Architecture of fibrin network inside thrombotic material obtained from the right atrium and pulmonary arteries: flow and location matter

Pulmonary embolectomy is a treatment option in selected patients with high-risk pulmonary embolism (PE). Efficiency of thrombus degradation in PE largely depends on the architecture of its fibrin network, however little is known about its determinants. We present the case of a 56-year-old woman with high-risk PE and proximal deep-vein thrombosis, whose thrombotic material removed during embolectomy from the right atrium and pulmonary (lobar and segmental) arteries has been studied using scanning electron microscopy (SEM). SEM images showed that distally located thrombi are richer in densely-packed fibrin fibers and contain more white cells and less erythrocytes than the proximal ones and the atrial thrombus. Fibrin fibers alignment along the flow vector was observed in the thrombi removed from high-velocity flow pulmonary arteries, and not in the atrial thrombus. The content of denser fibrin network and platelet aggregates was increased in segmental thromboemboli. Our findings describe the relation between thrombus architecture and location, and might help to elucidate thrombus resistance to anticoagulant therapy in some PE patients.     

Development of early reperfusion after the first episode of acute pulmonary embolism

IntroductionFactors influencing the early reperfusion after pulmonary embolism (PE), with possible impact on development of chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension (CTEPH), have not been completely identified yet.Study population and methodsThe total of 85 patients hospitalized with the first episode of acute PE underwent a ventilation–perfusion lung scan before hospital discharge. The reperfusion was evaluated based on clinical, echocardiographic and laboratory parameters.ResultsThe study population consisted of 37 men and 48 women, mean age 60 years. A high-risk PE was present in 9.4% of patients, medium-risk PE in 49.4% and low-risk PE in 41.2% of patients. 26 (30.5%) of patients were diagnosed with provoked pulmonary embolism. Prior to discharge, the residual perfusion defects were detectable in 66 patients, in 18 patients the perfusion was normal. The two groups did not significantly differ in clinical, echocardiographic or laboratory parameters.ConclusionThe analysis did not identify risk factors significantly associated with the absence of early reperfusion of the PE. This points toward the need of further follow-up of patients after a PE with the aim of identifying the patients with the high risk of developing the chronic thromboembolic disease and CTEPH.     

Predictors of residual pulmonary vascular obstruction after anticoagulation monotherapy in patients with intermediate-risk pulmonary embolism

BackgroundPatients with intermediate-risk pulmonary embolism (PE) can be treated with anticoagulation monotherapy. However, clinicians are concerned as to whether anticoagulation monotherapy is sufficient to reduce mortality in patients with a large embolic burden, and to resolve vascular obstruction. We investigated whether anticoagulation monotherapy was appropriate in patients with intermediate risk PE in terms of the occurrence of residual pulmonary vascular obstruction (RPVO), and the factors that independently predict the occurrence of RPVO.MethodsThis was a multicenter retrospective observational study of patients at intermediate risk of PE who were admitted to three hospitals between January 2012 and December 2017.ResultsOf total 91 patients, the median age was 72 years and 37 (40.7%) were male. Twenty-five patients (27.5%) were diagnosed with RPVO during follow-up. Multivariate logistic regression revealed chronic lung disease [odds ratio (OR), 4.14; 95% confidence interval (CI), 1.243–13.797; P=0.021] and the ratio of the diameters of the main pulmonary artery and ascending aorta ratio (P/A ratio) >1.0 documented on a chest computed tomography (CT) at presentation (OR, 3.46; 95% CI, 1.113–10.770; P=0.032) were significant independent predictors of RPVO occurrence. The incidence of RPVO in patients without these two factors was only 9.7%, but in those with the two factors it was 60% (P=0.004).ConclusionsAnticoagulation monotherapy did not seem to be a sufficient treatment to reduce RPVO, but the outcome was similar to that of patients treated with other therapies. Therefore, considering the risk-benefit ratio, we do not need to change the initial treatment as systemic thrombolytic therapy or catheter-based therapy in patient with intermediate risk PE. Underlying chronic lung disease and a P/A ratio >1 on the initial chest CT predicted the occurrence of RPVO. Therefore, we should carefully assess persistent of dyspnea and exercise limitations using various methods in patients with these risk factors, to detect the occurrence of chronic thromboembolic pulmonary disease (CTEPD) earlier.     

