Low-risk Pulmonary Embolism Research Articles

Prothrombotic fibrin clot properties associated with NETs formation characterize acute pulmonary embolism patients with higher mortality risk

Venous thromboembolism is associated with formation of denser fibrin clots resistant to lysis. We investigated whether prothrombotic plasma clot properties are associated with the severity of acute pulmonary embolism (PE). We enrolled 126 normotensive acute PE patients (aged 58 ± 14 years) and 25 age- and sex-matched healthy controls. Plasma fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP), plasminogen activator inhibitor-1 (PAI-1), and citrullinated histone H3 (citH3) were evaluated on admission. PE patients compared to controls had 370% higher citH3 levels, 41% higher ETP, 16.5% reduced Ks, and 25.6% prolonged CLT. Patients with intermediate-high (n = 29) and intermediate-low (n = 77) PE mortality risk had reduced Ks and prolonged CLT, increased PAI-1 and ETP as compared to low-risk PE (n = 20) patients. Prolonged CLT was predicted by PAI-1 and citH3, while low Ks by C-reactive protein. During a 12-month follow-up 9 (7.1%) patients who had 24% higher ETP, 45% higher citH3 levels, and 18% prolonged CLT at baseline died. High ETP combined with elevated citH3 levels and prolonged CLT was associated with eightfold increased risk of PE-related death. Prothrombotic fibrin clot properties and enhanced neutrophil extracellular traps formation are associated with higher early mortality risk in acute PE patients, which suggests a prognostic role of these biomarkers.

External validation of the modified HOPPE score to predict low risk pulmonary embolism suitable for early discharge.

ObjectiveRecently, a novel score for risk stratification of patients with pulmonary embolism (PE)—the HOPPE score—was derived. We aimed to externally validate the HOPPE score in emergency department-diagnosed PE, using SpO2 as a surrogate for PaO2—the modified HOPPE score.MethodsRetrospective observational study of adult patients with an emergency department diagnosis of PE was performed. Data collected included demographics, co-morbidities, clinical features, electrocardiogram and test results, in-hospital mortality and non-fatal major adverse clinical events (MACE; survived cardiac arrest, cardiogenic shock or thrombolysis administration). The primary outcome of interest was clinical performance of the modified HOPPE score for inhospital mortality and the composite outcome of in-hospital death and MACE. A secondary outcome was comparison of predictive performance between the modified HOPPE score and the simplified Pulmonary Embolism Severity Index score.ResultsTwo hundred and six patients were studied (median age 61, 55% female). There were no deaths or MACE in patients with a low risk modified HOPPE score of 0 to 6 (0%; 95% confidence interval, 0% to 1.8%). Negative predictive value of a low risk score was 100% (95% confidence interval, 92.2% to 100%) for in-hospital mortality and for the composite of in-hospital mortality or MACE. The modified HOPPE score had similar predictive performance to the simplified Pulmonary Embolism Severity Index score with an area under the curve of 0.88 vs. 0.80 for the composite outcome of in-hospital mortality or MACE (P=0.052). Twenty-eight percent of the patients were classified as low risk and potentially suitable for management as outpatients.ConclusionThe modified HOPPE score showed good clinical performance. Prospective validation is warranted.

Could HIF-1α be a novel biomarker for the clinical course and treatment of pulmonary embolism?

Background/aimPulmonary embolism (PE) is associated with high morbidity and mortality rates if not diagnosed and treated rapidly. The aim of our study was to investigate the relationship between levels of hypoxia-induced factor-1 alpha (HIF-1α) and clinical course and prognosis in patients with intermediate low-risk, intermediate high-risk, and high-risk PE.Materials and methodsThe study included 240 subjects in 4 groups: a healthy control group (n = 60, mean age = 60 ± 15.2, female/male = 30/30 ), intermediate low-risk PE group (n = 60, mean age = 60 ± 12,5, female/male = 27/33), intermediate high-risk PE group (n = 60, mean age = 61,4 ± 14,8, female/male = 36/24), and high-risk PE group (n = 60, mean age = 62,3 ± 15, female/male = 33/27). Plasma HIF-1α levels were measured using commercial enzyme-linked immunosorbent assay (ELISA) kit.ResultsComparison of HIF-1α levels revealed a statistically significant difference between the groups in proportion to clinical scoring (P = 0.001 for all). Comparison of initial HIF-1α and troponin levels in intermediate high-risk PE patients given thrombolytic therapy and those treated with enoxaparin sodium showed that HIF-1α levels were significantly higher in the group that received thrombolytic therapy (P = 0.001), while there was no difference in troponin levels (P = 0.146).ConclusionHIF-1α can be used in the PE clinical risk stratification and monitoring of PE and may also serve as a valuable early indicator in intermediate high-risk PE, for which early reperfusion therapy is important.

