultrasonography (DU) is the primary method for diagnosis of deep venous thrombosis (DVT) but is relatively expensive and not always readily available. Attempts to exclude the diagnosis of DVT with D-dimer or clinical criteria independently have been unsuccessful. The goal of our study was to evaluate a second-generation rapid quantitative D-dimer and simple clinical parameters for screening of outpatients for DVT. Patients and Methods: Patients undergoing DU of the lower extremities for suspected DVT were prospectively evaluated. Patients undergoing lower extremity venous ultrasound scan for suspected pulmonary embolism or already on anticoagulant therapy were excluded from the study. Data were analyzed to assess the optimal combination of characteristics to include and exclude proximal DVT. RESULTS: One hundred fifty-six outpatients met inclusion criteria and were enrolled in the study. Elevated levels of D-dimer of 0.5 ng/mL or more were noted in 21 of 22 patients diagnosed with DVT, yielding a sensitivity of 95% and negative predictive value of 99%. Subjective symptoms of swelling or pain were present in 94% of all outpatients. Asymmetric calf swelling of more than 2.0 cm was noted in 14 of 22 patients (64%) with proximal DVT compared with 22 of 134 patients (16%) without DVT (P <.003). No single clinical history variable was significant on multivariate analysis. All outpatients with proximal DVT had either leg swelling of more than 2 cm or a positive D-dimer. CONCLUSION: A combination of a second-generation quantitative D-dimer and calf measurement provides an easy and effective means of excluding proximal DVT when screening outpatients. Patients with calf circumference 2.0 cm or less and a negative D-dimer may undergo nonemergent DU. Patients with a positive D-dimer or asymmetrical calf swelling of more than 2.0 cm alone or in combination should undergo emergent DU.     

Pulmonary embolism after spinal surgery: report of two cases

We present two cases of pulmonary embolism (PE) without deep venous thrombosis (DVT) after spinal surgery with an anterior approach. On the seventh day after surgery, the patients’ plasma D-dimer levels were high without symptoms, so computed tomography (CT) was performed from chest to lower limb, revealing PE without lower limb DVT. After the exam, we immediately started anticoagulation therapy with heparin and warfarin. The patients were discharged with no complications. Previous reports have documented that DVT causes most cases of PE; however, our cases had no lower limb DVT. Some reports hypothesize that anterior spinal surgery might have a differential pathogenesis of PE. Simple mechanical prophylaxis for DVT may not protect these patients. On the other hand, the administration of chemical anticoagulants therapy after spinal surgery is controversial because of the risk of epidural hematoma. We should explain the risk of PE to patients undergoing spinal surgery with an anterior approach.     

D-dimer monitoring combined with ultrasonography improves screening for asymptomatic venous thromboembolism in acute spinal cord injury

Objective: We compared screening methods for asymptomatic venous thromboembolism (VTE) in patients with acute spine and spinal cord injuries (SCI). Patients were screened by D-dimer monitoring alone (DS group) or by D-dimer monitoring combined with ultrasonography (DUS group).

Design: Prospective cohort study.

Setting: One department of a university hospital in Japan.

Participants: 114 patients treated for acute SCI between 2011 and 2017.

Interventions: N/A.

Outcome Measures: D-dimers were measured upon admission and 1, 3, 5, 7, and 14 days thereafter. DUS-group patients also underwent an ultrasound 7 days after admission. If ultrasonography indicated deep venous thrombosis (DVT), or if D-dimer levels increased to ≥?10?µg/mL, the patient was assessed for VTE, including DVT or pulmonary embolism (PE), by contrast venography. We analyzed the incidence of VTE detected in the DS and DUS groups.

Results: In the DS group, D-dimers were elevated (≥?10?µg/mL) in 15 of 70 patients (21.4%), and 9 of the 15 had asymptomatic VTE (12.9%, DVT 11.4%, PE 5.7%). In the DUS group, one patient developed VTE on day 4, and D-dimers were elevated in 13 of 43 patients (30.2%), ultrasonography indicated DVT in 12 patients (27.9%), and asymptomatic VTE was diagnosed in 12 patients (27.9%, DVT 27.9%, PE 4.7%). The DUS group had a higher incidence of DVT (P?=?0.002) and VTE (P?=?0.042) than the DS group.