Pulmonary hypertension from chronic pulmonary thromboembolism

Pulmonary hypertension may develop whenever chronic obstruction of pulmonary arterial blood flow occurs. Although repeated pulmonary embolism is thought to be the usual underlying cause, there is little clinical evidence to support this theory. Studies of the pulmonary vascular endothelium have shown that perturbations of the normal endothelium can create a procoagulant environment, which could lead to the development of thrombosis in situ at the level of the large or smaller pulmonary vessels. Some patients develop proximal pulmonary thromboemboli, which may be the result of retrograde propagation of thrombus after an initial pulmonary embolus. Others present with unexplained pulmonary hypertension secondary to thrombotic occlusion of the pulmonary microvasculature. A perfusion lung scan will show abnormalities that should lead to correct clinical diagnosis and confirmatory evaluation. Thromboendarterectomy in selected cases provides dramatic clinical improvement in patients with proximal thromboemboli. Vasodilators may be effective in some patients with obstruction at the arteriolar level. Both groups should be treated with chronic warfarin anticoagulant therapy to protect against progression of thromboembolism.     

Saddle pulmonary embolism diagnosed by CT angiography: frequency, clinical features and outcome

OBJECTIVE: To assess the frequency, clinical presentation and outcome associated with saddle pulmonary embolism (PE) diagnosed by computed tomographic angiography (CTA). PATIENTS: Retrospective review of 546 consecutive patients diagnosed to have acute PE by CTA from 1 September 2002 to 31 December 2003. RESULTS: Fourteen of 546 patients (2.6%) had saddle PE; 10 were men (71%). None of these patients had pre-existing cardiopulmonary disease. Most common presenting symptoms included dyspnea (72%) and syncope (43%). Hypotension was documented in 2 patients (14%). The most common risk factor for PE was obesity (64%). CTA revealed saddle PE and additional filling defects in the main pulmonary arteries in all patients. Echocardiography was performed within 48 h of the PE diagnosis in 10 patients and revealed right ventricular dysfunction in 8 (80%). All patients were initially managed in the hospital, median length of stay of 4 days (range, 1-45 days). Standard anticoagulant therapy with heparin and warfarin was administered to all patients. Five patients (36%) received additional therapy; thrombolytic therapy was administered to 1 patient (7%) and 4 patients (29%) received an inferior vena cava filter. None of the patients died during their hospitalization. Four patients (29%) died following their hospitalization after intervals of 1, 5, 6, and 12 months, respectively. Causes of death were known in 3 patients, all of whom died from progressive malignancy. CONCLUSION: Saddle PE in patients without pre-existing cardiopulmonary disease is associated with a relatively low in-hospital mortality rate and may not necessitate aggressive medical management.     

N-Terminal Pro-B-Type Natriuretic Peptide Predicts the Burden of Pulmonary Embolism

BackgroundIn acute pulmonary embolism (PE), brain natriuretic peptides are markers of right ventricular dysfunction and they could point out the size of the occluded pulmonary vessel.MethodsN-terminal pro-B-type natriuretic peptide (BNP) was measured in 93 consecutive outpatients diagnosed with acute PE by means of helical computed tomography. Central PE was diagnosed when thrombotic material was seen in the main trunk or right or left main branches of the pulmonary artery, and peripheral PE was diagnosed when thrombi were seen exclusively in segmental or subsegmental arteries.ResultsCentral PE occurred in 51 (55%) patients and peripheral PE in 42 (45%). Plasma level of pro-BNP greater than 500 ng/L was independently associated with central PE. The area under the receiver operating characteristic curve was 0.753 (CI 95% 0.700-0.806), sensitivity 0.82 (CI 95% 0.69-0.91), specificity 0.67 (CI 95% 0.50-0.79), positive predictive value 0.75 (CI 95% 0.61-0.85), and negative predictive value 0.76 (CI 95% 0.58-0.87). Six (6%) patients died, 3 from PE, 2 from brain hemorrhage, and 1 from advanced gallbladder cancer. N-terminal pro-BNP level was greater than 500 ng/L in all patients who died. The area under receiver operating characteristic curve for death was 0.712 (CI 95% 0.635-0.789), sensitivity 0.10 (CI 95% 0.04-0.22), specificity 1 (CI 95% 0.88-1), positive predictive value 1 (CI 95% 0.51-1), and negative predictive value 0.42 (CI 95% 0.32-0.53).ConclusionsPreliminary data suggest that N-terminal pro-BNP levels higher than 500 ng/L could serve as indicator of the burden of PE and perhaps as a predictor of death.     

