Pulmonary Angiography Research Articles

CT pulmonary angiography in the inpatients: A 5-year retrospective view at the end of COVID-19 public health emergency.

To retrospectively evaluate the trends in utilization and results of computed tomography pulmonary angiography (CTPA study) for detection of acute pulmonary embolism (PE) in the hospital inpatients during different phases of COVID-19 public health emergency. We conducted an Institutional Review Board (IRB)-approved retrospective review of CTPA studies for our hospital inpatients in the years from 2019 to 2023, ranging from the prepandemic year (2019) to the year coinciding with the end of public health declarations (2023). Collected characteristics included patient age, patient sex, and result of the study. The utilization of CTPA studies for inpatients was higher in 2020 to 2023, compared to 2019 (3.8% in 2023 compared to 2.4% in 2019, P < .001). The increase in utilization was also statistically significant in each group, when stratified by age and sex (OR = 1.46 for female, OR = 1.71 for male, OR = 1.93 for elderly, and OR = 1.29 for non-elderly inpatients in 2023, compared to 2019). The positivity rate of acute PE in the inpatients was overall higher in 2021, 2022, and 2023, compared to 2019 (for example, 18.5% in 2023 compared to 14.3% in 2019, P = .01). When stratified by age and sex, only the non-elderly patients continued to have a significantly higher rate of acute PE in 2023, compared to 2019 (OR = 1.39). While studies spanning longer time frames and involving multiple institutions are needed to understand and generalize this conclusion, we conclude that the utilization and positivity rates of CTPA studies in inpatients remains high at the end of the COVID-19 pandemic public health emergency.

Diagnostic value of systematic compression ultrasonography for the detection of unrecognized venous thromboembolism in patients admitted to an internal medicine ward for dyspnea.

The diagnosis of venous thromboembolism (VTE) is complex, and many cases of pulmonary embolism (PE) and deep vein thrombosis (DVT) go undetected despite validated diagnostic algorithms. This study evaluated the diagnostic performance of compression ultrasound (CUS) when systematically performed in patients admitted to an internal medicine department for dyspnea and/or respiratory failure. We conducted a prospective observational cohort study of consecutive adult hospitalized patients admitted for dyspnea and/or respiratory failure with at least one of the following: tachycardia (> 100bpm), tachypnea (> 20/min), chest pain, cough, syncope, or hemoptysis. Patients with a previous diagnosis of VTE or who underwent computed tomography pulmonary angiography (CTPA) or CUS during evaluation in the emergency department were excluded. The study included 263 patients (50.2% women, average age 84years). CUS was positive in 31 patients (11.8%); Bilateral DVT was diagnosed in two patients and unilateral DVT in 29 patients. Of these, 10 underwent CT scan, with PE confirmed in 9 cases. Using the Wells score for DVT (cut-off ≥ 2), only 8 patients (25.8%) were at high risk. The accuracy of the Wells score in identifying PE was suboptimal, as 5 of 9 patients (55.5%) with confirmed PE were in the low-risk group (three-level interpretation) and 8 (89.9%) were in the "EP unlikely" group (two-level interpretation). The systematic use of CUS as a point-of-care tool can improve the diagnostic accuracy for VTE in patients admitted to internal medicine departments with dyspnea/respiratory failure.

Management of Acute Pulmonary Embolism: A Review.

Pulmonary embolism (PE) is an important cause of morbidity and mortalityespecially among hospitalized patients. Although the exact epidemiology of PE is not known in India, several studies have shown that it is missed and mismanaged not infrequently, leading to significant cardiovascular morbidity and mortality. Indian consensus for the diagnosis and treatment of acute PE has been previously published. Recent findings from studies including data available from Indian studies have expanded our knowledge with respect to the optimal diagnosis, assessment, and treatment of patients with PE and have been integrated into this review article. Acute PE patients should be stratified according to early mortality risk. Clinical measures, right ventricular (RV) dysfunction markers, and myocardial injury should be used to determine risk stratification. The clinical prediction criteria [pulmonary embolism severity index (PESI) and Hestia criteria] should be routinely used in emergency departments. Investigations, such as D-dimer, electrocardiogram (ECG), chest X-ray, routine labs, N-terminal pro B-type natriuretic peptide/brain natriuretic peptide (NT-ProBNP/BNP), troponin I or troponin T, heart-type fatty acid binding protein (H-FABP), echocardiography, lower limb compression ultrasonography (CUS), computed tomographic-pulmonary angiography (CTPA), ventilation-perfusion scintigraphy (V/Q scan), and pulmonary angiography should be appropriately selected in suspected cases of PE as per risk stratification. The main treatment in medical management of acute PE comprises anticoagulants and thrombolytics. According to current guidelines, oral anticoagulants such as warfarin are recommended to be started at the time of diagnosis together with unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or fondaparinux (all grade IA). Owing to their predictable bioavailability and pharmacokinetics, novel oral anticoagulants (NOACs) can be given at fixed doses without routine laboratory monitoring. Recurrence is not uncommon on cessation of therapy, and hence long-term anticoagulation may be required in selected cases. Strong positive evidence is available for the use of thrombolytics in the management of acute PE.