Conclusions: Combined D-dimer and ultrasound screening in patients with acute SCI improved the detection of VTE, including PE, compared with D-dimer screening alone.     

Fibrin monomer could be a useful predictor of pulmonary embolism after total hip arthroplasty: preliminary report

We examined 17 total hip arthroplasty patients in order to develop a method for the predictive diagnosis of pulmonary embolism (PE) after joint arthroplasty. Scintigraphy revealed the presence of PE in 4 patients. Prothrombin time (PT), activated partial thromboplastin time (aPTT), antithrombin III (ATIII), and thrombin-AT III complex (TAT) did not show significant differences between patients with and without PE. D-dimer 7 days after surgery showed significant differences between patients with and without PE. Fibrin monomer (FM) increased sharply after surgery, and it was significantly different between the patients with and without PE immediately after surgery and 2 days after surgery. Our findings suggest the importance of FM in the predictive diagnosis of pulmonary embolism after total hip arthroplasty, and 40 μg/ml or higher levels with our measurement method could represent a high-risk condition. Received: June 12, 2000 / Accepted: November 27, 2000     

Diagnosis of pulmonary embolism with various imaging modalities

Pulmonary embolism (PE) is a major health concern that affects approximately 600,000 new patients annually. The diagnosis of PE can be difficult to make, and several imaging studies have been developed to aid in this process. Initial evaluation involves the acquisition of a chest radiograph. Findings on radiography, however, are often non-specific. The gold-standard study historically has been pulmonary angiography, with increasing diagnostic yield since the implementation of digital subtraction technology. This is an invasive procedure, however, but the incidence of major complications is low. Less invasive modalities have been developed and include ventilation-perfusion lung scans. These are used as one of the initial screening tests in evaluation of patients with suspected PE. The presence of a high-probability scan usually indicates the presence of a PE, although few patients have high probability scans. The test is significantly affected by underlying pulmonary disease or previous PE. Given this, ventilation-perfusion lung scans are limited as a primary diagnostic tool in the evaluation of suspected PE. Helical computed tomography (CT) is currently under much scrutiny as a diagnostic tool for PE. Currently a prospective, multicenter trial evaluating its efficacy (PIOPED II) has been initiated, but the results are pending. Preliminary reports suggest the helical CT and venous phase CT may become a first line study in patient evaluation. The diagnosis of PE is challenging and several imaging modalities are currently used to assist the clinician. Currently, multiple modalities are often required to make the diagnosis. With the advent of new technology and improved imaging techniques, the diagnosis of PE will become easier.     

Failure of low dose heparin to prevent pulmonary embolism after hip surgery or above the knee amputation.

In a randomized, double-blind trial, 5,000 USP units of sodium heparin or saline were give subcutaneously at least two hours before surgery and at 12 hour intervals thereafter to patients requiring total hip replacement, surgical correction of hip fracture, or major lower extremity amputation for vascular insufficiency. Lung perfusion scans were performed before surgery and at weekly intervals during the postoperative period. Pulmonary arteriograms were requested in patients developing new perfusion defects on serial scans. Two hundred twelve patient hospitalizations were analyzed. We diagnosed acute pulmonary embolism by serial lung perfusion scans or at autopsy in 37 patients. The incidence of pulmonary embolism in 40 patients with below the knee amputation was too low to warrant conclusions. The incidence of acute pulmonary embolism in 94 patients undergoing above the knee amputation was 25% in patients receiving heparin and 27% in patients receiving saline. The incidence of acute pulmonary embolism in 78 patients undergoing hip surgery was 13% in patients receiving heparin and 12% in patients receiving saline. We conclude that the regimen used had no significant effect on the incidence of acute pulmonary embolism in patients undergoing hip surgery or above the knee amputation.     