Resolution of thromboemboli in patients with acute pulmonary embolism: a systematic review

STUDY OBJECTIVES: Much attention has been paid in recent years to optimizing the diagnosis of acute pulmonary embolism (PE). However, little is known about the changes in clot burden that occur at the level of the pulmonary arteries after documented PE. It is often problematic to distinguish between a new or residual defect on lung scintigraphy or helical CT. This may lead to falsely labeling patients with residual PE as having recurrent PE and consequent unnecessary treatment changes. DESIGN: We performed a systematic analysis of studies of imaging tests (radionuclide and CT) evaluating resolution rate of PE with independent assessment of predefined methodologic criteria by two investigators. RESULTS: We identified 29 clinical studies. Of these, 25 studies were excluded and 4 studies were included in our review. Because studies differed largely in patient selection, duration of anticoagulation, and timing of follow-up, the studies were not pooled but briefly described. The percentage of patients with residual pulmonary thrombi was 87% at 8 days after diagnosis, 68% after 6 weeks, 65% after 3 months, 57% after 6 months, and 52% after 11 months. DISCUSSION: This review shows that complete resolution of PE is not routinely achieved between 8 days and 11 months after diagnosis. More than 50% of patients with PE still have defects 6 months after diagnosis, after which resolution of thrombi appears to reach a plateau phase. Physicians should be aware of the high percentage of incomplete resolution of pulmonary emboli. Routine re-imaging after cessation of anticoagulant therapy in patients with PE to obtain a new baseline could be considered.     

Incidence and risk factors of chronic thromboembolic pulmonary hypertension in patients after acute pulmonary embolism

Background

Early identification and treatment of chronic thromboembolic pulmonary hypertension (CTEPH) are critical to prevent disease progression. We determined the incidence and risk factors for CTEPH in patients with a first episode of acute pulmonary embolism (PE).

Methods

In this study, consecutive patients with first-episode acute PE were followed for ≤5 years. Pulmonary hypertension (PH) was screened for by echocardiography. Suspected cases were evaluated by right heart catheterization (RHC) and pulmonary angiography (PA). If invasive procedures were not permitted, PH was diagnosed by systolic pulmonary artery pressure (SPAP) >50 mmHg. Diagnosis of CTEPH was confirmed by PA, ventilation/perfusion (V/Q) lung scan, or computed tomography (CT) PA (CTPA).

Results

Overall, 614 patients with acute PE were included (median follow-up, 3.3 years). Ten patients were diagnosed with CTEPH: cumulative incidence 0.8% [95% confidence interval (CI), 0.0-1.6%] at 1 year, 1.3% (95% CI, 0.3-2.3%) at 2 years, and 1.7% (95% CI, 0.7-2.7%) at 3 years. No cases of CTEPH developed after 3 years. History of lower-limb varicose veins [hazard ratio (HR), 4.3; 95% CI, 1.2-15.4; P=0.024], SPAP >50 mmHg at initial PE episode (HR, 23.5; 95% CI, 2.7-207.6; P=0.005), intermediate-risk PE (HR, 1.2; 95% CI, 1.0-1.4; P=0.030), and CT obstruction index over 30% at 3 months after acute PE (HR, 42.5; 95% CI, 4.4-409.8; P=0.001) were associated with increased risk of CTEPH.