A case of chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially fatal complication of pulmonary embolism (PE). Organized thrombus in the pulmonary artery causes a chronic obstruction, leading to a vascular system remodeling, an increase of pulmonary vascular resistance and a chronic pulmonary hypertension. Epidemiology is mostly unknown due to the difficult diagnostic process that often leads to a late diagnosis: findings of persistent pulmonary hypertension (PH), despite correct treatment of PE, lead to the diagnostic suspect. The first choice treatment is pulmonary endarterectomy (PEA) associated with lifelong anticoagulant therapy with vitamin K antagonist. We present the case of a 53-year-old male affected by dyspnea for months, admitted to a sub-intensive care unit for intermediate low-risk PE; echocardiography showed signs of PH persisting after anticoagulant therapy; after 2 months of specific treatment the diagnosis of CTEPH was confirmed and the patient was successfully treated with PEA.

Need for Transthoracic Echocardiogram in Patients with Low-Risk Pulmonary Thromboembolism: A Systematic Review and Meta-Analysis

IntroductionIt is unclear whether low-risk patients with acute symptomatic pulmonary embolism (PE) should undergo echocardiogram. MethodsWe performed a meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of echocardiographic diagnosis of right ventricular (RV) dysfunction for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We used a random-effects model to pool study results, a Begg rank correlation method to evaluate for publication bias, and I2 testing to assess heterogeneity. ResultsThe meta-analysis included a total of 11 studies with 1868 low-risk PE patients. Ten of the 447 (2.2%; 1.1%–4.1%) low-risk patients with echocardiographic RV dysfunction died soon after the diagnosis of PE compared with 10 of 1421 (0.7%; 0.3%–1.3%) patients without RV dysfunction. RV dysfunction was not significantly associated with short-term all-cause mortality (odds ratio 2.0; 95% confidence interval, 0.8–5.1, P=.14; I2=8%). RV dysfunction was significantly associated with short-term PE-related mortality (odds ratio 5.2; 95% confidence interval, 1.7–16, P<.01; I2=0%). ConclusionsIn patients with low-risk PE, echocardiographic RV dysfunction is not associated with all-cause mortality, but identifies patients with an increased risk for short-term PE-related mortality.

Provider Perspectives on the Use of Evidence-based Risk Stratification Tools in the Evaluation of Pulmonary Embolism: A Qualitative Study.

Providers often pursue imaging in patients at low risk of pulmonary embolism (PE), resulting in imaging yields <10% and false-positive imaging rates of 10% to 25%. Attempts to curb overtesting have had only modest success and no interventions have used implementation science frameworks. The objective of this study was to identify barriers and facilitators to the adoption of evidence-based diagnostic testing for PE. We conducted semistructured interviews with a purposeful sample of providers. An interview guide was developed using the implementation science frameworks, consolidated framework for implementation research, and theoretical domains framework. Interviews were recorded, transcribed, and analyzed in an iterative process. Emergent themes were identified, discussed, and organized. We interviewed 23 providers from four hospital systems, and participants were diverse with regard to years in practice and practice setting. Barriers were predominately at the provider level and included lack of knowledge of the tools, particularly misunderstanding of the validated scoring systems in Wells, as well as risk avoidance and need for certainty. Barriers to prior implementation strategies included the perception of a clinical decision support (CDS) tool for PE as adding steps with little value; most participants reported that they overrode CDS interventions because they had already made the decision. All providers identified institution-level strategies as facilitators to use, including endorsed guidelines, audit feedback with peer comparison about imaging yield, and peer pressure. This exploration of the use of risk stratification tools in the evaluation of PE found that barriers to use primarily exist at the provider level, whereas facilitators to the use of these tools are largely perceived at the level of the institution. Future efforts to promote the evidence-based diagnosis of PE should be informed by these determinants.

Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review.

The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.

Association between risk stratification for pulmonary embolism and deep vein thrombosis of lower extremities.

