Pulmonary Artery Obstruction Index Research Articles

Elevation of Serum Prostate-Specific Antigen Levels in Males With Pulmonary Embolism.

Hypoxemia is a clinical characteristic of pulmonary embolism (PE). Hypoxemia is associated with variations in serum prostate-specific antigen (PSA) levels. Thus, the present study aimed to determine serum PSA levels in patients with PE, which may be helpful in improving clinical evaluation in screening for prostate diseases in those with PE. Clinical data from 61 consecutive male patients with PE and 113 age-matched healthy male controls were retrospectively analyzed. The pulmonary artery obstruction index (PAOI) was used to evaluate the pulmonary embolic burden. Compared with healthy controls, serum total PSA (tPSA) levels were significantly increased (P = .003), and free PSA (fPSA)/tPSA ratio was significantly decreased in patients with PE (P < .001). There was no significantly difference in serum fPSA levels between patients with PE and healthy controls (P = .253). A significant positive association was observed between serum tPSA levels and PAOI in patients with PE (β = .270, P = .036). Multivariable linear regression analysis revealed that serum tPSA levels were independently associated with PAOI in patients with PE (β = .347, P = .003). Serum tPSA levels were higher in male patients with PE than those in healthy controls, but fPSA was not affected. These findings highlight that PE may elevate serum tPSA levels, and that measures of tPSA should be interpreted with caution in screening for prostate diseases in patients with PE.

Predictive Value of Pulmonary Artery Distensibility for Short-Term Adverse Clinical Outcomes in Patients with Acute Pulmonary Embolism.

We aimed to explore the relationship between pulmonary artery distensibility obtained from computed tomography pulmonary angiography (CTPA) and short-term adverse clinical outcomes in patients with acute pulmonary embolism (APE). We included patients who underwent retrospective electrocardiogram-gated CTPA and were subsequently diagnosed with APE. Patients were categorized into good and poor outcome groups based on short-term clinical outcomes. Pulmonary artery distensibility (AD), right ventricle/left ventricle (RV/LV) ratio, and pulmonary artery obstruction index (PAOI) were measured, and the receiver operating characteristic curves were constructed. Sixty-four patients with APE (good outcome, 46; poor outcome, 18) were enrolled. AD, RV/LV ratio, and PAOI differed significantly between groups (P < 0.05). Pulmonary artery AD in the good outcome group was greater than that in the poor outcome group (P < 0.001). The poor outcome group exhibited a higher RV/LV ratio and PAOI than the good outcome group (P < 0.05). AD and PAOI were independent predictors of adverse clinical outcomes. Areas under the curve for AD and PAOI were 0.860 (95% confidence interval [CI]: 0.750-0.934) and 0.675 (95%CI: 0.546-0.786), and the combined curve of the AD and RV/LV ratio was 0.906 (95%CI: 0.806-0.965). The calibration curve showed a combined curve superior to the other curves. The decision curve showed high clinical application value of the combined curve. Retrospective electrocardiogram-gated CTPA-derived AD could serve as an indicator for predicting short-term adverse clinical outcomes in APE. Combining AD and PAOI has a high predictive value for short-term adverse clinical outcomes.

Alterations and Significance of Computed Tomography Pulmonary Angiography-Derived Parameters in Older Patients With Acute Pulmonary Embolism.

This study aimed to investigate changes of computed tomography pulmonary angiography (CTPA)-derived parameters in older adults with acute pulmonary embolism (APE). According to the pulmonary artery obstruction index (PAOI), patients with APE were divided into the A1 (PAOI ≥30%, n = 57) and A2 (PAOI <30%, n = 40) groups. Participants without APE were placed in group B (n = 170). The left atrial (LA) and left ventricular (LV) parameters among the three groups were compared, and the parameter changes in the 44 patients with APE were analyzed before and after treatment. The correlation between APE severity and the parameters was analyzed using correlation analysis. The left-to-right diameters (LR) of LA, and LR × anteroposterior diameters (AP) of LA and LV: A1 < A2 < B; LR of LV: A1 < A2, B; AP of LA and LV: A1, A2 < B. After treatment, LR and LR × AP of the LA and LV were significantly increased in the group A1 and LR of the LV and LR × AP of the LA and LV were elevated in the group A2. Acute pulmonary embolism severity was closely associated with LR × AP ( r = -0.557) and LR ( r = -0.477) of LA. With an increase in the degree of obstruction, older adults had a smaller LA and LV. Furthermore, the LR and LR × AP values of the LA were significantly decreased. These results contribute to in-time risk stratification.