Conclusions

CTEPH was not rare after acute PE in this Chinese population, especially within 3 years of diagnosis. Lower-limb varicose veins, intermediate-risk PE with elevated SPAP in the acute phase, and residual emboli during follow-up might increase the risk of CTEPH.     

The post-PE syndrome: a new concept for chronic complications of pulmonary embolism

Long-term follow-up studies have consistently demonstrated that after an episode of acute pulmonary embolism (PE), half of patients report functional limitations and/or decreased quality of life up to many years after the acute event. Incomplete thrombus resolution occurs in one-fourth to one-third of patients. Further, pulmonary artery pressure and right ventricular function remain abnormal despite adequate anticoagulant treatment in 10–30% of patients, and 0.5–4% is diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH) which represents the most severe long term complication of acute PE. From these numbers, it seems that CTEPH itself is the extreme manifestation of a much more common phenomenon of permanent changes in pulmonary artery flow, pulmonary gas exchange and/or cardiac function caused by the acute PE and associated with dyspnea and decreased exercise capacity, which in analogy to post-thrombotic syndrome after deep vein thrombosis could be referred to as the post-pulmonary embolism syndrome. The acknowledgement of this syndrome would both be relevant for daily clinical practice and also provide a concept that aids in further understanding of the pathophysiology of CTEPH. In this clinically oriented review, we discuss the established associations and hypotheses between the process of thrombus resolution or persistence, lasting hemodynamic changes following acute PE as well as the consequences of a PE diagnosis on long-term physical performance and quality of life.     

Impact of morphologic characteristics of central pulmonary thromboemboli in massive pulmonary embolism

STUDY OBJECTIVE: To assess the impact of morphologically different central pulmonary artery thromboemboli in patients with massive pulmonary emboli (MPEs) on short-term outcome. DESIGN: A prospective registry of consecutive patients. SETTING: An 11-bed closed medical ICU at a 860-bed community general hospital PATIENTS: Forty-seven patients with shock or hypotension due to MPE and central pulmonary thromboemboli detected by transesophageal echocardiography who were treated with thrombolysis between January 1994 and April 2000. PROCEDURES: Patients were divided into two groups according to the following characteristics of the detected thromboemboli: group 1, thrombi with one or more long, mobile parts; and group 2, immobile thrombi. Right heart catheterization was performed. RESULTS: The incidence of both types of thromboemboli was comparable. Groups 1 and 2 showed no differences in demographic data, risk factors for pulmonary embolism, length of preceding clinical symptoms, percentage of patients in shock, hemodynamic variables, serum lactate levels on hospital admission, and treatment. Seven fatal cases due to obstructive shock and right heart failure were present in group 2, but none were present in group 1 (7 of 23 patients vs 0 of 24 patients, respectively; p < 0.05). At 12 h, the cardiac index was lower in group 2 than in group 1 (2.6 +/- 1.0 vs 3.1 +/- 0.9 L/min/m(2), respectively; p < 0.05), and the central venous pressure (15.0 +/- 6.2 vs 12.5 +/- 3.7 mm Hg, respectively; p < 0.05) and total pulmonary resistance (12.9 +/- 5.9 vs 8.6 +/- 2.7 mm Hg/L/min/m(2), respectively; p < 0.001) were higher in group 2 compared to group 1. On hospital admission, inclusion in group 2 (p < 0.03; hazard ratio, 9.53; 95% confidence interval [CI], 1.19 to 76.47) and preexisting chronic medical or neurologic disease (p < 0.01; hazard ratio, 16.4; 95% CI, 1.97 to 136.3) were independent predictors of 30-day mortality. CONCLUSION: On hospital admission, morphology of the thromboemboli and the presence of pre-existing chronic medical or neurologic disease are independent predictors of 30-day mortality. Patients with immobile central pulmonary thromboemboli have a worse short-term outcome than those with mobile central pulmonary thromboemboli.     

