scholarly journals Pulmonary Embolism in COVID-19 Patients: Facts and Figures

2021 ◽  
Author(s):  
Nissar Shaikh ◽  
Narges Quyyum ◽  
Arshad Chanda ◽  
Muhammad Zubair ◽  
Muhsen Shaheen ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Point Of Care ◽  
Pulmonary Arteries ◽  
Pulmonary Angiography ◽  
Standard Test ◽  
Plasma Therapy ◽  
Therapeutic Anticoagulation ◽  
Increased Risk ◽  
Lower Mobility ◽  
Von Willebrand

COVID-19 infection affects many systems in the body including the coagulation mechanisms. Imbalance between pro-coagulant and anticoagulant activities causes a roughly nine times higher risk for pulmonary embolism (PE) in COVID-19 patients. The reported incidence of PE in COVID-19 patients ranges from 3 to 26%. There is an increased risk of PE in hospitalized patients with lower mobility and patients requiring intensive care therapy. Obesity, atrial fibrillation, raised pro-inflammatory markers, and convalescent plasma therapy increases the risk of PE in COVID-19 patients. Endothelial injury in COVID-19 patients causes loss of vasodilatory, anti-adhesion and fibrinolytic properties. Viral penetration and load leads to the release of cytokines and von Willebrand factor, which induces thrombosis in small and medium vessels. D-dimers elevation gives strong suspicion of PE in COVID-19 patients, and normal D-dimer levels effectively rule it out. Point of care echocardiogram may show right heart dilatation, thrombus in heart or pulmonary arteries. DVT increases the risk of developing PE. The gold standard test for the diagnosis of PE is CTPA (computerized tomographic pulmonary angiography) which also gives alternative diagnosis in the absence of PE. Therapeutic anticoagulation is the corner stone in the management of PE and commonly used anticoagulants are LMWH (low molecular weight heparin) and UFH (unfractionated heparin). Mortality in COVID-19 patients with PE is up to 43% compared to COVID patients without PE being around 3%.

scholarly journals Pulmonary embolism severity before and during the COVID-19 pandemic

2021 ◽  
pp. 20210264
Author(s):  
Vicky Tilliridou ◽  
Rachael Kirkbride ◽  
Rebecca Dickinson ◽  
James Tiernan ◽  
Guo Liang Yong ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Frequency ◽  
Pulmonary Angiography ◽  
Demographic Information ◽  
Right Heart ◽  
Computed Tomography Pulmonary Angiography ◽  
Health Records ◽  
Retrospective Audit ◽  
Increased Risk ◽  
Age And Sex

Objectives: Early in the coronavirus 2019 (COVID-19) pandemic, a high frequency of pulmonary embolism was identified. This audit aims to assess the frequency and severity of pulmonary embolism in 2020 compared to 2019. Methods: In this retrospective audit, we compared computed tomography pulmonary angiography (CTPA) frequency and pulmonary embolism severity in April and May 2020, compared to 2019. Pulmonary embolism severity was assessed with the Modified Miller score and the presence of right heart strain was assessed. Demographic information and 30-day mortality was identified from electronic health records. Results: In April 2020, there was a 17% reduction in the number of CTPA performed and an increase in the proportion identifying pulmonary embolism (26%, n = 68/265 vs 15%, n = 47/320, p < 0.001), compared to April 2019. Patients with pulmonary embolism in 2020 had more comorbidities (p = 0.026), but similar age and sex compared to 2019. There was no difference in pulmonary embolism severity in 2020 compared to 2019, but there was an increased frequency of right heart strain in May 2020 (29 vs 12%, p = 0.029). Amongst 18 patients with COVID-19 and pulmonary embolism, there was a larger proportion of males and an increased 30 day mortality (28% vs 6%, p = 0.008). Conclusion: During the COVID-19 pandemic, there was a reduction in the number of CTPA scans performed and an increase in the frequency of CTPA scans positive for pulmonary embolism. Patients with both COVID-19 and pulmonary embolism had an increased risk of 30-day mortality compared to those without COVID-19. Advances in knowledge: During the COVID-19 pandemic, the number of CTPA performed decreased and the proportion of positive CTPA increased. Patients with both pulmonary embolism and COVID-19 had worse outcomes compared to those with pulmonary embolism alone.

scholarly journals Symptomatic subsegmental pulmonary embolism: to treat or not to treat?