Type of D-dimer assay determines the diagnostic yield of Computed Tomography in patients suspected for pulmonary embolism

ImportancePulmonary embolism (PE) is a life-threatening condition with high morbidity and mortality. The diagnosis of PE is challenging due to nonspecific symptoms, making reliable diagnostic tools essential. This study addresses the clinical impact of inter-assay variability in D-dimer measurements on the utilization and diagnostic yield of computed tomography pulmonary angiography (CTPA). ObjectiveTo investigate the effect of different D-dimer assays on the decision to perform CTPA and the subsequent diagnostic yield in patients with suspected PE. DesignThis retrospective cohort study analyzed data from three teaching hospitals in the Netherlands, covering the years 2018, 2019, 2022, and 2023. SettingMulticenter study involving three teaching hospitals in the south-west region of the Netherlands. ParticipantsThe study included data from 40,096 clinically requested D-dimer results and 11,372 CTPA records of patients with suspected PE. The D-dimer assays used were the Roche Tinaquant and Siemens Innovance. ResultsThe study found significant differences in CTPA utilization and diagnostic yield based on the D-dimer assay used. Hospitals using the Roche Tinaquant assay ordered 21% fewer CTPAs and had an 7% higher positivity rate compared to those using the Siemens Innovance assay. Conclusion and relevanceThe findings highlight the necessity for assay-specific cut-off values or, ideally, the standardization of the D-dimer assay to optimize the accuracy and efficiency of PE diagnosis. This study demonstrates that the choice of D-dimer assay significantly influences the clinical management of suspected PE, affecting both the number of CTPAs performed and the positivity rate of these scans. Implementing assay-specific cut-off values or standardization of the D-dimer assay could reduce unnecessary CTPA scans, minimize patient exposure to radiation, and lower healthcare costs. These results advocate for enhanced collaboration between clinicians and laboratory specialists to accurately interpret D-dimer results within the context of the specific assay used. Future research should validate these findings in prospective studies and explore standardized protocols that account for inter-assay variability.

Prognostic Value of Incidental Coronary Artery Calcifications in Computed Tomography Pulmonary Angiography for Suspected Pulmonary Embolism

Computed tomography (CT) has emerged as a noninvasive method to identify coronary artery calcifications (CAC). We sought to investigate the association between opportunistic visual CAC evaluation in patients without known coronary artery disease who underwent CT pulmonary angiography (CTPA) for pulmonary embolism (PE) suspicion, and cardiovascular prognosis. We analyzed data of patients who underwent CTPA for suspected PE in 2017 at CHU Dupuytren, Limoges, France. Patients were categorized into 4 groups according to a simple visual ordinal score to assess the extent and severity of CAC on a whole-patient basis: none (grade 0), mild (grade 1), moderate (grade 2), and severe (grade 3). The primary outcome was a composite of cardiovascular mortality, myocardial infarction (MI), or coronary revascularization. The secondary outcomes were all-cause mortality, and an extended composite outcome including cardiovascular mortality, MI, coronary revascularization, ischemic stroke, ischemic peripheral events, and hospitalization for heart failure. A total of 414 patients (mean age 69.7 ± 14.3 years, 42% men, 18.1% PE) were included in the analysis and subdivided according to CAC categories as follows: grade 0 (n = 123; 29.7%), grade 1 (n = 133; 32.1%), grade 2 (n = 79; 19.1%) and grade 3 (n = 79; 19.1%). The mean follow-up was 3.5 ± 2.4 years. After adjustment, the presence of CAC grade 2 to 3 CAC independently predicted the primary outcome (hazard ratio [HR] = 5.30, 95% CI 2.56 to 10.98, p <0.001). CAC grade 2 to 3 were also independent predictors for all-cause mortality (HR = 1.52, 95% CI 1.10 to 2.11, p = 0.011); and the extended composite event (HR = 1.82, 95% CI 1.13 to 2.95, p = 0.014). In conclusion, the opportunistic assessment of CAC in CTPA for suspected PE could provide important mid-term prognostic information, independently from the PE findings.

Current practices in diagnosing acute pulmonary embolism: a comprehensive analysis of adherence to contemporary practice guidelines.