Residual emboli on lung perfusion scan or multidetector computed tomography after a first episode of acute pulmonary embolism

The rate of resolution of a first episode of pulmonary embolism (PE) is uncertain. A baseline test indicating any residual PE is pivotal in aiding a more accurate diagnosis of recurrent PE. This study aimed to assess the rate and risk factors of residual PE with either multidetector computed tomography imaging (MDCT) or lung perfusion scan (LPS) using a cross-sectional study in which consecutive patients were enrolled with a first objectively documented episode of symptomatic PE, and who were considered for possible treatment withdrawal after at least 3 months of anticoagulation. A first cohort of patients (n = 80) underwent MDCT, while the subsequent cohort (n = 93) underwent LPS. The two cohorts had similar characteristics, and 98.3% of patients had non high-risk index PE. MDCT detected residual PE in 15% of subjects (12/80, 95% CI 8–25%) after a mean of 9 months of anticoagulation. No clinical characteristics were significantly associated with residual PE at MDCT. LPS detected residual PE in 28% (26/93, 95% CI 19–38%) of patients after a period of a mean of 9 months of anticoagulation with a significant association with increasing age and known pulmonary disease. Resolution of PE was high after a first episode of non high-risk PE treated with heparin followed by at least 3 months of anticoagulation. Age and coexistent pulmonary disease influence the presence of residual PE detected by LPS, but not by MDCT. Further studies are warranted in which the presence of residual embolism is detected by repetition of the same test that had been initially carried out.     

Impact of spiral computed tomography on the diagnosis of pulmonary embolism in a community hospital setting

BACKGROUND: While the optimal role of spiral CT angiography (CTA) in the diagnosis of pulmonary embolism (PE) remains controversial, this technology is already being widely utilized in the community setting. OBJECTIVES: To assess the impact CTA has had on angiography utilization rates and the overall diagnostic rate of PE. METHODS: All patients evaluated for PE during a 4-year period were studied. PE was defined as either a high-probability V/Q scan, a positive conventional angiogram, or a CTA with emboli in the segmental or larger pulmonary vessels. Diagnostic rates of PE per 1,000 hospital admissions were determined and analyzed for time periods before and after the introduction of CTA. CT reports were compared with their concurrent chest radiograph (CXR) reports and additional findings that were not apparent on CXR were abstracted. RESULTS: The diagnostic rate of PE per 1,000 hospital admissions was 1.8 prior to the introduction of CTA and increased to 2.8 per 1,000 admissions after the introduction of CTA (p < 0.0001). Total costs for diagnostic testing per PE diagnosis made went from US 2,518 dollars to US 2,572 dollars. While the number of PE diagnosed by V/Q scan remained constant, the number of PE diagnosed by conventional angiography decreased while the number diagnosed by CTA increased. In patients with intermediate probability V/Q scan results, the percentage of patients receiving subsequent angiography (conventional or CTA) increased from 17 to 26% (p = 0.043). When conventional angiography was performed, CT imaging of the chest still had to be ordered for other reasons 38% of the time. Additional information was obtained in 78% of cases when CTA was performed. CONCLUSIONS: Increased utilization of CTA was associated with an increase in angiography utilization rates and diagnostic rates of PE, was cost effective, and often provided additional, useful, and unanticipated diagnostic information.     

Incidence of pulmonary embolism in non-critically ill COVID-19 patients. Predicting factors for a challenging diagnosis

Recent studies suggest that thrombotic complications are a common phenomenon in the novel SARS-CoV-2 infection. The main objective of our study is to assess cumulative incidence of pulmonary embolism (PE) in non critically ill COVID-19 patients and to identify its predicting factors associated to the diagnosis of pulmonary embolism. We retrospectevely reviewed 452 electronic medical records of patients admitted to Internal Medicine Department of a secondary hospital in Madrid during Covid 19 pandemic outbreak. We included 91 patients who underwent a multidetector Computed Tomography pulmonary angiography(CTPA) during conventional hospitalization. The cumulative incidence of PE was assessed ant the clinical, analytical and radiological characteristics were compared between patients with and without PE. PE incidence was 6.4% (29/452 patients). Most patients with a confirmed diagnosed with PE recieved low molecular weight heparin (LMWH): 79.3% (23/29). D-dimer peak was significatly elevated in PE vs non PE patients (14,480 vs 7230 mcg/dL, p?=?0.03). In multivariate analysis of patients who underwent a CTPA we found that plasma D-dimer peak was an independen predictor of PE with a best cut off point of?>?5000 µg/dl (OR 3.77; IC95% (1.18–12.16), p?=?0.03). We found ninefold increased risk of PE patients not suffering from dyslipidemia (OR 9.06; IC95% (1.88–43.60). Predictive value of AUC for ROC is 75.5%. We found a high incidence of PE in non critically ill hospitalized COVID 19 patients despite standard thromboprophylaxis. An increase in D-dimer levels is an independent predictor for PE, with a best cut-off point of?>?5000 µg/ dl.