Hematology ◽  
2017 ◽  
Vol 2017 (1) ◽  
pp. 237-241 ◽  
Author(s):  
Marc Carrier ◽  
Fredrikus A. Klok
Keyword(s):  
Pulmonary Embolism ◽  
Anticoagulation Therapy ◽  
Pulmonary Arteries ◽  
Clinical Importance ◽  
Case Fatality ◽  
Pulmonary Angiography ◽  
Significant Rise ◽  
Computed Tomographic ◽  
Individualized Approach ◽  
Computed Tomographic Pulmonary Angiography

Abstract The introduction of computed tomographic pulmonary angiography and its recent increasing availability has led to a significant rise in its use to help clinicians diagnose acute pulmonary embolism (PE). This has led to a significant increase in the incidence of PE diagnoses. Simultaneously, the case fatality rate of acute PE has been decreasing and no significant change in its mortality has been noted, suggesting that the additional PE diagnoses are less severe and these patients might not benefit from anticoagulation therapy. This also seems to be correlated with an increase in the diagnosis of PE localized in the subsegmental pulmonary arteries (subsegmental pulmonary embolism [SSPE]). The clinical importance of SSPE is unclear. Whereas some studies have shown that it might be reasonable to manage patients with SSPE without anticoagulation, others have not. Although the current medical literature is limited, it suggests that a subgroup of patients with SSPE might be safely managed without the use of anticoagulant therapy. Current clinical practice guidelines suggest that clinicians take an individualized approach after carefully assessing the risk/benefit ratio for patients with SSPE and negative leg limb ultrasonography results. Prospective studies are ongoing and results are eagerly awaited to help tailor the management of this patient population.

Beyond the Pulmonary Arteries: Alternative Diagnoses in Children With MDCT Pulmonary Angiography Negative for Pulmonary Embolism

2009 ◽  
Vol 193 (3) ◽  
pp. 888-894 ◽  
Author(s):  
Edward Y. Lee ◽  
Supika Kritsaneepaiboon ◽  
David Zurakowski ◽  
Claudia Martinez Rios Arellano ◽  
Keith J. Strauss ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Arteries ◽  
Pulmonary Angiography

Outcome of Saddle Pulmonary Embolism: A Nested Case-Control Study.

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 1102-1102
Author(s):  
Gauruv Bose ◽  
Esteban Gandara ◽  
Marc Carrier ◽  
Petra MG Erkens ◽  
Marc Rodger ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Pulmonary Embolism ◽  
Systolic Blood Pressure ◽  
Conflicts Of Interest ◽  
Management Strategies ◽  
Pulmonary Arteries ◽  
Pulmonary Angiography ◽  
Control Group ◽  
P Value ◽  
Case Group

Abstract Abstract 1102 Introduction: The management of saddle pulmonary embolism (PE) is controversial. Evidence about outcomes and management strategies is scarce in the literature due to the small prevalence of saddle PE. Historically it has been recommended that this group of patients should be treated aggressively. Purpose: To determine the prevalence and outcomes of patients diagnosed with saddle PE. Methods: Retrospective cohort study of consecutive patients with saddle PE diagnosed at the Ottawa Hospital between January 2007 and December 2008. Patients were included if a thrombus was present on computed tomographic pulmonary angiography (CTPA) in the main pulmonary arteries spanning the bifurcation of the main pulmonary trunk. These cases were each matched with two non-saddle controls with proximal PE (thromboemboli in the main pulmonary arteries) based on age, sex, systolic blood pressure greater than or less than 90 mmHg, and the presence or absence of cancer. Demographics, prognostic factors, treatment, and outcomes were collected. Patients were followed over a 30 day period following the diagnosis. RESULTS: A total of 32 (5%) of 724 patients with PE had a saddle event. Baseline characteristics are depicted in Table 1. Differences between the saddle case group and non-saddle control group include the presence of right ventricular dilation (59% of saddle cases vs. 22% of controls, p-value: 0.0007) and in the proportion of patients managed as outpatients (7% of saddle cases vs. 33% of controls, p-value: 0.02). At 30 days no differences were found in patients with saddle PE or proximal PE for all cause mortality (6% vs. 10%; OR: 0.64; 95% CI: 0.08–3.2), PE related mortality (0% vs. 6%; OR: 0.52; 95% CI: 0.01–6.1), major bleeding (3% vs. 5%; OR: 0.65; 95% CI: 0.02–6.4), or recurrent venous thromboembolism (6% vs. 10%; OR: 0.64; 95% CI: 0.08–3.2). Conclusions: Patients with saddle PE do not have a worse 30-day prognosis than patients with proximal PE matched by age, sex, systolic blood pressure, and presence of cancer. Disclosures: No relevant conflicts of interest to declare.