Acute pulmonary embolism (APE) poses significant diagnostic challenges, with potentially fatal outcomes if not promptly identified and treated. Despite the availability of clinical guidelines, adherence to diagnostic strategies varies globally, impacting patient outcomes. Our aim was to investigate current practices for PE diagnosis among Polish physicians and their adherence to the contemporary 2019 European Society of Cardiology (ESC) guidelines. This cross‑sectional study, utilizing a web‑based survey developed with the Delphi methodology, included hospital‑based physicians of various specialties from Poland. The survey focused on diagnostic practices, risk stratification, and adherence to the ESC 2019 guidelines for PE. The study showed a limited use of guideline‑recommended clinical prediction rules, with predominant reliance on D‑dimer assessment and computed tomography pulmonary angiography. Risk stratification practices varied, and were often based on individual experience rather than evidence‑based strategies. The vast majority of physicians (80.5%) had never contacted a PE response team, but 88% stated that they would if it were available. Cardiologists were more likely to employ guideline‑recommended methods than other specialists. There is a need for increased adherence to guideline‑recommended diagnostic and risk stratification strategies in APE among physicians in Poland. Enhancing the availability of PE response teams and promoting guideline‑directed practices could improve diagnostic accuracy and patient outcomes.

Lipoprotein (a) is not associated with thrombus burden derived from CT pulmonary angiography in patients with acute pulmonary embolism

Lipoprotein (a) [Lp(a)] is suspected to have antifibrinolytic effects, however, its relevance for the severity of venous thromboembolic events remains unclear. We studied the association of Lp(a) levels with thrombus load in pulmonary embolism (PE). 90 patients (40% female, median age 70 [56–79] years) at our tertiary care hospital with a diagnosis of acute PE, available Lp(a) levels and CT pulmonary angiography (CT-PA) performed between April 2017 and December 2019 were included. All CT-PA scans were reanalyzed and thrombus load was determined via Qanadli CT obstruction index (CTOI) and most proximal thrombus location. Median Lp(a) levels were 11.4 [9.3–29.1] mg/dL, median D-dimer levels were 4.6 [2.1–9.8] mg/L, median CTOI was 23 [8–50], central PE was present in 27 (30%) patients. Lp(a) did not correlate with CTOI (r = 0.02, p = 0.922) and was not associated with thrombus location (p = 0.369). CTOI significantly correlated with D-dimer (r = 0.43, p < 0.001) and right to left ventricular diameter ratio (r=-0.49, p = < 0.001). Our findings showed that Lp(a) is not associated with thrombus burden in PE, which suggests that a relevant effect of Lp(a) on the extent of venous thromboembolism is unlikely.

The relationship of clinical presentation, d-dimer levels and previous SARS-CoV-2 positivity in outpatients with suspected pulmonary embolism

Abstract Introduction Elevated D-dimer levels can be detected in patients with pulmonary embolism (PE), but also in patients with the disease caused by the novel coronavirus (COVID-19). Aims To investigate relationship between clinical presentation, D-dimer levels and previous SARS-CoV-2 positivity in outpatients with suspected PE. Material and methods This retrospective study included 609 consecutive outpatients (mean age 68±15 years, 50% female) who underwent computed tomography pulmonary angiography for suspected PE from 2021 to 2023. By reviewing electronic databases, clinical and laboratory data were collected, as well data on previously documented SARS-CoV-2 infection. Results PE was confirmed in 130 (21%) patients who had higher D-dimer values than patients without PE (p&amp;lt;0.001). Patients with previous COVID-19 had significantly higher D-dimer values compared to those without prior COVID-19, but only during the first 8 months from infection to pulmonary angiography (Figure, upper panel). Clinical probability of PE, as indicated by Geneva score [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.55 – 3.58)], and age-adjusted D-dimer (OR 4.52, 95%CI 1.58 – 12.90) were independently associated with PE, while previous COVID-19 was not. Main clinical reasons for emergency department presentation are shown in Figure (bottom panel). In 45/609 (7.4%) patients evaluated primarily for elevated D-dimer, the prevalence of COVID-19 in the previous 6 months was higher in those with PE compared to those without PE (100% vs. 49%, p=0.019). Conclusion Within 8 months of infection, patients with a history of COVID-19 had higher D-dimer levels than those without COVID-19. Age-adjusted D-dimer and standard clinical probability scores retained their predictive power in outpatients with suspected PE, regardless of COVID-19 history.

Echocardiography in acute pulmonary embolism for the prediction of subsequent CTEPH