Does Adding the Pulmonary Infarction and Right Ventricle to Left Ventricle Diameter Ratio to the Qanadli Index (A Combined Qanadli Index) More Accurately, Predict Short-Term Mortality in Patients with Pulmonary Embolism?

Background The Qanadli index can be used to assess the severity of pulmonary arterial involvement in patients with acute pulmonary embolism. However, it seems that considering pulmonary infarction and right ventricle/left ventricle (RV/LV) ratio along with this index (called the combined Qanadli index) can provide a more accurate view of changes in cardiovascular parameters in these patients and help predict mortality in a better manner. In this regard, we evaluated the ability of the combined Qanadli index versus the Qanadli index in predicting short-term mortality in patients with pulmonary embolism. Methods This retrospective study enrolled 234 patients with acute pulmonary embolism. Patients were divided into two groups: those who expired in 30 days and who survived. Then they were evaluated by computed tomography angiography of pulmonary arteries. The RV/LV diameter ratio and also pulmonary artery obstruction index (PAOI) were calculated. The patient's computed tomography scans were reviewed for pulmonary infarction. By adding the RV/LV ratio and pulmonary infarction to PAOI, a new index called the modified Qanadli score was made. Univariable and multivariable logistic regression was done for finding predictors of mortality. Results Nine cases (40%) of patients in the mortality group and 42 (20%) of survivors had ischemic heart disease and the difference was significantly meaningful. The mean Qanadli index in the mortality group was 16.8 ± 8.45 and in survivors was 8.3 ± 4.2. By adding the pulmonary infarction score and PAOI score to RV/LV ratio score, the odds ratio (OR) for predicting mortality increased significantly to 13 and 16, respectively, which were significantly meaningful. Based on our findings, the highest OR for predicting short-term mortality was obtained through a combined Qanadli index (PAOI score + pulmonary infarction score + RV/LV score) that was 17 in univariable and 18 in multivariable logistic regression analysis ( p -value = 0.015). Conclusion The new combined Qanadli index has more ability than the Qanadli index and RV/LV ratio for predicting changes in cardiovascular parameters and short-term mortality in patients with pulmonary embolism.

Neutrophil levels upon admission for the assessment of acute pulmonary embolism with intermediate- and high-risk: an indicator of thrombosis and inflammation

BackgroundRisk prediction rules are important to establish appropriate treatment and management strategy for patients with different risk classification of pulmonary embolism (PE). Neutrophils are considered to be related to PE as an essential marker of inflammation. However, few studies have reported the association between neutrophil levels and risk classification of acute PE (APE). The aim of this study was to investigate the role of neutrophil levels upon admission in the assessment of risk classification of APE.MethodsA total of 299 consecutive APE patients and 90 patients without APE confirmed by computed tomographic pulmonary angiography were retrospectively screened. APE patients were stratified into two subgroups according to clinical guidelines: low- (n = 233) and intermediate- and high-risk (n = 60) APE.ResultsThe neutrophil levels in intermediate- and high-risk APE patients were significantly higher compared to low-risk APE or non-APE patients (P < 0.001). In multivariable logistic regression analysis, neutrophil levels were significantly and independently associated with intermediate- and high-risk APE (odds ratio = 1.239, 95% confidence interval [CI] 1.055–1.455, P = 0.009). Neutrophil levels were positively correlated with the pulmonary embolism severity index score (r = 0.357, P < 0.001), high sensitive C-reactive protein, D-dimer and pulmonary artery obstruction index (PAOI), in the overall population of APE patients. Receiver-operating characteristic curve analysis revealed that neutrophils had a better diagnostic value for intermediate- and high-risk APE (area under the curve [AUC] = 0.760, 95% CI 0.695–0.826; P < 0.001) compared to PAOI (AUC = 0.719) and D-dimer (AUC = 0.645).ConclusionsHigh neutrophil levels upon admission were significantly and independently associated with intermediate- and high-risk APE, which could be regarded as an indicator of inflammation and thrombosis in APE simultaneously. The potent diagnostic role of neutrophil levels and their competitive advantage over PAOI and D-dimer for the assessment of APE risk classification are suggested.