CT pulmonary angiography in lower limb arthroplasty

2018 ◽  
Vol 100-B (7) ◽  
pp. 938-944 ◽  
Author(s):  
P. N. Karayiannis ◽  
J. C. Hill ◽  
C. Stevenson ◽  
S. Finnegan ◽  
L. Armstrong ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Total Knee Arthroplasty ◽  
Lower Limb ◽  
Medical Records ◽  
Pulmonary Angiography ◽  
Ct Pulmonary Angiography ◽  
Main Indication ◽  
Primary Arthroplasty ◽  
Therapeutic Anticoagulation ◽  
Total Knee

AimsThe aims of this study were to determine the indications and frequency of ordering a CT pulmonary angiography (CTPA) following primary arthroplasty of the hip and knee, and to determine the number of positive scans in these patients, the location of emboli and the outcome for patients undergoing CTPA.Patients and MethodsWe analyzed the use of CTPA, as an inpatient and up to 90 days as an outpatient, in a cohort of patients and reviewed the medical records and imaging for each patient undergoing CTPA.ResultsOut of 11 249 patients, scans were requested in 229 (2.04%) and 86 (38%) were positive. No patient undergoing CTPA died within 90 days. The rate of mortality from pulmonary embolism (PE) overall was 0.08%. CTPA was performed twice as often following total knee arthroplasty (TKA) compared with total hip arthroplasty (THA), and when performed was twice as likely to be positive. Hypoxia was the main indication for a scan, being the indication in 149 scans (65%); and in 23% (11 of 47), the PE was peripheral and unilateral. Three patients suffered complications resulting from therapeutic anticoagulation for possible PE, two of whom had a negative CTPA.ConclusionCTPA is more likely to be performed following TKA compared with THA. Hypoxia was the main presenting feature of PE. A quarter of PEs which were diagnosed were unilateral and peripheral. Further study may indicate which patients who have a PE after lower limb arthroplasty require treatment, and which can avoid the complications associated with anticoagulation. Cite this article: Bone Joint J 2018;100-B:938–44.

Negative spiral CT in acute pulmonary embolism

2002 ◽  
Vol 43 (5) ◽  
pp. 486-491 ◽  
Author(s):  
T. Nilsson ◽  
A. Olausson ◽  
H. Johnsson ◽  
U. Nyman ◽  
P. Aspelin
Keyword(s):  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Pulmonary Arteries ◽  
Negative Contrast ◽  
Spiral Ct ◽  
Pulmonary Angiography ◽  
Diagnostic Quality ◽  
Anticoagulation Treatment ◽  
Acute Pe

Purpose: To retrospectively evaluate the clinical outcome of non-anticoagulated patients with clinically suspected acute pulmonary embolism (PE) and no symptoms or signs of deep venous thrombosis (DVT) following a negative contrast medium-enhanced spiral CT of the pulmonary arteries (s-CTPA). Material and Methods: During a 24-month period, 739 of 751 patients underwent s-CTPA with acceptable diagnostic quality for clinically suspected acute PE. All patients who had a CT study not positive for PE were followed up with a questionnaire, a telephone interview and review of all medical reports, including autopsies and death certificates for any episodes of venous thromboembolism (VTE) during a 3-month period. Results: PE was diagnosed in 158 patients. Of the remaining 581 patients with a negative s-CTPA, 45 patients were lost to follow-up. 88 patients were excluded because of anticoagulation treatment (cardiac disorder n=32, chronic VTE or acute symptomatic DVT n=31, PE diagnosed at pulmonary angiography n=1, thrombus prophylaxis during diagnostic work-up or other reasons than VTE n=24) and 7 patients undergoing lower extremity venous studies because of symptoms of DVT (all negative). Thus, 441 patients with a negative s-CTPA and no DVT symptoms, venous studies or anticoagulant treatment constituted the follow-up cohort. Four of these patients had proven VTE (all PE) during the 3-month follow-up period. Two of the PE episodes contributed to the patient's death. Conclusion: Patients with clinically suspected acute PE, no symptoms or signs of DVT and a negative single slice s-CTPA using 3–5 mm collimation, may safely be left without anticoagulation treatment unless they are critically ill, have a limited cardiopulmonary reserve and/or if a high clinical suspicion remains.