Abstract Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a long term complication of acute pulmonary embolism (APE) with poor outcomes if untreated. Identifying already at APE diagnosis patients at risk of subsequent CTEPH can lead to earlier goal-directed management. Since standard echocardiography (TTE) is frequently performed during APE episode for short term risk stratification we aimed to asses prediction vale of echocardiography for subsequent CTEPH. Methods We analyzed retrospectively TTE performed at admission due to APE in consecutive patients, without known CTEPH who were anticoagulated for at least 3 months and were followed up for at least 24 months. After follow-up all patients underwent diagnostic workup for CTEPH according to ESC recommendations. We tried to define a set of echocardiographic parameters recorded during the acute episode predictive for CTEPH. Results The study included consecutive 625 patients with APE diagnosed at computed tomography pulmonary angiogram and managed according to ESC recommendations. During follow up 25 (4%) pts were diagnosed with CTEPH. At APE diagnosis CTEPH(+) group presented more prominent echocardiographic signs of right ventricular (RV) overload than pts without CTEPH (CTEPH(-))(table 1). However, multivariate analysis revealed that only increased TRPG and RV/LV ratio were significant CTEPH predictors with AUC 0.792 (95% CI: 0.683-0.900), p&amp;lt;0.001 and 0.777 (95% CI: 0.675-0.878), p&amp;lt;0.001 respectively (fig 1). Using Youden index in ROC analysis we defined following cut off values useful to identify patients at CTEPH risk and subjects with low probability of CTEPH development. TRPG &amp;gt;44mmHg and RV/LV&amp;gt;1.15 showed PPV for CTPEH 12.9 (95% CI: 9.8-16.7) and 13.8 (95% CI: 10.4-18.1), with high NPV of 98.4 (95% CI: 97.1-99.2) and 98.2 (95% CI: 96.8-99.0) respectively. Importantly, in the group of 61 (9.7%) patients with both signs of RV overload present in the acute phase CTEPH during follow-up was diagnosed in 14 patients (23.0%). Conclusion TRPG above 44 mmHg recorded at APE diagnosis identifies patients at risk of subsequent CTEPH especially in patients with increased RV/LV ratio.

A patient with unexplained hypoxemia after a fall diagnosed with platypnea orthodeoxia syndrome: approaches to resolving discrepancies between level of hypoxemia and clinical presentation.

Platypnea orthodeoxia syndrome (POS) is a rare cause of hypoxemia. Diagnosis of POS is challenging, requiring a high index of clinical suspicion, special investigations, and collaboration with multiple specialists. We describe an 86-yr-old male who presented to the emergency department with hip pain after a witnessed fall. He was noted to be hypoxemic at presentation with a peripheral oxygen saturation (SpO2) of 84% on room air, with an inadequate increase in oxygenation after administration of a fractional concentration of inspired oxygen (FIO2) of 1.00. A chest radiograph, computed tomography pulmonary angiogram, and Doppler ultrasound of the liver were unremarkable. In the supine position with an FIO2 of 0.65, his SpO2 and arterial partial pressure of oxygen (PaO2) (96% and 74mm Hg, respectively) increased significantly relative to the seated position (84% and 50mm Hg, respectively). Contrast transthoracic echocardiography (TTE) showed a large patent foramen ovale (PFO) with right-to-left shunt. Transthoracic echocardiography showed rotation of the patient's heart, enabling direct alignment of the inferior vena cava with the PFO, creating a large anatomical right-to-left shunt in the seated position. Right heart catheterization confirmed a large PFO with normal right-sided heart pressures. He was treated with a septal occlusion and his SpO2 in the seated position improved immediately. The patient was discharged home without requiring supplemental oxygen. Platypnea orthodeoxia syndrome is a rare presentation of hypoxemia. Positional changes in oxygenation are the cardinal feature of POS. Discordance between lung imaging and the severity of hypoxemia should prompt investigation for an intracardiac shunt, which can occur in POS even in the absence of increased right-sided heart pressures. Either contrast TTE or transesophageal echocardiography is necessary to make this diagnosis.

Quantitative texture analysis using machine learning for predicting interpretable pulmonary perfusion from non-contrast computed tomography in pulmonary embolism patients

BackgroundPulmonary embolism (PE) is life-threatening and requires timely and accurate diagnosis, yet current imaging methods, like computed tomography pulmonary angiography, present limitations, particularly for patients with contraindications to iodinated contrast agents. We aimed to develop a quantitative texture analysis pipeline using machine learning (ML) based on non-contrast thoracic computed tomography (CT) scans to discover intensity and textural features correlated with regional lung perfusion (Q) physiology and pathology and synthesize voxel-wise Q surrogates to assist in PE diagnosis.MethodsWe retrospectively collected 99mTc-labeled macroaggregated albumin Q-SPECT/CT scans from patients suspected of PE, including an internal dataset of 76 patients (64 for training, 12 for testing) and an external testing dataset of 49 patients. Quantitative CT features were extracted from segmented lung subregions and underwent a two-stage feature selection pipeline. The prior-knowledge-driven preselection stage screened for robust and non-redundant perfusion-correlated features, while the data-driven selection stage further filtered features by fitting ML models for classification. The final classification model, trained with the highest-performing PE-associated feature combination, was evaluated in the testing cohorts based on the Area Under the Curve (AUC) for subregion-level predictability. The voxel-wise Q surrogate was then synthesized using the final selected feature maps (FMs) and model score maps (MSMs) to investigate spatial distributions. The Spearman correlation coefficient (SCC) and Dice similarity coefficient (DSC) were used to assess the spatial consistency between FMs or MSMs and Q-SPECT scans.ResultsThe optimal model performance achieved an AUC of 0.863 during internal testing and 0.828 on the external testing cohort. The model identified a combination containing 14 intensity and textural features that were non-redundant, robust, and capable of distinguishing between high- and low-functional lung regions. Spatial consistency assessment in the internal testing cohort showed moderate-to-high agreement between MSMs and reference Q-SPECT scans, with median SCC of 0.66, median DSCs of 0.86 and 0.64 for high- and low-functional regions, respectively.ConclusionsThis study validated the feasibility of using quantitative texture analysis and a data-driven ML pipeline to generate voxel-wise lung perfusion surrogates, providing a radiation-free, widely accessible alternative to functional lung imaging in managing pulmonary vascular diseases.Clinical trial numberNot applicable.