Incidence and management of pulmonary embolism following spinal surgery occurring while under chemical thromboprophylaxis

Patients undergoing spinal surgery are at risk of developing thromboembolic complications even though lower incidences have been reported as compared to joint arthroplasty surgery. Deep vein thrombosis (DVT) has been studied extensively in the context of spinal surgery but symptomatic pulmonary embolism (PE) has engaged less attention. We prospectively followed a consecutive cohort of 270 patients undergoing spinal surgery at a single institution. From these patients, only 26 were simple discectomies, while the largest proportion (226) was fusions. All patients received both low molecular weight heparin (LMWH) initiated after surgery and compressive stockings. PE was diagnosed with spiral chest CT. Six patients developed symptomatic PE, five during their hospital stay. In three of the six patients the embolic event occurred during the first 3 postoperative days. They were managed by the temporary insertion of an inferior vena cava (IVC) filter thus allowing for a delay in full-dose anticoagulation until removal of the filter. None of the PE patients suffered any bleeding complication as a result of the introduction of full anticoagulation. Two patients suffered postoperative haematomas, without development of neurological symptoms or signs, requiring emergency evacuation. The overall incidence of PE was 2.2% rising to 2.5% after exclusion of microdiscectomy cases. The incidence of PE was highest in anterior or combined thoracolumbar/lumbar procedures (4.2%). There is a large variation in the reported incidence of PE in the spinal literature. Results from the only study found in the literature specifically monitoring PE suggest an incidence of PE as high as 2.5%. Our study shows a similar incidence despite the use of LMWH. In the absence of randomized controlled trials (RCT) it is uncertain if this type of prophylaxis lowers the incidence of PE. However, other studies show that the morbidity of LMWH is very low. Since PE can be a life-threatening complication, LMWH may be a worthwhile option to consider for prophylaxis. RCTs are necessary in assessing the efficacy of DVT and PE prophylaxis in spinal patients.     

Efficacy and safety of weight-adapted nadroparin calcium vs. heparin sodium in prevention of clinically evident thromboembolic complications in 1,190 general surgical patients

AIMS: In a prospective, randomized, single, general surgery center trial, comparison of the safety and efficacy of two low molecular weight heparin (LMWH; anti-Xa heparin sodium and weight-adapted nadroparin calcium) regimens was made. PATIENTS AND METHODS: Eleven hundred and ninety patients undergoing various elective and emergency operations were randomized to receive daily either a fixed dose of 3,000 IU anti-Xa heparin sodium or a variable body weight-dependent dose of nadroparin calcium (weight <50 kg, 2,050 IU anti-Xa (WHO); 51-80 kg, 3,075 UI; 81-100 kg, 4,100 UI, and >100 kg, 6,150 UI) once until discharge. The first injection was administered 2.5-6 h before elective and emergency operations, respectively. Patients with clinical suspicion of deep venous thrombosis (DVT) underwent phlebography. Patients with signs of pulmonary embolism (PE) were further investigated by a ventilation-perfusion scan. RESULTS: Statistically, there were no significant differences in the incidence of clinically evident DVT, PE or LMWH-related complications between both prophylactic regimens. Only 4 of the total of 15 hemorrhagic complications (4 wound hematomas in the nadroparin calcium group) were not classified as clearly surgically related, Two DVTs were confirmed by phlebography (both in the nadroparin calcium group). PE was confirmed by ventilation-perfusion scans (1 fatal, 1 on autopsy) in 1 patient with heparin sodium and in 6 patients with nadroparin calcium. CONCLUSIONS: Both regimens were equally safe and the risk of clinically evident DVT and PE was similar.     

Uses of different D-dimer levels can reduce the need for venous duplex scanning to rule out deep vein thrombosis in patients with symptomatic pulmonary embolism