Impact of obstructive sleep apnea on outcomes of pulmonary embolism: A systematic review and meta‑analysis.

The current review aimed to assess the effect of obstructive sleep apnea (OSA) on the severity and outcomes of pulmonary embolism (PE). PubMed, Embase, ScienceDirect, CENTRAL and Google Scholar were searched for studies assessing the impact of OSA on severity and outcomes of PE. A total of 12 studies were included. Meta-analysis revealed that simplified PE severity index of >1 and pulmonary artery obstruction index score was significantly higher in patients with OSA as compared with controls, but there was no difference in right ventricle to left ventricle short-axis diameter. The need for non-invasive ventilation was significantly higher in patients with OSA but there was no difference in the need for mechanical ventilation. Patients with OSA had a significantly higher incidence of recurrence of PE. Meta-analysis also showed a statistically significantly lower risk of in-hospital mortality in patients with OSA as compared with controls, but without any difference in the risk of late mortality. Adjusted data on mortality indicated a significantly lower risk of mortality in PE patients with comorbid OSA. Limited data shows that comorbid OSA increases the severity of PE but has no effect on right ventricular function. OSA may increase the risk of recurrent PE. Paradoxically, the presence of OSA may also reduce the risk of in-hospital mortality. Results must be interpreted with caution owing to high inter-study heterogeneity and lack of matching of baseline characteristics. Current evidence needs to be confirmed by high-quality prospective studies.

The relationship between pulmonary artery obstruction index and troponin in thorax computed tomography in pulmonary embolism

Aim: To study the relation between troponin and pulmonary artery obstruction index in thoracic computerized tomography in patients diagnosed with acute pulmonary embolism.&#x0D; Material and Method: Data obtained from patients hospitalized in the ward and intensive care units with a pulmonary embolism diagnosis between January 2016 and February 2022 were scanned retrospectively. The full blood count, D-dimer, C-reactive protein, procalcitonin, troponin I, thoracic computerized tomography (CT), angiography, and bilateral lower extremity venous Doppler ultrasonography data were extracted. Patients with left heart failure, renal failure, gastrointestinal hemorrhage, sepsis, respiratory system disease, burns, ischemic stroke, or subarachnoid hemorrhage were excluded. The obstruction indices were calculated according to storage defects in the main, right, left, lobar, and segmental pulmonary artery branches in CT angiography.&#x0D; Results: While 57.0% of the 69 patients included in the study were female, 42.1% were male. The obstruction index in the high troponin-I group was significantly higher than that in the normal troponin-I group (p=0.006). In addition, the obstruction index was significantly higher in patients with bilateral pulmonary embolism than in those with unilateral pulmonary embolism (

Evaluation of serum YKL-40 level among clinical risk scores for early mortality in acute pulmonary thromboembolism

IntroductionPulmonary embolism (PE) often occurs secondary to deep vein thrombosis and is an important cause of mortality and morbidity. This study aimed to evaluate the relationship between YKL-40 level and clinical risk score in patients with PE. MethodsThe study included a total of 100 patients, 80 patients diagnosed with PE in the emergency department and 20 healthy controls. Patients with PE were divided into four groups: high-risk patients (n = 20), high-intermediate-risk patients (n = 20), low-intermediate-risk patients (n = 20), and low-risk patients (n = 20). Serum YKL-40 levels were measured by enzyme-linked immunosorbent assay. Pulmonary artery obstruction index (PAOI) was calculated from computed tomography angiography images. ResultsPAOI increased in correlation with PE risk and differed significantly between all patient groups (p < 0.001). Troponin-I levels were significantly higher in the high-risk and high-intermediate-risk groups compared to the other groups (p < 0.001), but did not differ significantly between high-risk and high-intermediate-risk patients (p = 0.09). YKL-40 level was significantly higher in the high-risk PE group than the high-intermediate-risk group (p < 0.001). In receiving operator characteristic curve analysis assessing the discriminatory value of YKL-40 for high-risk PE patients, a cut-off value of 227.2 ng/mL had sensitivity of 85 % and specificity of 70 %. DiscussionYKL-40 may be an important biomarker in decisions regarding early thrombolytic treatment in patients with high-intermediate-risk PE. In addition, medical treatments targeting YKL-40 may also reduce thrombotic tendency in high-risk patient groups.