The association of clinical risk factors, in particular deep vein thrombosis (DVT), with risk stratification for pulmonary embolism (PE) remains to be identified. We therefore aimed to establish the relationship between risk stratification of PE patients and DVT of lower extremities. In this retrospective study, 93 out of 485 PE patients with uncompleted clinical data were excluded, resulting in 392 patients included for analysis. Based on the ESC criteria, 24, 171, and 197 patients were categorized into high (6.1%), intermediate (43.6%), and low risk (50.3%) subgroups, respectively. DVT was detected in 304 patients (77.6%). The incidence of DVT in patients with high and intermediate risk PE was much lower than in those patients with low risk PE (67.2% vs 87.8%, P < .0001). Further analyses of the 304 patients with DVT showed higher incidence of high and intermediate risk PE in patients with isolated distal DVT than proximal DVT (59.0% vs 39.1%, P = .005), with asymptomatic DVT than symptomatic DVT (63.0% vs 36.8%, P < .0001), and with bilateral DVT than unilateral DVT (54.5% vs 39.9%, P = .03). Stepwise logistic regression showed that symptomatic or asymptomatic DVT was an independent risk factor for risk stratification of PE patients with DVT (0.320, 95% confidence interval, 0.186-0.550). Patients with high and intermediate risk PE presented lower incidence of DVT compared with patients with low risk PE. In PE patients with comorbid DVT, asymptomatic DVT is an independent risk factor for high and intermediate risk of PE.

Роль предрасполагающих факторов в развитии тромбоза глубоких вен у пациентов пожилого и старческого возраста

Введение. Тромбоз глубоких вен (ТГВ) является жизнеугрожающим заболеванием и осложнением, имеющим большое количество этиологических факторов. В современной литературе основным предрасполагающим фактором развития ТГВ в пожилом и старческом возрасте принято считать онкологические заболевания. Цель исследования: оптимизировать скрининговую диагностику и тактику антикоагулянтной терапии у пациентов пожилого и старческого возраста с ТГВ в зависимости от этиологического фактора. Материалы и методы. В рамках исследования проводили лечение 40 больных c ТГВ из них 29 пациентов находились на амбулаторном лечении, 11 на стационарном. Среди них было 18 (45) мужчин и 22 (55) женщины в возрасте от 61 года до 87 лет, средний возраст составил 72 года. Диагноз ТГВ устанавливали на основании клинического обследования и данных ультразвукового дуплексного сканирования (УЗДС) вен нижних конечностей. Амбулаторно обследовались и получали лечение пациенты с низким риском развития тромбоэмболии легочной артерии по шкале Geneva. Все пациенты сдавали анализы крови на наличие наследственных тромбофилий. Наблюдение осуществляли в течение 1 года, что включало визиты в клинику и телефонные звонки, а также регулярные УЗДС нижних конечностей и лабораторный контроль пациента через 3, 14 дней, 1, 3, 6 мес и 1 год. Результаты. У 26 (65) человек тромботический процесс локализовался в подвздошно-бедренном сегменте, изолированный дистальный тромбоз обнаружен у 8 (20) пациентов. Новообразования найдены у 16 (40) обследованных, причем в органах малого таза в 33 случаев. По классификации ТNM (tumor, nodus, metastasis) выявленные онкологические патологии были представлены IIII стадиями. У 6 (9) пациентов обнаружена мутация V фактора (Лейденская мутация) свертывания крови (у 5 гетерозиготная, у 1 гомозиготная), 3 (3) пациента имели мутацию гена протромбина (у всех гетерозиготная). Заключение. Генетические тромбофилии очень скромный предиктор развития ТГВ у пациентов пожилого и старческого возраста. Онкологическая патология является более сильным драйвером тромбоза глубоких вен, чем генетическая предрасположенность. Introduction. Deep vein thrombosis (DVT) is a life-threatening disease and complication, and has a large number of etiological factors. In modern literature cancer is considered to be the main predisposing factor for DVT development in elderly and senile age. Aim: to optimize the screening diagnostics and tactics of anticoagulant therapy in elderly and senile patients with DVT depending from etiological factor. Materials and methods. We treated 40 patients with DVT 29 of them were outpatient and 11 inpatient. Among them were 18 (45) men and 22 (55) women aged 6187 years, the average age was 72 years. DVT was diagnosed on the basis of clinical examination and ultrasound duplex scanning (USDS) of the veins of lower extremities. Patients with a low risk of pulmonary embolism according to the Geneva scale were examined and received treatment on an outpatient basis. All patients were examined for hereditary thrombophilia. The observation was carried out for 1 year: visits to the clinic and phone calls, as well as regular USDS of the lower extremities and laboratory monitoring after 3, 14 days, 1, 3, 6 months and 1 year. Results. In 26 (65) patients the thrombotic process was localized in the ileo-femoral segment isolated distal thrombosis was found in 8 (20) patients. Neoplasms were found in 16 (40) patients, and in pelvic organs in 33 of cases. According to the TNM classification (tumor, nodus, metastasis), the identified oncological pathologies were represented by stages IIII. In 6 (9) patients factor V mutation (Leiden mutation) of blood coagulation was detected (in 5 heterozygous, in 1 homozygous), 3 (3) patients had a prothrombin gene mutation (all heterozygous). Conclusion. Genetic thrombophilia is a very modest predictor of DVT development in elderly and senile patients. Oncological pathology is a stronger driver of DVT than a genetic predisposition.