OBJECTIVE: This study investigated the prevalence and distribution of deep vein thrombosis (DVT) in patients with symptomatic pulmonary embolism (PE) to establish a screening protocol to reduce unnecessary venous duplex scanning using different D-dimer level rather than single cutoff point of 0.5 microg/mL in patients with low and moderate pretest clinical probability (PTP). METHODS: The PTP score and D-dimer testing were used to evaluate 85 consecutive patients with symptomatically proven PE before venous duplex scanning. After calculating the PTP score, patients were divided into low (or=3 points) PTP groups. The receiver operating characteristic (ROC) curves analysis was used to determine the appropriate D-dimer cutoff point in low and moderate PTP, with a negative predictive value of >98%. RESULTS: The study enrolled 81 patients. The prevalence of DVT was 63%, with 27 patients (33%) classified as low, 38 (47%) as moderate, and 16 (20%) as high PTP. DVT was detected in nine patients (33%) in the low PTP group, in 27 (71%) in the moderate group, and in 15 (94%) in the high group. In the low PTP patients, the difference in the value of D-dimer assay between positive-scan and negative-scan patients was statistically significant (9.99 +/- 7.33 vs 3.46 +/- 4.20, respectively; P = .008). Conversely, no significant difference in the D-dimer assay value between positive and negative scan results was found in the moderate PTP patients. ROC curves analysis were used to select D-dimer cutoff points of 2.0 microg/mL for the low PTP group and 0.7 microg/mL for the moderate PTP groups. For both groups, D-dimer testing provided 100% sensitivity and 100% negative predictive value in the diagnosis of DVT. In the low PTP group, specificity increased from 33% to 67% (P = .046). In the moderate PTP group, however, the determined D-dimer level did not improve the specificity. Overall, venous duplex scanning could have been reduced by 17% (14/81) by using different D-dimer cutoff points. CONCLUSIONS: A combination of specific D-dimer level and clinical probability score is most effective in the low PTP patients in excluding DVT. In the moderate PTP group, however, the recommended cutoff point of 0.5 microg/mL may be preferable. These results show that a different D-dimer level is more useful than single cutoff point of 0.5 microg/mL in excluding DVT in established PE patients.     

Prediction of Pulmonary Embolism Following Resection of Pulmonary Infarction: A Case Series

Purpose: Pulmonary nodules suspected to be cancerous are rarely diagnosed as pulmonary infarction (PI). This study examined the clinical, radiological, and laboratory data in cases diagnosed with PI to determine their potential utility as preoperative diagnostic markers. We also assessed factors affecting the postoperative course.Methods: A total of 603 cases of peripheral pulmonary nodules undiagnosed preoperatively were resected at Hokkaido University Hospital from 2012 to 2019. Of these, we reviewed cases with a postoperative diagnosis of PI. We investigated clinical symptoms, preoperative laboratory data, radiological characteristics, and postoperative complications.Results: Four patients (0.7%) were diagnosed with PI. All patients had a smoking history. One patient received systemic steroid administration, and none had predisposing factors for thrombosis. One case showed chronologically increased nodule size. Three cases showed weak uptake of ¹⁸F-fluorodeoxyglucose. One patient with preoperative high D-dimer levels developed a massive pulmonary embolism (PE) in the postoperative chronic phase and was treated with anticoagulants.Conclusions: Preoperative diagnosis of PI is difficult, and we could not exclude lung cancer. However, if a patient diagnosed with PI has a high D-dimer level, we recommend postoperative physical examination for deep venous thrombosis. Prophylactic anticoagulation therapy should be considered to avoid fatal PE.     

Morbidity and Mortality Associated with Brachial Vein Thrombosis

We have noted a significant incidence of pulmonary embolism (PE) and mortality associated with upper extremity deep venous thrombosis (UEDVT). Since there is an association between site of lower extremity DVT (LEDVT) and PE, we hypothesized that there might also be a correlation between site of UEDVT and PE with associated mortality. To further elucidate this hypotheses, we analyzed the mortality and incidence of PE diagnosed with subclavian/axillary/internal jugular vein thrombosis during an 11-year period at our institution and compared the data to those of patients diagnosed with brachial DVT. We studied 598 patients diagnosed with acute internal jugular, subclavian, axillary, or brachial DVT by duplex scanning. The patients were divided into three groups based on the most proximal location of the thrombus: group I, UEDVT involving the subclavian or axillary veins (n = 467); group II, isolated internal jugular DVT (n = 80); group III, brachial DVT alone (n = 52). Mortality rates at 2 months were 29%, 25%, and 21% for each group, respectively. The number of patients diagnosed with PE by ventilation/perfusion scans in groups I, II, and III, respectively, were 5%, 6.25% and 11.5% (p = 0.13). Furthermore, stratification by risk factors failed to demonstrate factors associated with increased 2-month mortality. Contrary to the initial hypothesis of a relationship between the site of thrombosis and the incidence of PE and mortality, these data demonstrated no statistical differences in mortality or incidence of PE among the groups studied. Additionally, these data suggest that brachial vein thrombosis is a disease process related to comparable associated mortality and morbidity similar to other forms of UEDVT. Based on these data, we suggest that UEDVT may be thought of as a marker for the severity of systemic illness of the patient rather than just as a cause of venous thromboembolism.Presented at the Western Vascular Society, Victoria, British Columbia, Canada, September 13, 2004.     