     

Role of clinical and pulmonary computed tomography angiographic parameters in the prediction of short- and long-term mortality in patients with pulmonary embolism

The utility of pulmonary computed tomography angiography (CTA) in the prediction of short- and long-term outcomes after pulmonary embolism (PE) is controversial. Between November 2011 and September 2014, 190 normotensive patients (age, 61 ± 16.90 years, 53.7 % female) were diagnosed with acute PE using a 128-slice dual-source pulmonary CTA scanner. All the related clinical and cardiovascular measurements were recorded. Primary endpoints were 30-day PE-related death, 30-day composite complications (death, hemodynamic instability, thrombolysis and thrombectomy, inotrope, and mechanical ventilation use), and long-term all-cause mortality during a median follow-up of 14.78 months. Overall 1-month mortality is 5.8 %, and death is PE-related in 4.7 % of total patients. Although non-significant, O₂ saturation <90 % and the right ventricular short-axis to left ventricular short-axis diameters (RV/LV) ratio increase the risk of PE-related death by 3.5 and 2 times, respectively. The independent predictors of 30-day complications (15.8 %) are O₂ saturation <90 % (OR: 3.924, 95 % CI 1.505–10.229), RV/LV ratio (OR: 3.018, 95 % CI 1.455–6.263), and heart rate ≥110 beats/min (OR: 2.607, 95 % CI 1.063–6.391). For long-term mortality (13.7 %), O₂ saturation <90 % is an independent predictor (HR: 4.454, 95 % CI 2.016–8.862). The independent impact of the RV/LV ratio on the long-term mortality has a trend towards statistical significance (HR: 1.762, 95 % CI 0.968–4.218; p value = 0.064). The PE-related death is 4.7 % within 30 days after admisson and 13.7 % after a median follow-up of 14 months. Among the pulmonary CTA parameters, only the RV/LV ratio and among the clinical and paraclinical measures, O₂ saturation <90 % remain independent predictors of short- and long-term mortality and complications after the diagnosis of PE.     

Extensive pulmonary arterial thrombi in situ in association with atrial septal defect.

A 48-year-old woman with cyanosis was referred for investigation of atrial septal defect (ASD). Blood gas analysis on admission revealed moderate hypoxemia, and a pressure study during right heart catheterization revealed pulmonary hypertension (PH). Spiral computed tomography (CT) scan disclosed extensive thrombi in dilated large symmetrical pulmonary arteries with clear lung fields, and large strand-like thrombi on the inner surface of the pulmonary arterial wall along the vascular curvature were visualized by virtual CT angioscopic imaging. The thrombi were eventually considered to be not thromboemboli but thrombi in situ, because no segmental or larger defects were detected in the lung perfusion scan, although it showed cardiovascular imprints and an inhomogeneously decreased perfusion pattern. Pulmonary thrombi in situ are an uncommon manifestation in patients with ASD, and have not been described from the evidence of both CT and lung perfusion scans. The findings indicate that pulmonary thrombi in situ are not associated with occlusion of the large pulmonary arteries and the resultant development of PH. The patient was conservatively treated with medication, and the pulmonary thrombi did not show significant change with anticoagulant therapy. She died suddenly at the age of 51 years.     