Baseline characteristics, management patterns and outcome in patients with pulmonary embolism and malignancy: Insights from a single-centre study

Abstract Background and aim The presence of malignancy is an important factor that increases the risk of venous thromboembolism. On the other hand, acute pulmonary embolism (PE) is one of the main causes of death in this setting. In this study, we evaluated the impact of active malignancy on the treatment choices, and short and long term clinical outcomes in patients with acute PE. Methods In this study conducted in a tertiary center, 872 acute PE patients (age 61.6±16.8 years, female 57.5 %) from different risk categories were treated with thrombolytic, anticoagulant and catheter-based therapies in accordance with currently available acute PE guidelines. The population was retrospectively analyzed and divided into two groups according to the presence of active malignancy. Results Active malignancy was documented in 129 (14.8 %) patients. In the groups with and without malignancy, the proportions of low-, intermediate-low-, intermediate-high-, and high-risk PE patients were 3.1 % vs. 15.6 %, 17.8 % vs. 16.7 %, 60.5 % vs. 60 %, and 18.6 % vs. 7.7 %, respectively (p&amp;lt;0.001). While the two groups did not differ in terms of echocardiographic and computed tomographic pulmonary angiography (CTPA) characteristics, the presence of contraindications for thrombolytic were more frequent in the malignancy group (22.5% vs. 10.9%, p&amp;lt;0.001). Ultrasound-assisted thrombolysis (USAT), rheolytic thrombectomy (RT), systemic thrombolysis (ST) and anticoagulation-alone (AC) therapies were noted in 27.3 %, 6.4 %, 6.4 % and 49.7 % of overall PE patients. The RT and AC therapies were more frequent in PE patients with malignancy whereas ST and USAT were more frequently used in the absence of malignancy. Notably, lytic dosages and treatment durations in USAT and ST protocols were comparable between malignant and non-malignant PE cohorts. Regardless of the presence of malignancy and the treatment modality chosen, significant improvements were achieved in the clinical, echocardiographic and CTPA measures of the PE severity (p&amp;lt;0.001 for all). Major and minor bleeding rates were also similar in both groups, while in-hospital and, as expected, long-term mortality were higher in the malignancy cohort. Active malignancy and PESI score were found to be independent predictors for composite end-point of 60-day mortality and PE-related rehospitalization (adjusted odds ratio (OR): 2.43; 95 % CI: 1.32 - 4.47, p=0.04) and (OR: 1.02; 95 % CI: 1.01-1.01, p&amp;lt;0.001), respectively. Malignancy (OR: 3.5, 95 % CI: 2.15-5.75, p&amp;lt; 0.001) and chronic obstructive pulmonary disease (OR: 2.51, 95 % CI: 1.35-4.68, p&amp;lt; 0.003) were independent predictors of long-term mortality. Conclusion Concomitant malignancy adversely affects both short- and long-term outcomes in patients with acute PE. Although these patients are more vulnerable, it is possible to achieve satisfactory treatment success with acceptable bleeding rates with the inclusion of catheter-based methods as treatment option.Survival plot

The efficacy and safety of thrombolytic therapy for acute pulmonary embolism in patients with active malignant disease

Abstract Background Active malignant disease is associated with pulmonary embolism and the treatment of this condition is very challenging. The efficacy and safety of thrombolytic therapy for acute severe PE in patients with active malignant disease is unknown. Aim This study aimed to investigate hospital mortality rate and the incidence of major bleeding at 7 days according to the International Society of Thrombosis and Hemostasis (ISTH) criteria in patients with active malignant disease who were treated with thrombolytic therapy due to severe acute PE. Methods Patients with acute PE proven by computed tomography pulmonary angiography who were admitted to intensive care units have enrolled in the Regional PE Registry (REPER) since 2015, consisting of 10 hospitals from the 4 east Balkan countries. The decision to use thrombolytic therapy was at the discretion of the attending physicians, and it was used in high-risk, and intermediate-high-risk PE patients. Hospital mortality and the incidence of major bleeding at 7 days were compared between patients with active cancer and those without it who received thrombolytic therapy. Alteplase-based therapy was used. Results Among 2070 patients with acute PE enrolled in REPER, intermediate-high and high-risk PE had 795 patients without malignant disease and 135 had active malignant disease in the last 6 months. Patients with malignant disease had less chance to be treated with thrombolysis than patients without it (29.1% vs 44.7%, OR 0.508, 95%CI 0.341-0.756, p=0.001). For patients treated with thrombolysis, hospital mortality was non significantly higher in patients with the malignant disease compared to patients without it (25.6% vs 16,1%, OR 1.803, 95%CI 0.833-3.904, p=0.132), and the incidence of major bleeding at seven days was similar (15.4% vs 18.5%, OR 0.800, 95%CI 0.322-1.989, p=0.6131). There was no significant difference in age, sex, and PE risk distribution between patients with active malignant disease and those without it who were treated with thrombolysis. Conclusion Thrombolytic therapy seems to be underutilized in patients with the active malignant disease compared to patients without it in severe acute PE. In the selected patients who were treated with thrombolysis for severe acute PE, the efficacy and safety are similar between patients with and without active malignant disease.