Pulmonary alterations in the acutely injured patient

Alterations in pulmonary function in 10 patients following acute chest trauma were studied in a prospective manner in an attempt to determine the criteria for initiation and maintenance of respiratory support and to estimate residual impairment of pulmonary function. Commonly used factors such as central venous pressure, blood gas determinations, and chest roentgenograms were supplemented by serial xenon ventilation-perfusion lung scans in all patients. A definite correlation was found between the degree of trauma and alterations in lung function. Tracheostomy with assisted ventilation was required in 7 patients because of flail segments of the chest wall and hypoxia, and all had severe alterations in ventilation and perfusion. Repeat lung scan showed a return to normal as early as two months following injury. Late (mean, 1 year) follow-up lung scan and spirometry in 8 of the 10 patients demonstrated normal values in the majority. Serial blood gas determinations proved to be the best guide to adequacy of ventilation in patients with acute chest trauma.     

Role of venous duplex scanning in patients with suspected pulmonary embolism

Purpose: We examined the use of venous duplex scanning (VDS) in the diagnosis of pulmonary embolism (PE) at our institution.Methods: Patients undergoing lower extremity VDS from October 1988 through June 1995 were cross-referenced with those who underwent ventilation perfusion (V/Q) scans and pulmonary angiography (PA) for PE.Results: A total of 664 of 3534 VDS were for “rule out PE.” Deep venous thrombosis was found in 13%. A total of 256 VDS were in conjunction with V/Q scans in 249 patients, with only 8% undergoing PA. Deep venous thrombosis was present in 18% for those with both V/Q and VDS compared with 10% ( p < 0.01) for those with VDS as the sole study. The order in which V/Q, VDS, and PA were obtained and the relationship of positive studies was examined.Conclusion: We found no pattern to the sequence of tests ordered. V/Q scan rather than VDS should be the first study in the evaluation of PE. PE was diagnosed or excluded in nearly one third of patients based on V/Q as the initial study. A total of 29% of VDS could have been avoided. Treatment could be determined on the basis of VDS as the initial study in only 13%. We found only 14% incidence of positive PA in patients with nondiagnostic V/Q scans. We advocate judicious use of diagnostic tests in a stepwise fashion to appropriately treat patients with suspected PE. (J Vasc Surg 1996;24:768-73.)     

Upper extremity deep vein thrombosis in orthopaedic and trauma surgery: a systematic review

Upper extremity deep venous thrombosis (DVT) is considered a rare phenomenon. Little is known as to what factors may contribute to the development of upper extremity DVT following trauma or elective orthopaedic surgery. The incidence of pulmonary embolism (PE) related to upper extremity thrombosis is reported as 12 to 36%, where up to 16% of cases are fatal. The purpose of this paper was to systematically review the literature to assess all cases of upper extremity DVT presented in the literature in order to determine epidemiology and outcome. A review of EMBASE, Medline, CINAHL and AMED from their inception to November 2009, sources of grey literature and a pertinent hand search of specialist orthopaedic journals was undertaken. A total of 38 cases of upper extremity DVT and 19 cases with PE were identified from 20 publications. The incidence of upper extremity DVT and PE was greatest in cases following shoulder surgery. There did not appear to be any greater risk in patients with diabetes or obesity. In total, one patient died after a PE following shoulder surgery. Although a relatively uncommon complication, the literature suggests that upper extremity DVT can lead to PE, which should be considered by orthopaedic clinicians in patients following upper extremity surgery or trauma.