Incidence and Clinical Outcomes of Occult Malignancies Detected by Computed Tomographic Pulmonary Angiography in Patients with Acute Pulmonary Embolism.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2983-2983
Author(s):  
Yi-Hao Shen ◽  
Phil Wells ◽  
Carole Dennie ◽  
Marc Carrier
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Outcomes ◽  
Conflicts Of Interest ◽  
Filling Defect ◽  
Pulmonary Angiography ◽  
Advanced Stage ◽  
Ottawa Hospital ◽  
Computed Tomographic ◽  
Occult Malignancy ◽  
Acute Pe

Abstract Abstract 2983 Poster Board II-959 Introduction: Venous thromboembolism (VTE) can be the earliest sign of malignancy. Approximately 10% of patients with unprovoked VTE will be diagnosed with cancer within the next 12 months. Diagnosis of pulmonary embolism (PE) using computed tomographic pulmonary angiograhy (CTPA) allows the visualization of anatomy in addition to thoracic vasculature. Hence, CTPA might be useful for detecting occult cancers in patients with PE. Objective: To evaluate the incidence and clinical outcomes of occult cancers detected by CTPA in patients with acute PE. Methods: This is a retrospective cohort study of consecutive patients with suspected PE undergoing CTPA at the Ottawa Hospital from Jan 1, 2007 to Dec 31, 2008. PE was defined as a subsegmental or larger pulmonary artery filling defect on CTPA. Occult malignancy was defined as any new cancer first detected by CTPA with index PE diagnosis in patients with no known history of malignancy. All patients were followed for a minimum of 6 months after the index PE. Results: A total of 4410 CTPA were reviewed and 748 (17%) were positive for acute PE. Of these, 57 (7.6%; 95% CI: 5.7 to 9.5) revealed abnormalities suggestive of possible occult cancers. Twenty-two (2.9%; 95% CI: 1.7 to 4.2) patients were diagnosed with occult cancers. Among these 22 patients with occult cancers, 20 (91%) had unprovoked PE. Thirteen (59%) patients had occult lung cancer and 16 (73%) had advanced stage (stage 3 or 4) cancers. Sixteen (73%) patients have died following the diagnosis of occult cancer, and their median survival following the diagnosis of PE was 51 days. Conclusion: CTPA detected occult cancers in approximately 3% of patients with acute PE. Most of these cancers were detected at an advanced stage and were associated with high mortality and short survival. Disclosures: No relevant conflicts of interest to declare.

Incidence and Management of Isolated Subsegmental Pulmonary Embolism.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2989-2989
Author(s):  
Yi-Hao Shen ◽  
Phil Wells ◽  
Carole Dennie ◽  
Marc Carrier
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Clinical Management ◽  
High Probability ◽  
Conflicts Of Interest ◽  
Anticoagulation Therapy ◽  
Pulmonary Arteries ◽  
Filling Defect ◽  
Pulmonary Angiography ◽  
Acute Pe

Abstract Abstract 2989 Poster Board II-965 Introduction: The use of computed tomographic pulmonary angiography (CTPA) in patients with suspected pulmonary embolism (PE) has improved the visualization of subsegmental pulmonary arteries. However, the clinical significance of subsegmental PE is unclear. In the PIOPED Study, PE limited to subsegmental pulmonary arteries was most prevalent among patients with low-probability ventilation/perfusion (V/Q) scans. Patients with non-diagnostic (low or intermediate) V/Q scans can be safely managed without anticoagulation. The incidence and clinical management of subsegmental PE remains uncertain. Objective: To evaluate the incidence and clinical management of subsegmental PE in patients with suspected acute PE. Methods: This is a retrospective cohort study of consecutive patients with suspected acute PE undergoing CTPA at the Ottawa Hospital from Jan 1, 2007 to Dec 31, 2008. Subsegmental PE was defined as one or more pulmonary artery filling defects located in the subsegmental level, with no filling defects visualized at more proximal pulmonary artery levels. All patients were followed for a minimum of 6 months after the index PE. Results: A total of 78 (10.4%, 95% CI: 8.4 to 12.8%) cases of subsegmental PE were identified out of 748 cases of PE diagnosed by CTPA. Forty-three (77%) of these had a single isolated subsegmental filling defect. Data could be extracted in 56 (72%) of the 78 cases. Among these 56 patients, 18 (32%) had unprovoked PE. Further investigations were performed in 50 patients (Ultrasonography (U/S) of legs (n=38), U/S and V/Q scan (n=11) or V/Q scan alone (n=1)). Deep vein thrombosis was detected in 12 patients and two patients had a high probability V/Q scan. Forty-eight (86%) patients were anticoagulated. All patients with concurrent DVT or high probability V/Q scan were started on anticoagulation therapy. Two patients experienced a major bleeding episode after anticoagulation. Out of the 8 patients left untreated, there were no recurrent VTE. Conclusion: Isolated subsegmental PE represents approximately 10% of all acute PE diagnosed by CTPA. Patients with subsegmental PE diagnosed on CTPA are more commonly receiving anticoagulation than not. Further studies are needed to establish the risk benefit ratio of anticoagulation therapy in patients with subsegmental PE diagnosed on CTPA. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Right-to-left Ventricular Diameter Ratio At Computed Tomographic Pulmonary Angiography in Patients with Acute Pulmonary Embolism and Obstructive Sleep Apnea