scholarly journals Non-surgical management of an abrupt cavitation and large oval-shaped lung abscess secondary to acute thromboembolic pulmonary infarction: a case report

2021 ◽  
Vol 49 (8) ◽  
pp. 030006052110316
Author(s):  
Guofeng Ma ◽  
Dan Wang ◽  
Chao Yan ◽  
Liang Li ◽  
Xiaoling Xu ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Rare Complication ◽  
Pulmonary Arteries ◽  
Surgical Excision ◽  
Pulmonary Angiography ◽  
Lung Abscess ◽  
Ct Pulmonary Angiography ◽  
Pulmonary Infarction ◽  
Once Daily ◽  
Non Surgical Treatment

Infected cavitating pulmonary infarction is a rare complication of pulmonary embolism with a high mortality rate. Surgical excision for this complication has been used in past decades. Abrupt cavitation and a large oval-shaped lung abscess caused by acute thromboembolic pulmonary infarction during anticoagulation are rare. We present a 70-year-old man who suffered from pleuritic pain and breathlessness, accompanied by nausea and vomiting for 1 day. A physical examination showed tachycardia and tachypnea with moist rales in the left upper chest. High D-dimer levels, leukocytosis, respiratory failure and left upper lobe consolidation were found on plain computed tomography (CT). CT pulmonary angiography was performed 2 days after the previous CT scan because pulmonary embolism was suspected. This scan showed emboli in the main, right upper, middle, lower and left upper pulmonary arteries with deteriorated left upper lobe consolidation and cavitation. Thromboembolic pulmonary infarction and an abscess were diagnosed. Enoxaparin 60 mg was administered every 12 hours for 10 days, followed by rivaroxaban, antibiotics and drainage of the hydrothorax. The patient improved after the strategy of non-surgical treatment and was discharged approximately 1 month later. The patient had an uneventful course during rivaroxaban 20 mg once daily for 1 year.

Saddle pulmonary embolism on non-contrast CT

2021 ◽  
Vol 8 (2) ◽  
pp. 76-79
Author(s):  
Bilal Chaudhry ◽  
Kirill Alekseyev ◽  
Lidiya Didenko ◽  
Gennadiy Ryklin ◽  
David Lee
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Arteries ◽  
Pulmonary Angiography ◽  
Pleuritic Chest Pain ◽  
History Of ◽  
Chest X Ray ◽  
Jugular Venous Distension ◽  
Low Probability ◽  
The Right ◽  
Contrast Ct

Background: A saddle pulmonary embolism (PE) is a large embolism that straddles the bifurcation of the pulmonary trunk. This PE extends into the right and left pulmonary arteries. There is a greater incidence in males. Common features of a PE include dyspnea, tachypnea, cough, hemoptysis, pleuritic chest pain, tachycardia, hypotension, jugular venous distension, and severe cases Kussmaul sign. The Wells criteria for PE is used as the pretest probability. Diagnostics include D-dimer levels, CT pulmonary angiography (CTPA), ventilation/perfusion scintigraphy (V/Q scan), echocardiography, lower extremity venous ultrasound, chest x-ray, pulmonary angiography, and electrocardiography (ECG). Case description: We present a 65-year-old male that presented with a two-week history of dyspnea with non-radiating intermittent chest pressure. Initial V/Q scan showed a low probability for PE, but a subsequent non-contrast CT revealed that he indeed had a saddle PE.