Pulmonary embolism and thrombus-in-transit: a hazardous combination

Acute pulmonary thromboembolism (PTE) is an important cause of morbidity and mortality that can reduce quality of life due to long-term complications during and after treatment discontinuation.The aim of this study was to evaluate patients for these complications before discontinuing treatment and determine the necessity of computed tomography pulmonary angiography (CTPA) imaging.This retrospective study included 116 patients over the age of 18 who received anticoagulant treatment for at least 3 months and presented for treatment discontinuation to the Atatürk University Research Hospital Chest Diseases Outpatient Clinic between January 2015 and September 2019.CTPA performed at treatment discontinuation showed complete thrombus resolution with treatment in 73 patients (62.9%). High pulmonary artery obstruction index (PAOI) at diagnosis was statistically associated with findings of residual or chronic thrombus on CTPA at treatment discontinuation (p = 0.001). In the differentiation of patients with residual/chronic thrombus and those with thrombus resolution, D-dimer at a cut-off value of 474 µg/L had 60% sensitivity and 70% specificity. At a cut-off value of 35.5 mmHg, mean pulmonary artery pressure on echocardiography had sensitivity and specificity of 72% and 77%, respectively. At a cut-off of 23.75, PAOI had sensitivity and specificity of 93% and 69%, respectively.In addition to physical examination findings, D-dimer and echocardiography were guiding parameters in the evaluation of treatment discontinuation and thrombus resolution in patients presenting to the outpatient clinic for discontinuation of treatment for acute PTE. PAOI at diagnosis may be another important guiding parameter in addition to these examinations.

Investigation of the need for computed tomography pulmonary angiography in the decision to discontinue treatment for pulmonary thromboembolism

BackgroundAcute pulmonary thromboembolism (PTE) is an important cause of morbidity and mortality that can reduce quality of life due to long-term complications during and after treatment discontinuation. ObjectivesThe aim of this study was to evaluate patients for these complications before discontinuing treatment and determine the necessity of computed tomography pulmonary angiography (CTPA) imaging. MethodsThis retrospective study included 116 patients over the age of 18 who received anticoagulant treatment for at least 3 months and presented for treatment discontinuation to the Atatürk University Research Hospital Chest Diseases Outpatient Clinic between January 2015 and September 2019. ResultsCTPA performed at treatment discontinuation showed complete thrombus resolution with treatment in 73 patients (62.9%). High pulmonary artery obstruction index (PAOI) at diagnosis was statistically associated with findings of residual or chronic thrombus on CTPA at treatment discontinuation (p = 0.001). In the differentiation of patients with residual/chronic thrombus and those with thrombus resolution, D-dimer at a cut-off value of 474 µg/L had 60% sensitivity and 70% specificity. At a cut-off value of 35.5 mmHg, mean pulmonary artery pressure on echocardiography had sensitivity and specificity of 72% and 77%, respectively. At a cut-off of 23.75, PAOI had sensitivity and specificity of 93% and 69%, respectively. ConclusionIn addition to physical examination findings, D-dimer and echocardiography were guiding parameters in the evaluation of treatment discontinuation and thrombus resolution in patients presenting to the outpatient clinic for discontinuation of treatment for acute PTE. PAOI at diagnosis may be another important guiding parameter in addition to these examinations.

Pulmonary artery obstruction index, pulmonary artery diameter and right ventricle strain as prognostic CT findings in patient with acute pulmonary embolism

ObjectiveThis study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. Materials and methodsIn the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. ResultsPAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). ConclusionsPAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.

The value of ventilation/perfusion scanning and CT pulmonary angiography in predicting chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a one-year follow-up study.