Outpatient management of pulmonary emboli: when to ambulate.

Pulmonary embolism is a potentially fatal consequence of venous thromboembolism and constitutes a significant proportion of the acute medical take. Standard management has previously required admission of all patients presenting with acute pulmonary embolism for initiation of anticoagulation and initial investigations. However, clinical trial data have demonstrated the feasibility and safety of managing a subset of patients with low-risk pulmonary embolism in the outpatient setting and this has since been reflected in national guidelines. This article provides a practical overview for general physicians with regards to identifying patients with low-risk pulmonary embolism, and when and how to manage these patients on an outpatient basis.

Safety of early orthopedic surgery in patients with intermediate/low- or low-risk pulmonary embolism.

BackgroundPreoperative pulmonary embolism (PE) is one of the comorbidities in patients with hip fracture. However, previous studies have not identified the optimal timing of surgery in these patients, who might require early surgery. This study aimed to investigate the safety and clinical feasibility of early surgery in patients with hip fracture and acute PE.MethodsThe medical records of 156 patients with hip fracture, who were suspected to have PE and underwent pulmonary computed tomography angiography at Asan Medical Center from January 2008 to December 2017, were retrospectively reviewed. After excluding patients who were diagnosed with PE during the postoperative period, the baseline characteristics and clinical course were compared between patients preoperatively diagnosed with PE (PE group) and patients without PE during the hospital stay (non-PE group). Adverse outcomes were evaluated during 3 months postoperatively.ResultsThe baseline characteristics were not different between the PE group (n=90) and the non-PE group (n=50). All patients in the PE group were classified as having an intermediate/low or low risk according to the European Society of Cardiology guidelines and underwent surgery within 30 days after the PE diagnosis (median duration: 2 days). None of the patients in both groups developed symptomatic venous thromboembolism (VTE) during the follow-up. Moreover, there were no statistically significant differences in major bleeding, clinically relevant nonmajor (CRNM) bleeding, transfusion amount, bleeding site, and length of hospital stay between the PE and non-PE groups.ConclusionsOur results suggest that early surgery might be a reasonable treatment option in patients with hip fracture and acute PE.

Home vs hospital treatment of low-risk venous thromboembolism: a systematic review and meta-analysis

AbstractIncreasing evidence supports the safety and effectiveness of managing low-risk deep vein thrombosis (DVT) or pulmonary embolism (PE) in outpatient settings. We performed a systematic review to assess safety and effectiveness of managing patients with DVT or PE at home compared with the hospital. Medline, Embase, and Cochrane databases were searched up to July 2019 for relevant randomized clinical trials (RCTs), and prospective cohort studies. Two investigators independently screened titles and abstracts of identified citations and extracted data from relevant full-text papers. Risk ratios (RRs) were calculated, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Seven RCTs (1922 patients) were included in meta-analyses on managing patients with DVT. Pooled estimates indicated decreased risk of PE (RR = 0.64; 95% confidence interval [CI], 0.44-0.93) and recurrent DVT (RR = 0.61; 95% CI, 0.42-0.90) for home management, both with moderate certainty of the evidence. Reductions in mortality and major bleeding were not significant, both with low certainty of the evidence. Two RCTs (445 patients) were included in meta-analyses on home management of low-risk patients with PE. Pooled estimates indicated no significant difference in all-cause mortality, recurrent PE, and major bleeding, all with low certainty of the evidence. Results of pooled estimates from 3 prospective cohort studies (234 patients) on home management of PE showed similar results. Our findings indicate that low-risk DVT patients had similar or lower risk of patient-important outcomes with home treatment compared with hospital treatment. In patients with low-risk PE, there was important uncertainty about a difference between home and hospital treatment.