The role of comorbidities for hospital outcome of patients with severe acute pulmonary embolism treated with thrombolytic therapy

Abstract Background The association between the outcome of severe acute pulmonary embolism treated with thrombolytic therapy and the presence of common comorbidities is fairly known. Methodology In this study we investigated the influence of common comorbidities (arterial hypertension, atrial fibrillation, heart failure, coronary disease, diabetes mellitus, active malignant disease, chronic obstructive lung disease, chronic renal failure, anemia and previous stroke) to hospital mortality and the composite of major and clinically relevant non-major bleeding at 7 days from hospital admission in patients with severe acute PE treated with thrombolytic therapy enrolled in the Regional PE Registry from the 4 west-Balkan countries. Univariate and multivariable regression analysis (adjusted to age and the presence of arterial hypotension – systolic blood pressure below 90 mmHg) was used to establish association between comorbidities and hospital outcome of acute PE treated with thrombolysis. Results 2068 patients enrolled with computed tomography pulmonary angiography proven acute, symptomatic PE, and of them 645 patients had features of intermediate-high PE (right ventricle dysfunction with positive biomarkers without severe hypotension) and 283 patients had high-risk PE with arterial hypotension. Of them, 394 (42.5%) were treated with thrombolytic therapy (245 with intermediate-high and 149 with high-risk PE). Overall hospital mortality was 17.0% and the composite of major and clinically relevant non-major bleeding at 7 days was 17.5% (11.2% was major bleeding). Among all tested comorbidities, only 3-staged renal failure (OR 3.56, 95%CI 1.78-7.15, p&amp;lt;0.001 for creatinine clearance 30-59 ml/min compare to clearance ≥ 60 ml/min; and OR 6.01, 95%CI 2.35-15.37, p&amp;lt;0.001 for creatinine clearance &amp;lt;30 ml/min versus ≥ 60 ml/min), and the presence of either paroxysmal or chronic atrial fibrillation had significant higher risk for hospital mortality adjusted to age and the presence of arterial systolic hypotension (OR 2.11, 95% 1.03-4.29, p=0.04). Between all presented comorbidities only the presence of diabetes mellitus type 2 was independently associated with the higher risk for bleeding on thrombolytic therapy OR adjusted to age 2.03, 95%CI 1.126-3.659, p=0.019. Conclusion Creatinine clearance and atrial fibrillation were the independent predictors of hospital death and diabetes mellitus type 2 for bleeding in patients with severe acute PE who were treated with thrombolysis.

Routine use of ultrasound-assisted catheter-directed thrombolysis for the management of intermediate-high risk pulmonary embolism: a service evaluation project

Abstract Background Intermediate-high risk Pulmonary Embolism (PE) has considerable morbidity. Conservative management could be sub-optimal. Ultrasound-Assisted Catheter-Directed Thrombolysis (UACDT) is used in our centre for the routine management of this presentation. Purpose We assessed the procedure safety and short-term outcomes by reviewing locally performed procedures. Methods This is an observational retrospective cohort study, with a historic control group. Our centre is a District General Hospital (DGH) in the United Kingdom, and we receive referrals from local acute hospitals. Since the introduction of this service in June 2018 until November 2023, 129 patients (2 patients/month) received routine management with UACDT for intermediate-high risk PE. The controls are 75 acute PE patients of comparable risk classes, managed from January to December 2016. We assessed procedural and in-hospital outcomes including minor, major bleeding/complications and death. We also assessed Length of Stay (LoS) in hospital, recurrent Venous Thrombo-Embolism (VTE) and re-admission rates for recurrent PE at 30 days. Reduction of oxygen requirements and improved estimated systolic Pulmonary Artery Pressure (sPAP) post-procedure were assessed as surrogate measures. Continuous variables were analysed with a Mann-Whitney U test, and categorical variables with a Chi-square Test. Results Baseline demographics are listed in Table 1. Mean duration between CT Pulmonary Angiography (CTPA) and the UACDT procedure was 1.6 (±SD 1.4) days, including inter-hospital transfer. Only 6% (8/129) of UACDT cohort received ≤12 mg standard alteplase dose. In the control group, 4% (3/75) of patients received standard 100mg systemic thrombolysis. There was no significant difference in the rates of minor (p= 0.9), major bleeding/complications (p= 0.8), or death (p= 1.0) between both groups. There was also no significant difference in rates of recurrent VTE (p= 1.0) or re-admission within 30 days for PE (p=0.1) (Table 2). LoS in hospital data were ratified, to exclude inappropriate delays (e.g. physiotherapy requirements, etc). We used the date when the patient was declared medically fit for discharge, and no significant difference was noted (p= 0.2). This was confirmed with a regression analysis of UACDT treatment effect (p= 0.9, CI= -3.5 to 3.1). Nonetheless, there was a 25% reduction of median LoS in hospital from 8 days in the controls to 6 days with UACDT. The proportion of patients requiring O2 was also reduced from 69% (89/129) to 41% (54/129) on day 1 post-procedure. A significant reduction of the estimated sPAP by TTE post-procedure was detected by a mean of 10.4 (±SD 13.9) mmHg (p= &amp;lt;0.01). Conclusion UACDT is generally safe with low complications rate. Compared to the control group, there was a reduction in absolute deaths and median LoS in hospital. This can be secondary to the significant acute reduction of systolic pulmonary artery pressure identified.