To investigate the value of ventilation/perfusion (V/Q) scanning and CT pulmonary angiography (PA) in predicting CTEPH development after acute pulmonary embolism (APE). This study was performed in APE patients who had undergone both V/Q and CT PA after 3-month anticoagulation. The residual pulmonary obstructions were assessed based on V/Q and CT PA, and then recorded as pulmonary perfusion detect score (PPDs) and CT pulmonary artery obstruction index (PAOI). The predictive performance of PPDs and CT PAOI for CTEPH were determined and risk factors for predicting CTEPH development were identified. A total of 235 patients withinitial diagnosis of APE were included in this study. ROC analysis showed that the AUCs of the PPDs and CT PAOI were 0.957 and 0.895, with corresponding cut-off values of 20.50% and 17.50% for predicting CTEPH development. Neither sensitivity nor specificity differed significantly between PPDs and CT PAOI (Sensitivity:92.00% vs. 80.00%, P = 0.25; Specificity:88.10% vs. 89.52%, P = 0.69). The univariable and multivariable logistic regression analysis demonstrated that pulmonary arterial hypertension confirmed by echocardiography at initial APE diagnosis (OR: 6.16, 95%CI: 1.31-29.02, P = 0.02), a PPDs of > 20.50% (OR: 22.95, 95%CI: 2.37-222.19, P = 0.007), and a CT PAOI of > 17.50% (OR: 9.98, 95%CI: 2.06-48.49, P = 0.004) were associated with CTEPH development. Both V/Q and CT PA after 3-month anticoagulation for APE showed great performance in predicting CTEPH development, and V/Q scanning has a tendency to be more sensitive but less specific than CT PA. The residual pulmonary embolism detected by V/Q and CT PA was associated with an increased risk of CTEPH development.

Catheter Directed Thrombolysis in the Treatment of Acute Pulmonary Embolism: Early Hemodynamic Recovery and Improvement in Prognosis.

Aim In this study, we aimed to investigate the efficacy of catheter directed thrombolysis (CDT) and peripheral intravenous thrombolysis (PIT) in the treatment of patients with acute pulmonary embolism (APE) and assess its effect on the prognosis of patients. Methods We recruited 74 patients with APE, who were assigned to CDT and PIT groups, according to the treatments received by them. The arterial partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (Pa CO2), pulmonary artery pressure (PAP), pulmonary artery obstruction index (PAOI), thrombus volume, pain score, and therapeutic benefits were compared between the two groups before and after treatment, and the factors affecting patient prognoses were also analyzed. Results Using the clinical data before treatment as the baseline, it was found that changes in indicators of plasma, thrombus volume, and pain scores were significantly better in the CDT group than in the PIT group after treatment. The total effective rate of CDT was higher than that of PIT in the treatment of APE. The mean follow-up time for both the CDT and PIT groups was 41.08 ± 9.12 months, and the total mortality rate was 14.8% and 31%, respectively. The logistic regression analysis revealed the significant impacts of previous incidences of pulmonary embolism (PE), concurrent deep vein thrombosis (DVT), and pulmonary arterial hypertension (PAH) on the occurrence and progression of APE, and these factors were subsequently identified as risk factors for APE using Kaplan–Meier survival analysis. Observations from PAE onset to the end of follow-up revealed that there was a difference in survival rates between the CDT and PIT groups. Conclusions Taken together, CDT is an effective treatment strategy for APE and can provide effective symptomatic relief. In addition, the previous incidences of PE, concurrent DVT, and PAH are important risk factors that affect the survival rates of patients with APE.

Differential diagnosis of acute pulmonary embolism using contrast echocardiography.