2020 ◽  
Vol 14 ◽  
pp. 117954842097643
Author(s):  
Thomas M Berghaus ◽  
Fabian Geissenberger ◽  
Dinah Konnerth ◽  
Michael Probst ◽  
Thomas Kröncke ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Obstructive Sleep Apnea ◽  
Acute Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Left Ventricular ◽  
Diameter Ratio ◽  
Computed Tomographic ◽  
Obstructive Sleep ◽  
Computed Tomographic Pulmonary Angiography ◽  
Acute Pe

Purpose: Right ventricular (RV) dysfunction in acute pulmonary embolism (PE) is a critical determinant of outcome. Obstructive sleep apnea (OSA) is a common comorbidity of PE and might also affect RV function. Therefore, we sought to investigate RV dysfunction in PE patients in proportion to the severity of OSA by evaluating the right-to-left ventricular (RV/LV) diameter ratio on computed tomographic pulmonary angiography (CTPA). Materials and Methods: 197 PE patients were evaluated for sleep-disordered breathing by portable monitoring and nocturnal polysomnography. RV dilatation was defined as an RV/LV diameter ratio of ⩾ 1.0. Results: RV dilatation was significantly more frequent in OSA patients compared to study participants without OSA (66.4% vs 49.1%, P = .036). Elevated troponin I values, indicating myocardial injury due to acute, PE-related RV strain, were significantly more frequent in OSA patients with an apnea-hypopnea index (AHI) ⩾ 15/h compared to those with an AHI < 15/h (62.1% vs 45.8%, P = .035). However, RV dysfunction documented by the RV/LV diameter ratio on CTPA was not significantly associated with the severity of OSA in multivariable regression analysis. Conclusion: Patients with moderate or severe OSA might compensate acute, PE-related RV strain better, as they are adapted to repetitive right heart pressure overloads during sleep.

scholarly journals Gallium-68 Ventilation/Perfusion PET-CT and CT Pulmonary Angiography for Pulmonary Embolism Diagnosis: An Interobserver Agreement Study

2021 ◽  
Vol 7 ◽  
Author(s):  
Romain Le Pennec ◽  
Amir Iravani ◽  
Beverley Woon ◽  
Brieg Dissaux ◽  
Bibiche Gest ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Interobserver Agreement ◽  
Clinical Information ◽  
Filling Defect ◽  
Pulmonary Angiography ◽  
Ct Scans ◽  
Imaging Tool ◽  
Pet Ct ◽  
Pulmonary Embolism Diagnosis ◽  
Acute Pe

Objectives:68Ga Ventilation/Perfusion V/Q PET-CT is a promising imaging tool for pulmonary embolism diagnosis. However, no study has verified whether the interpretation is reproducible between different observers. The aim of this study was to assess the interobserver agreement in the interpretation of V/Q PET-CT for the diagnosis of acute PE, and to compare it to the interobserver agreement of CTPA interpretation.Methods: Twenty-four cancer patients with suspected acute PE underwent V/Q PET-CT and CTPA within 24 h as part of a prospective pilot study evaluating V/Q PET-CT for the management of patients with suspected PE. V/Q PET-CT and CTPA scans were reassessed independently by four nuclear medicine physicians and four radiologists, respectively. Physicians had different levels of expertise in reading V/Q scintigraphy and CTPA. Interpretation was blinded to the initial interpretation and any clinical information or imaging test result. For each modality, results were reported on a binary fashion. V/Q PET/CT scans were read as positive if there was at least one segmental or two subsegmental mismatched perfusion defects. CTPA scans were interpreted as positive if there was a constant intraluminal filling defect. Interobserver agreement was assessed by calculating kappa (κ) coefficients.Results: Out of the 24 V/Q PET-CT scans, the diagnostic conclusion was concordantly negative in 22 patients and concordantly positive in one patient. The remaining scan was interpreted as positive by one reader and negative by three readers. Out of the 24 CTPA scans, the diagnostic conclusion was concordantly negative in 16 and concordantly positive in one. Out of the seven remaining scans, PE was reported by one reader in four cases, by two readers in two cases, by three readers in one case. Most of discordant results on CTPA were related to clots reported on subsegmental arteries. Mean kappa coefficient was 0.79 for V/Q PET-CT interpretation and 0.39 for CTPA interpretation.Conclusions: Interobserver agreement in the interpretation of V/Q PET-CT for PE diagnosis was substantial (kappa 0.79) in a population with a low prevalence of significant PE. Agreement was lower with CTPA, mainly as a result of discrepancies at the level of the subsegmental arteries.