A Rare Case of Pulmonary Vascular Anomaly: MDCT Pulmonary Angiography in Diagnosis of Arteriovenous Malformation and Post-operative Imaging

Objective. To demonstrate the diagnostic algorithm and tactics of a surgical management of patients with pulmonary arteriovenous malformations.Materials and Methods. Based on a patient`s clinical data analysis, further examination tactic was chosen: in the pre and postoperative periods multispiral computed tomography (MSCT) angiopulmonography (on a Canon Aquillion Prime, Japan) was performed before and after intravenous administration of a iodine-containing contrast agent (Ultravist, 370 mg/ ml) at the rate of 1 ml/kg. Brain magnetic resonance tomography was performed on a Signa Voyager, General Electric, China, 1,5 Tl in the pulse sequences T1, T2, T2 FLAIR, DWI, SWAN in three mutually perpendicular planes with a slice thickness of 1-5 mm to examine the neurological complications. Interventional angiopulmonography was implemented by using General Electric Innova IGS530, France, angiographic system before and after endovascular occluder ("AMPLATZER Vascular PLUG 4", USA) and spirals ("2D-Helical-35" 9 mm in diameter and 2,7 mm long (4 spirals) and "Complex–Helical-18" 11 mm in diameter and 17 mm long, USA) placement. A literature review in Russian and English languages for the last 5 years was searched using CyberLeninka, PubMed Central, Elibrary data bases, by keywords: pulmonary arteriovenous malformation, MSCT angiopulmonography, endovascular treatment. The prospective longitudinal study was conducted in compliance with the principles of ethics in accordance with the Helsinki Declaration, and informed voluntary consent was obtained from the patient.Results. According to clinical and instrumental data, the tactics of combined endovascular treatment of a vascular malformation with subsequent postoperative control was collectively chosen. During the curation, an increase in saturation parameters, general wellbeing improvement, decrease in pulmonary pressure parameters, and diminution in the size of the right heart's parts were achieved.Conclusion. Arteriovenous malformations (AVMs) are rare vascular abnormalities that represent a pathological communication between the arterial and venous bed. The fistulous link leads to an abnormal discharge of blood, bypassing the physiological capillary channel. Radiation and interventional visualization methods play the most important diagnostic, and the latest — therapeutic role in management of patients and are able to establish indications for surgical intervention, prevent the occurrence of life-threating complications: abscesses, paradoxical embolism and heart attacks, progressive respiratory and heart failure.

A review of the use of CT pulmonary angiography in pregnant and postpartum women at an academic centre.

Pulmonary embolism (PE) is a common cause of maternal death during pregnancy and the puerperium yet data on its prevalence in middle-income countries is lacking. We examined the medical records and CTPA (computed tomography pulmonary angiography) images of 67 women in an obstetric high care unit during pregnancy and the puerperium. We aimed to determine the prevalence of PE in a high-risk obstetric population undergoing CTPA, assess associated clinical features in this cohort, and determine the prevalence of alternative CT findings. CTPA detected PE in 11 women (16.42%) and alternative CT findings in 46 (68.6%). Women with PE had a lower systolic blood pressure than those without PE (P = 0.001). Multiple gestation, preterm rupture of membranes, and gestational diabetes were linked to higher PE prevalence. This study, set in an upper middle-income country, demonstrated a higher CTPA yield for PE and alternative diagnoses than in international literature, emphasising context-specific assessments.