Prevalence of pulmonary embolism in patients with obstructive sleep apnea and chronic obstructive pulmonary disease: The overlap syndrome

ObjectiveGrowing evidence indicates that both obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) may be closely associated with the prevalence of pulmonary embolism (PE). However, the relationship of overlap syndrome (OS) (coexistence of OSA and COPD) with PE is unclear. The purpose of this study was to investigate whether OS were associated with increased PE prevalence.MethodsWe performed a retrospective chart review of patients who underwent sleep study at Beijing An Zhen Hospital from 2011 to 2014. The association of OS with PE prevalence was estimated by using logistic regression models.ResultsIn contrast to control patients (neither OSA nor COPD), those subjects with OS had higher odds of PE (OR9.61; 95%CI 4.02–21.31, p < 0.001) with significance persisting after adjusting for covariates (OR 5.66; 95%CI 1.80–16.18, p = 0.004). Meanwhile, patients with OS compared with those with isolated OSA also had significantly higher odds of PE in univariate (OR 4.79; 95%CI 2.04–10.33, p = 0.0007) and adjusted models (OR 3.89; 95%CI 1.27–10.68, p = 0.019). In subgroup analysis, patients with OS had higher odds of PE than control group among male subjects (OR 8.12, 95%CI1.86–31.87, p = 0.007) and patients ≥ 58years (OR 5.50, 95%CI 1.51–18.14, p = 0.012) in multivariable models. Percentage of total sleep time with saturation lower than 90% (T90) ≥ 2.6% was significantly associated with prevalence of PE (OR 4.72, 95%CI1.34–19.83, p = 0.015) in subgroup of patients older than 58.ConclusionsOS is independently associated with PE prevalence. Longitudinal studies are needed to better understand the relationship with incident PE.     

Percutaneous Vacuum-Assisted Thrombectomy Using AngioVac Aspiration System

BackgroundSurgical embolectomy and thrombolytic therapy are two common approaches for the treatment of large intra-cardiac or intravascular thrombi to prevent new or worsening pulmonary embolism (PE). Considering high operative mortality with surgical embolectomy and high bleeding risk with thrombolytic therapy, patients who are poor candidates for these treatments may benefit from percutaneous aspiration thrombectomy/Vacuum-assisted thrombectomy (VAT). AngioVac aspiration system was granted 510(k) clearance by the United States Food and Drug Administration (FDA) in April 2009. We present a case series to describe its use and outcomes in evacuating large caval thrombi or intracardiac masses.MethodsWe did a retrospective analysis of AngioVac catheter based thrombectomy in 16 consecutive patients treated between January 2016 and January 2019 to report case characteristics and in-hospital clinical outcomes.ResultsSixteen patients (mean age 48) underwent 16 AngioVac procedures over 48 months. Indications included intracardiac mass (68.8%), caval thrombus (56.3%), and catheter associated thrombus (43.8%). 7 (43.8%) patients had concurrent PE. Peri-procedure mortality was 0% and in-hospital mortality was 12.5% at a mean follow-up of 14 days. There were no pulmonary hemorrhages, strokes or myocardial infarctions. 62.5% had a significant drop in hemoglobin, which required a blood transfusion but there was no episode of overt bleeding.ConclusionThe AngioVac aspiration system has been shown to be effective at aspirating large volumes of intravascular and intracardiac thrombus. It is a reasonable alternative to surgical thrombectomy in patients with large central thrombi or masses in-transit who are at risk of complicated PE.     

Initial thrombolysis treatment compared with anticoagulation for acute intermediate-risk pulmonary embolism: a meta-analysis

Background

The use of thrombolysis in patients with acute, intermediate-risk pulmonary embolism (PE) remains controversial. This meta-analysis compared the efficacy and safety of thrombolysis and anticoagulation treatments for intermediate-risk PE patients.

Methods

Two investigators independently reviewed the literature and collected data from randomized controlled trials (RCTs) of thrombolysis for intermediate-risk PE in the PubMed, MEDLINE, EMBASE, the Cochrane Library, and Chinese Biomedical Literature Databases (CBM).