Hypothyroidism and the Risk of Venous Thromboembolism: A Nationwide Cohort Study.

Previous studies have shown that hypothyroidism may have an impact on blood coagulation. However, how hypothyroidism and thyroxine replacement therapy (TRT) affect the risk of venous thromboembolism (VTE) remains controversial. This study aimed to examine the associations of hypothyroidism and TRT with VTE risks. This nationwide population-based cohort study was conducted using Taiwan's National Health Insurance Research Database. We enrolled 10,818 hypothyroid patients (the exposed cohort) and 21,636 non-hypothyroid subjects (the unexposed cohort) between 2001 and 2014 after 1:2 exact matching according to age, sex, and index year. Hypothyroid patients were further divided into two groups depending on whether they received TRT or not. Adjusted hazard ratios (aHRs) for VTE were calculated using Fine and Gray competing risk models. The mean follow-up period was 7.5 years. Hypothyroidism was significantly associated with a higher risk of VTE (aHR = 1.83 [95% confidence interval [CI]: 1.44-2.33, p < 0.001]). Among hypothyroid patients, the TRT subgroup had a non-significant trend of lower VTE risk than the non-TRT subgroup (aHR = 0.73 [95% CI: 0.52-1.01, p = 0.058]). The analysis for individual events revealed a significant association between TRT use and a lower risk of pulmonary embolism among hypothyroid patients (aHR = 0.34 [95% CI: 0.13-0.88, p = 0.026]). The data suggest that hypothyroidism was significantly associated with an increased risk of VTE. Among hypothyroid patients, a non-significant trend of lower VTE risk in patients treated with TRT was observed. Further prospective studies or clinical trials are necessary to confirm causality.

Reducing length of stay with the direct oral anti-coagulants in low and intermediate risk pulmonary embolism: a single center experience.

Direct oral anti-coagulants (DOACs) reduce hospital length-of-stay (LOS) in patients with acute pulmonary embolism (PE) in clinical trials. There is a paucity of literature describing real world utility of DOACs, particularly in intermediate-risk patients. To evaluate if the utilization of DOACs vs. non-DOACs in acute PE patients, reduces LOS without a difference in safety in patients defined as low and intermediate-risk of mortality by the European Society of Cardiology. This was a retrospective cohort study of prospectively collected data from a single center registry of consecutive adult outpatients diagnosed with acute PE who survived to hospital discharge. Primary outcome was median hospital LOS. Secondary outcomes were 30-day readmission, survival, and incidence of major and minor bleeding. There were 307 outpatients admitted with acute PE 88 (28.7%) low-risk, 213 (69.4%) intermediate-risk, and 6 (2.0%) high-risk. Two hundred and twenty-six (73.6%) received a DOAC. There was a statistically significant shorter median LOS in all patients treated with a DOAC (2.9days, IQR 1.8-4.7) vs non-DOAC (4.9days, IQR 3-8.9) (Generalized Linear Model p < 0.001). There was a shorter median LOS between intermediate-risk patients treated with a DOAC (3.6days, IQR 2-5.8) vs non-DOAC (5, IQR 3-9). There was no difference in 30-day readmission, survival, or bleeding complications in both cohorts. There was a reduction in LOS in low and intermediate risk patients treated with a DOAC without a difference in 30-day safety and efficacy. Treating acute PE patients with DOACs including intermediate-risk patients, compared to conventional anticoagulation, may facilitate early discharge, and potentially reduce hospital costs.

Outpatient Treatment in Low-Risk Pulmonary Embolism Patients Receiving Direct Acting Oral Anticoagulants Is Associated With Cost Savings.