Use of Computed Tomography Pulmonary Angiography for Suspected Pulmonary Embolism in Patients with Malignancy- a Single Center Experience

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 5907-5907
Author(s):  
Sravanthi Ravulapati ◽  
Cerena K Leung ◽  
Mudresh R Mehta ◽  
Kara M Christopher ◽  
Susan K. Woelich ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Emergency Department ◽  
Pulmonary Embolism ◽  
Conflicts Of Interest ◽  
Tertiary Care ◽  
Pulmonary Angiography ◽  
Screening Tools ◽  
Intermediate Risk ◽  
Computed Tomography Pulmonary Angiography ◽  
Increased Risk

Abstract Background: Pulmonary embolism (PE) is a potentially lethal condition commonly suspected in patients with malignancy. Computed Tomography Pulmonary Angiography (CTPA) is increasingly used in the diagnosis of PE, and guidelines have incorporated various screening tools including the Modified Geneva and Wells criteria to facilitate exclusion of pulmonary embolism. There is an increased risk of venous thromboembolism in patients with active malignancy and therefore an increased suspicion in patients who present to the emergency department (ED) with concerning symptoms. Methods: This is a retrospective analysis at a single tertiary care institution. All patients initially diagnosed with an active malignancy since 2005 and underwent a CTPA between January 2010 and October 2015 were reviewed. Patients were excluded if the CTPA was performed in the setting of trauma, a history of benign malignancy, or if the diagnosis of malignancy was made subsequent to the CTPA. Data collected included patient demographics, clinical presentation, type of malignancy and treatment regimen received. The modified Geneva and Wells criteria were applied to all patients independent from the initial ED risk assessment for a PE. Results: There were 796 patient records reviewed, of which 162 patients met inclusion criteria. Out of these 162 patients, only 8 (4.9%) were found to have a pulmonary embolism. All patients with a positive CTPA had an intermediate risk per the Geneva criteria while only 62.5% had an intermediate risk per the Wells criteria. Of the 154 patients with a negative CTPA, 71.5% and 78.7% had an intermediate risk; 22.5% and 18.7% were classified as low risk based on Wells and Geneva criteria, respectively. The median age of patients was 59 years old, and the majority were male (58%). The most common malignancies in which a CTPA was ordered were lung cancer (27.7%) followed by breast cancer (14.9%) and prostate cancer (6.8%). Despite a negative CTPA, 82 out of 154 patients (53%) were admitted to the hospital. Conclusion: Pulmonary embolism is commonly associated with and frequently suspected in patients with active malignancy. The incidence of PE over a 5-year period in oncology patients was 5% in our emergency department. In total, 18.7% to 22.5% of patients could have avoided a CTPA if scoring was based on the Wells or Geneva criteria. Based on the review at our institution, the modified Geneva and Wells criteria are not adequate, and a new tool needs to be developed for risk stratification for the diagnosis of PE specifically in patients with active malignancy. Disclosures No relevant conflicts of interest to declare.

scholarly journals A near miss: subclinical saddle pulmonary embolism diagnosed by handheld ultrasound

2021 ◽  
Vol 2021 (4) ◽  
Author(s):  
Travis M Skipina ◽  
S Allan Petty ◽  
Christopher T Kelly
Keyword(s):  
Pulmonary Embolism ◽  
Point Of Care ◽  
Pulmonary Arteries ◽  
High Specificity ◽  
Near Miss ◽  
Pulmonary Vasculature ◽  
Point Of Care Ultrasound ◽  
Right Ventricular Strain ◽  
Threatening Condition ◽  
Low Sensitivity

ABSTRACT Introduction: Pulmonary embolism (PE) is a life-threatening condition characterized by occlusive disease of the pulmonary vasculature. Point-of-care ultrasound (POCUS) of right ventricular strain patterns have high specificity and low sensitivity for diagnosis. Here, we describe a patient with a saddle PE and low pre-test probability who was diagnosed primarily by handheld POCUS. Case Report: An 80-year old female was admitted to the intensive care unit with hypotension and lactic acidosis. She also had mild leukocytosis and troponinemia. No other clinical or metabolic abnormalities were present. After transfer to the floor, handheld POCUS demonstrated D-sign and McConnell’s sign. Computed tomography angiography showed a saddle PE involving both main pulmonary arteries. The patient was immediately initiated on anticoagulation without further complications. Conclusion: Handheld POCUS is inexpensive, carries a low risk of harm and is an invaluable extension of the physical exam when interpreted in the appropriate context.

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