scholarly journals Is computed tomographic pulmonary angiography justified in all patients with suspected pulmonary embolism – tertiary multidisciplinary hospital perspective

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Morawiec ◽  
O Brycht ◽  
M Nadel ◽  
J Drozdz
Keyword(s):  
Heart Failure ◽  
Pulmonary Embolism ◽  
Creatinine Level ◽  
Pulmonary Angiography ◽  
Hospital Death ◽  
Contrast Induced Nephropathy ◽  
Computed Tomographic ◽  
Level Increase ◽  
Computed Tomographic Pulmonary Angiography ◽  
Egfr Decline

Abstract Background According to 2019 ESC guidelines for management in patients with the pulmonary embolism (PE), the computed tomographic pulmonary angiography (CTPA) is the diagnostic method of choice in suspected high-risk PE defined as patients with hemodynamic instability. In stable cases, it is recommended to assess the pre-test probability of the PE. However, CTPA with its great accuracy and wide availability in most medical centers is used as often to confirm as to exclude the diagnosis in PE suspected patients, despite the fact that it is linked with the risk of radiation and iodine-containing contrast exposure. Purpose The aim of the study was to assess the validity of CTPA use in patients with suspected PE form the perspective of multidisciplinary clinical center. Methods We retrospectively analyzed the data of from 52,474 hospitalized patients between 01.2018 and 12.2019. A total of 261 (0.5%) consecutive patients with suspected PE (in the emergency department or during hospitalization) were included into the study. Due to suspicion of PE all patients underwent the CTPA. In this group, we analyzed all available clinical data, results of laboratory and diagnostic tests (before and after CTPA) including estimated glomerular filtration rate (eGFR), creatinine level, transthoracic echocardiography (TTE) and planar ventilation/perfusion (lung scintigraphy) scan (V/Q SPECT) if performed. Results The CTPA confirmed PE in 28.9% of patients. The most common final diagnoses, established in the group with negative CTPA result, include heart failure (33.9%), pneumonia (14.4%) exacerbation of chronic obstructive pulmonary disease or asthma (9.3%) and acute coronary syndrome (5.9%). Acute PE was the cause of in-hospital death in 2.4% of patients and the rate of all cause in-hospital death was 11.4%. In 54.2% of patients we observed the eGFR decline and creatinine level increase, meeting the criteria of the acute contrast-induced nephropathy in 33 of them of them (19.8%). In the group with excluded PE, mean eGFR before CTPA was 70.9ml/min/1.73m2 with the decline to mean 60.4ml/min/1.73m2 during the hospitalization (p&lt;0.01). In patients with negative CTPA result and the worsening of the renal function mean eGFR decline was 17.8ml/min/1.73m2 (p&lt;0.01) and mean creatinine level increase was 38.6μmol/l (p&lt;0.01). CONSLUSIONS The initial data collected show the overuse of CTPA in suspected PE, as the diagnosis was confirmed in less than one-third of them. Although CTPA allows to exclude or confirm PE unambiguously, its use is associated with risk of acute contrast-induced nephropathy. Additionally, in patients with exacerbation of heart failure established as final diagnosis after excluding PE, intensive diuretic treatment is crucial and may cause further accompanying renal function worsening. Therefore, optimizing the diagnostic pathway in patients with suspected PE into less aggravating procedures such as TTE or V/Q SPECT is justifiable. Funding Acknowledgement Type of funding source: None

Diagnosis of acute pulmonary embolism and evolving imaging modalities

ESC CardioMed ◽  
2018 ◽  
pp. 2761-2766
Author(s):  
Helia Robert-Ebadi ◽  
Grégoire Le Gal ◽  
Marc Righini
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Thoracic Imaging ◽  
Diagnostic Strategies ◽  
Computed Tomographic ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Venous Compression ◽  
Computed Tomographic Pulmonary Angiography ◽  
Deep Vein

Modern non-invasive diagnostic strategies for pulmonary embolism rely on the sequential use of clinical probability assessment, D-dimer measurement, and thoracic imaging tests. Planar ventilation/perfusion scintigraphy was the cornerstone test for the diagnosis of pulmonary embolism for more than two decades and has now been replaced by computed tomographic pulmonary angiography (CTPA). Diagnostic strategies using CTPA are very safe to rule out pulmonary embolism and have been well validated in large prospective management outcome studies. Venous compression ultrasonography is the cornerstone test to diagnose deep vein thrombosis but is not mandatory for the diagnosis of pulmonary embolism when using multidetector CTPA.

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.

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