0337: Prognostic value of reflux of contrast into the inferior vena cava or hepatic veins in pulmonary embolism

Abstract

Computed tomography pulmonary angiography (CTPA) is routinely used to diagnose pulmonary embolism (PE). Reflux of contrast medium into the inferior vena cava or hepatic veins (IVC) on CTPA is a simple sign that could help for PE risk stratification. The purpose of this study was therefore to investigate prognosis significance of contrast reflux into IVC in acute PE. 141 consecutive patients with acute PE confirmed by CTPA were prospectively included between March 2010 and February 2013. Degree of reflux into the IVC and the hepatic veins was graded from 1 (none) to 6 (severe) by 2 independent observers, blinded to each other. The presence of reflux in IVC was compared with clinical parameters used in the ESC guidelines for PE risk stratification: electrocardiographic signs, Troponine I, BNP and right ventricular dilatation (RV/ LV>0,9) or dysfunction (TAPSE < 17 mm, S’<10 cm/s) by echocardiography. Composite endpoint was 30-days mortality or clinical deterioration requiring treatment escalation (catecholamine infusion, thrombolytic treatment or cardiopulmonary resuscitation). The composite end-point was observed in 5% of patients with a 30-day mortality rate of 2.1%. Heart rate >110 bpm (OR 5.6, 1.03-30), atrial fibrillation (OR 6.3, 1.05-37.7), negative anterior T waves (OR 6.1, 1.3-29.1), elevated Troponin Ic (OR 5.4, 1.1-25.8), elevated BNP (OR 11.5, 1.3-98.2), right ventricular dysfunction (OR 5.3, 1.1-25.1) were predictors of death or clinical deterioration. Contrast reflux into IVC from grade 4 to 6 was observed in 17% of patients. Interobserver agreement was excellent (Concordance correlation coefficient 0.91). Grade 4 reflux or greater was a strong predictor of events (OR 15.1, 2.8-83.7) and had a 86% specificity and 71% sensitivity to predict adverse outcomes (AUC 0.88). A grade 4 or higher contrast reflux into the IVC is a simple and frequent CTPA sign, highly predictive of adverse outcomes in PE patients.