Direct oral anticoagulants (DOAC) are first line treatment for pulmonary embolism (PE). Treatment of acute PE is traditionally hospital based and associated with high costs. The aims of this study were to evaluate potential cost savings with outpatient DOAC treatment compared to inpatient DOAC treatment in patients with low risk PE. A retrospective study in patients with DOAC treated low risk PE (simplified pulmonary severity index [sPESI] ≤ 1) admitted to 8 hospitals during 2013-2015. Health care costs were compared in 223(44%) patients treated as outpatients and 287(56%) treated in hospital. Total cost per patient was 8293 EUR in the inpatient group, and 2176 EUR in the outpatient group (p < 0.001). Total costs for inpatients were higher (p < 0.001) compared to outpatients in both subgroups with sPESI 0 and 1. In multivariate analysis, type of treatment (in- or outpatient, p = < 0.001) and sPESI group (0 or 1, p = < 0.001) were associated with total cost below or above median, whereas age (p = 0.565) and gender (p = 0.177) was not. Adherence to guidelines recommending outpatient treatment with DOAC in patients with low risk PE enables significant savings.

P233 A new onset pulmonary artery stenosis in a young man

Abstract Background Poorly differentiated and undifferentiated sarcomas are the most common primary tumors of the pulmonary arteries. They usually affect large caliber vessels and present with predominantly intraluminal growth. Dyspnea, cough, chest pain, and hemoptysis are the most common presenting symptoms; patients may have signs of chronic pulmonary hypertension. Clinical and imaging manifestations can mimic pulmonary embolism. The overall prognosis is poor combined therapy with surgical resection and chemo-radiotherapy offers the best survival rates. Case presentation A 31-year-old male was referred to our department because of recent onset dyspnea, a pre-syncopal episode and a new heart murmur. He had normal spirometry results but a significant desaturation during the 6MWT. A thoracic CT scan showed an incremented diameter of the pulmonary artery.The echocardiogram showed the presence of a mass with irregular borders attached to the pulmonary trunk almost obliterating its lumen. The mass determined a flow acceleration with maximal velocity of 3.8 m/sec, and a peak gradient of 60mmHg; Doppler findings on the pulmonary valve and right heart function were within normal values. Compression ultrasonography ruled out the presence of deep vein thrombosis. The lesion showed a dishomogeneous impregnation in the contrastographic phase at cardiac MRI and had an intense glucidic metabolism at a PET-CT scan. These findings were highly suggestive of an angiosarcoma of the pulmonary artery. Biopsy specimens were taken through bronchoscopy. The patient then decided to continue treatment in another hospital, where the histologic samples were sent; the cytologic results showed atypical cellular elements. The patient died a few months later. Discussion The presence of a unique mass in the main pulmonary artery or proximal branches and rapidly progressive dyspnea in a patient at low risk of pulmonary embolism should raise the suspicion of primary sarcoma of the pulmonary artery, which is a rare but aggressive tumor with a very poor prognosis. Abstract P233 Figure.

The risk stratification for identification of patients with low-risk pulmonary embolism in active cancer patients

The risk stratification for identification of patients with low-risk pulmonary embolism in active cancer patients

Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Predict All-Cause Mortality in Acute Pulmonary Embolism.

The aim of this study was to investigate the utility of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) to predict all-cause mortality in patients presenting with acute pulmonary embolism (PE). Three hundred consecutive patients with acute PE between March 2016 and December 2018 were retrospectively analyzed. We identified 191 patients who met the study inclusion criteria. Twenty-eight patients died during the study period. There was a significant difference in PLR, but not NLR, between patients with low risk, submassive, and massive risk PE (P = .02 and P = .58, respectively, by the Kruskal-Wallis test). Elevated NLR and PLR were associated with all-cause mortality (P < .01 and P < .01, respectively). Neutrophil-to-lymphocyte ratio of 5.46 was associated with all-cause mortality with sensitivity of 75.0% and specificity of 66.9% (area under the curve [AUC]: 0.692 [95% confidence interval, CI]: 0.568-0.816); P < .01). Platelet-to-lymphocyte ratio of 256.6 was associated with all-cause mortality with sensitivity of 53.6% and specificity of 82.2% (AUC: 0.693 [95% CI: 0.580-0.805]; P < .01). Neutrophil-to-lymphocyte ratio and PLR are simple biomarkers that are readily available from routine laboratory values and may be useful components of PE risk prediction models.