Machine learning-based prediction of pulmonary embolism to reduce unnecessary computed tomography scans in gastrointestinal cancer patients: a retrospective multicenter study

This study aimed to develop a machine learning (ML) model for predicting pulmonary embolism (PE) in patients with gastrointestinal cancers, a group at increased risk for PE. We conducted a retrospective, multicenter study analyzing patients who underwent computed tomographic pulmonary angiography (CTPA) between 2010 and 2020. The study utilized demographic and clinical data, including the Wells score and D-dimer levels, to train a random forest ML model. The model’s effectiveness was assessed using the area under the receiver operating curve (AUROC). In total, 446 patients from hospital A and 139 from hospital B were included. The training set consisted of 356 patients from hospital A, with internal validation on 90 and external validation on 139 patients from hospital B. The model achieved an AUROC of 0.736 in hospital A and 0.669 in hospital B. The ML model significantly reduced the number of patients recommended for CTPA compared to the conventional diagnostic strategy (hospital A; 100.0% vs. 91.1%, P < 0.001, hospital B; 100.0% vs. 93.5%, P = 0.003). The results indicate that an ML-based prediction model can reduce unnecessary CTPA procedures in gastrointestinal cancer patients, highlighting its potential to enhance diagnostic efficiency and reduce patient burden.

Prognostic performance of the Bova, sPESI, and Qanadli scores in patients with acute pulmonary embolism.

Acute pulmonary embolism (PE) is a disease with a serious prognosis and a high probability of death in the emergency department. To investigate the prediction of PE-related mortality and intensive care admission (ICU) of Qanadli (Qscore), Bova, and simplified Pulmonary Embolism Severity Index (sPESI) scores. This retrospective observational study consisted of all patients diagnosed with acute PE who were imaged under computed tomography pulmonary angiography (CTPA) for a total of 5 years between 1 June 2018 and 1 June 2023. The prediction of radiological and clinical scores for mortality and ICU admission was examined. A total of 95 patients were analyzed. Patients who died and those who were admitted to the ICU had a significantly higher frequency of being found to have a high-risk (≥1) sPESI score (P = 0.04 and P = 0.016, respectively). For mortality, the sPESI score was found to be significant; the sensitivity and specificity were observed as 54% and 66% (area under the curve [AUC]=0.670, 95% confidence interval [CI]=0.527-0.814; P = 0.020). For ICU admission, the sensitivity and specificity of the Qscore, sPESI, and Bova scores were 35%, 77%, and 58%, and 78%, 65%, and 84% respectively (AUC=0.626, 95% CI=0.511-0.740, P = 0.031; AUC=0.769, 95% CI=0.674-0.865, P < 0.001; and AUC=0.767, 95% CI=0.671-0.862, P < 0.001, respectively). It was found that the sPESI score was effective at predicting mortality in patients with acute PE. Qscore, sPESI, and Bova scores have been shown to be useful in predicting ICU admission.

44 Spotting the clotting: a 3-year national surveillance study of paediatric pulmonary thromboembolism

Abstract Background Pulmonary thromboembolism (PE) is a rare event in the paediatric population but can be acutely life-threatening and result in chronic complications. Awareness of contemporary patterns of clinical presentation, diagnostic modalities, and management may aid clinicians in ensuring that patients are promptly identified and treated. Objectives To describe the risk factors, symptoms, diagnostic modalities, therapeutic interventions, and short-term outcomes in paediatric patients (neonate up to 18 years) with PE through national surveillance. Design/Methods Between January 2020 and December 2022, monthly surveillance was conducted with over 2,800 paediatricians and sub-specialists through the Canadian Paediatric Surveillance Program. Voluntary reporting of cases meeting a standardized definition of PE was followed up with a detailed questionnaire. Results 58 confirmed cases were reported; 33 (57%) were females age 15 to 18 years. Detailed information was available for 31 (53%) of 58 cases. At least 1 risk factor was identified in 28 (90%) cases and 12 (39%) patients had 2 or more risk factors. The most common risk factors were oral contraceptive use (n=10 of 31; 32%) and obesity (n=9 of 31; 29%). Presentation was symptomatic in 28 (90%) cases; 24 (77%) patients presented with 2 or more symptoms. The most common symptoms were chest pain (n=18; 58%), dyspnea (n=13; 42%) and tachycardia (n=13; 42%). The most common diagnostic modality utilized was computed tomography pulmonary angiography (n=25; 81%). Initiation of systemic anticoagulation was reported for 24 (77%) of 31 cases; thrombolysis and surgical interventions were uncommon (&amp;lt; 5 cases). Treatment complications were common (n=8; 29%). Mortality was reported, but in fewer than 5 cases. Conclusion PE in children often presents with non-specific symptoms, but usually occurs in patients with known risk factors. Clinicians should maintain a high index of suspicion in symptomatic patients, particularly those with risk factors and in cases when other diagnoses that may explain symptoms have been excluded. Anticoagulation is the mainstay of treatment; complications can occur. Prompt recognition and management presumably reduce morbidity and mortality, but this cannot be inferred from our data.