Results

A total of 1,631 intermediate-risk PE patients from seven studies were included. Significant differences were not found regarding the 30-day, all-cause mortality rates between the thrombolytic and anticoagulant groups [odds ratio (OR), 0.60; 95% confident interval (CI), 0.34-1.06; P=0.08]. The rate of clinical deterioration in the thrombolytic group was lower than that in the anticoagulant group (OR, 0.27; 95% CI, 0.18-0.41; P<0.01). Recurrent PE in the thrombolytic group was also significantly lower than that in the anticoagulant group (OR, 0.34; 95% CI, 0.15-0.77; P=0.01). Comparing the thrombolytic and anticoagulation groups, the incidence of minor bleeding was significantly higher in the thrombolytic group (OR, 5.33; 95% CI, 2.85-9.97; P<0.00001), but there were no difference in the incidences of major bleeding events (OR, 2.07; 95% CI, 0.60-7.16; P=0.25).

Conclusions

Thrombolytic treatment for intermediate-risk PE patients, if not contraindicated, could reduce clinical deterioration and recurrence of PE, and trends towards a decrease in all-cause, 30-day mortality. Despite thrombolytic treatment having an increased total bleeding risk, there was no difference in the incidence of major bleeding events, compared with patients receiving anticoagulation treatment.     

Clinical suspicion of autopsy-proven thrombotic and tumor pulmonary embolism in cancer patients

Cancer patients are prone to both thrombotic and tumor pulmonary embolism (PE). To identify similarities and differences in their clinical features, we reviewed all autopsies from 1978 to 1982 at Brigham and Women's Hospital and the Dana Farber Cancer Institute. Of 73 patients with solid malignant tumors and PE, 56 had major thrombotic PE and 17 had major tumor embolism to the lungs. Of the 56 with cancer and thrombotic PE, 25 (45%) had the correct diagnosis suspected antemortem. By contrast, only 1 of 17 (6%) patients with tumor embolism was diagnosed correctly antemortem (p = 0.005). Most presenting symptoms, signs, laboratory values, and associated conditions were not markedly different in patients with thrombotic PE and tumor embolism. These findings indicate that tumor PE is more difficult to diagnose clinically and may be misdiagnosed as thrombotic PE. Finally, these data suggest that in all cancer patients, the presence of both thrombotic and tumor PE should be considered because of similarities in their clinical features.     

Angioscopic Detection of Pulmonary Thromboemboli: with Special Reference to Comparison with Angiography,Intravascular Ultrasonography,and Computed Tomography Angiography

Introduction: Pulmonary embolism (PE) is often fatal and its incidence is increasing worldwide. Detection of thromboemboli (TEi) is essential for a definitive diagnosis of PE. The detection of TEi using most imaging methods is low in patients clinically suspected of having PE. This study was carried out to detect TEi in the pulmonary arterial trees by angioscopy (AS); to classify TEi; and to compare the sensitivity of detection for TEi among AS, angiography (AG), intravascular ultrasonography (IVUS), and computed tomography angiography (CTA) in patients with clinically suspected PE. Methods: After CTA, AG, and IVUS, the pulmonary arterial trees were surveyed by AS in 49 patients clinically suspected of having PE. Results: TEi were found by AS, AG, IVUS, and CTA in 81.6%, 24.4%, 34.8%, and 22.5% of 49 patients, respectively. The 48 TEi classified by AS were globular (35%), mural (10%), cap‐like (8%), web‐like (4%), patchy (33%), and micro (18%). Cap‐like, patchy, and micro‐TEi were not detectable by AG, IVUS, and CTA in any subjects. TEi color was classified as red, white, yellow, and red‐and‐yellow in a mosaic pattern in 10%, 31%, 38%, and 18%, respectively. Red and white globular TEi were observed in acute, and red‐and‐yellow TEi in both acute and chronic PE patients. TEi other than globular were observed in both patient groups. Conclusion: Although invasive, AS is superior to AG, IVUS, and CTA for the detection of TEi, and therefore is a helpful imaging method for the definitive diagnosis of PE. (J Interven Cardiol 2010;23:470–478)