Simultaneous Treatment of Acute Pulmonary Embolism and Deep Venous Thrombosis. A Preliminary Multicentre Experience

Introduction: Venous thromboembolism, which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), poses a global disease burden. New mechanical thrombus removal devices could represent a safe and effective treatment for acute PE, especially in patients with absolute contraindication to thrombolysis, resulting in high technical and clinical success of this procedure[i] . Moreover coexisting DVT could be treated with thrombus removal devices avoiding caval filter deployment. Aim of this study is to assess the feasibility of aspiration mechanical thrombectomy of massive or submassive PE and DVT, in a single session, in patients with contraindications to thrombolysis. Methods: In two centers, from April 2017 to April 2018, we prospectively enrolled all patients with contraindications to thrombolysis, suffering from DVT and massive or submassive PE according to ESC and AHA guidelines, undergone simultaneous mechanical thrombectomy of both pulmonary arteries and deep peripheral veins. All procedures were approved by our institutional review board and a written informed consent was obtained from all patients when possible. Exclusion criteria were: low risk PE and eligibility for first-line thrombolytic treatment. All patients included in the study were proved to have acute PE based on clinical and radiological findings, according to the presence of proximal arterial PE at computed tomography angiography (CTA) and DVT based on ultrasound and CTA. RV/LV ratio was measured from CTA using a four-chamber views on a dedicated workstation, before trombectomy, postoperatively and at 12 months follow-up. SpO2, Heart Rate (HR), and ultrasound venous examination were recorded at 12 months follow-up. Technical success was defined as pulmonary arterial systolic pressure reduction at 50% from the initial value for PE treatment and direct visualisation of thrombus significant reduction (> 70%) in peripheral DVT. Results: Six patients (2 male) were enrolled in our study. Mean age was 76 (55-91). All patients required before treatment high volume O2 therapy, with mean SpO2 of 85.8 (82-90), mean heart rate of 72.5 (42-100) and mean RV/LV of 1.37 (1.2-1.8). Contraindications for first-line thrombolytic treatment were: recent stroke in 4 cases, known bleeding risk in 1 case and brain metastasis in 1 case. Two patients presented popliteal residual DVT, 3 patients femoral DVT and 1 patient iliac DVT. No procedural or periprocedural complications were observed. PE technical success was achieved in all patients, peripheral venous revascularisation was effective in 4 patients, in two patients mechanical aspiration was unable to solve the subacute thrombosis and no further treatment was attempt. At 12 months follow up only 1 patient required 1L O2 therapy with mean SpO2 of 91.8 mmHg (90-94), mean heart rate of 68,3 (63-73) and mean RV/LV ratio of 0,90 (0,85-0,95). Vein ultrasound examination revealed that 4 patients still had patent veins, while in uneffective peripheral veins aspiration a chronic DVT was evident. Conclusion: In our preliminary series simultaneous treatment of DVT and PE is safe and effective. Low rate of complications encourage extensive use of this technique in selected patients, however larger prospective studies are needed to assess the feasibility of this treatment. Disclosure: Nothing ti disclose

Comparison of seven prognostic tools to identify low-risk pulmonary embolism in patients aged

In young patients with acute pulmonary embolism (PE), the predictive value of currently available prognostic tools has not been evaluated. Our objective was to compare prognostic value of 7 available tools (GPS, PESI, sPESI, Prognostic Algorithm, PREP, shock index and RIETE) in patients aged <50 years. We used the RIETE database, including PE patients from 2001 to 2017. The major outcome was 30-day all-cause mortality. Of 34,651 patients with acute PE, 5,822 (17%) were aged <50 years. Of these, 83 (1.4%) died during the first 30 days. Number of patients deemed low risk with tools was: PREP (95.9%), GPS (89.6%), PESI (87.2%), Shock index (70.9%), sPESI (59.4%), Prognostic algorithm (58%) and RIETE score (48.6%). The tools with a highest sensitivity were: Prognostic Algorithm (91.6%; 95% CI: 85.6–97.5), RIETE score (90.4%; 95%CI: 84.0–96.7) and sPESI (88%; 95% CI: 81–95). The RIETE, Prognostic Algorithm and sPESI scores obtained the highest overall sensitivity estimates for also predicting 7- and 90-day all-cause mortality, 30-day PE-related mortality, 30-day major bleeding and 30-day VTE recurrences. The proportion of low-risk patients who died within the first 30 days was lowest using the Prognostic Algorithm (0.2%), RIETE (0.3%) or sPESI (0.3%) scores. In PE patients less 50 years, 30-day mortality was low. Although sPESI, RIETE and Prognostic Algorithm scores were the most sensitive tools to identify patients at low risk to die, other tools should be evaluated in this population to obtain more efficient results.