Acute pulmonary embolism (aPE) leads to a significant decrease in antegrade pulmonary blood volume (PBV), which can be measured by contrast echocardiography at the bedside. The aim of this work was to evaluate the feasibility and performance of PBV differentiating between patients with and without aPE. A total of 89 patients underwent computed tomography pulmonary angiography (CTPA) for suspected aPE were enrolled in the study. Their clinical and conventional echocardiographic characteristics were collected. Contrast echocardiography with measurements of PBV were performed. There were 57 patients with aPE, with a mean Mastora pulmonary artery obstruction index (PAOI) of 56.14%. Pulmonary transit time (PTT), normalized PTT (nPTT) and PBV in patients with aPE was less than one half of those in patients without PE (p<0.05). There was significant negative correlation between PBV and Mastora PAOI (r=-0.897, p<0.01). None of the conventional echocardiographic parameters had an area under the receiver operating characteristic curve of >0.5, while it was 0.997(0.984~1.010) for PBV in differentiating between patients with aPE or not. The optimal cutoff valueof PBV was 370ml, with a sensitivity of 100%, a specificity of 95.45% and an accuracy of 96.55%. PBV had a powerful performance in differentiating between patients with aPE or not, and a PBV of <370ml indicated aPE. Contrast echocardiography is enormously useful in the recognition and differentiation of PE and can assess the severity of the PE and the patient's response to therapy.

CT Angiography Clot Burden Score from Data Mining of Structured Reports for Pulmonary Embolism.

Background Many studies emphasize the role of structured reports (SRs) because they are readily accessible for further automated analyses. However, using SR data obtained in clinical routine for research purposes is not yet well represented in literature. Purpose To compare the performance of the Qanadli scoring system with a clot burden score mined from structured pulmonary embolism (PE) reports from CT angiography. Materials and Methods In this retrospective study, a rule-based text mining pipeline was developed to extract descriptors of PE and right heart strain from SR of patients with suspected PE between March 2017 and February 2020. From standardized PE reporting, a pulmonary artery obstruction index (PAOI) clot burden score (PAOICBS) was derived and compared with the Qanadli score (PAOIQ). Scoring time and confidence from two independent readings were compared. Interobserver and interscore agreement was tested by using the intraclass correlation coefficient (ICC) and Bland-Altman analysis. To assess conformity and diagnostic performance of both scores, areas under the receiver operating characteristic curve (AUCs) were calculated to predict right heart strain incidence, as were optimal cutoff values for maximum sensitivity and specificity. Results SR content authored by 67 residents and signed off by 32 consultants from 1248 patients (mean age, 63 years ± 17 [standard deviation]; 639 men) was extracted accurately and allowed for PAOICBS calculation in 304 of 357 (85.2%) PE-positive reports. The PAOICBS strongly correlated with the PAOIQ (r = 0.94; P < .001). Use of PAOICBS yielded overall time savings (1.3 minutes ± 0.5 vs 3.0 minutes ± 1.7), higher confidence levels (4.2 ± 0.6 vs 3.6 ± 1.0), and a higher ICC (ICC, 0.99 vs 0.95), respectively, compared with PAOIQ (each, P < .001). AUCs were similar for PAOICBS (AUC, 0.75; 95% CI: 0.70, 0.81) and PAOIQ (AUC, 0.77; 95% CI: 0.72, 0.83; P = .68), with cutoff values of 27.5% for both scores. Conclusion Data mining of structured reports enabled the development of a CT angiography scoring system that simplified the Qanadli score as a semiquantitative estimate of thrombus burden in patients with pulmonary embolism. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Hunsaker in this issue.

Could VEGF-D level have a role in clinical risk scoring, estimation of thrombus burden, and treatment in acute pulmonary thromboembolism?

Pulmonary embolism (PE) is usually a complication of deep vein thrombosis and is an important cause of mortality and morbidity. Vascular endothelial growth factor D (VEGF-D) is a secretory protein that plays a role in the remodelling of blood vessels and the lymphatic system. This study aimed to determine the relationship between VEGF-D level and clinical risk scoring in patients with PE. The study included 117 patients admitted for PE that were divided into four groups: high-risk patients (n=35), high-intermediate-risk patients (n=30), low-intermediate-risk patients (n=24), and low-risk patients (n=28). Plasma VEGF-D was measured from peripheral venous blood samples (5mL) using a commercial enzyme-linked immunosorbent assay (ELISA) kit. Pulmonary Artery Obstruction Index (PAOI) was calculated from CT angiography imaging. There was no significant difference in troponin-I and NT-proBNP levels between the high-intermediate-risk and high-risk PE patients (P=.134, .146). VEGF-D and PAOI levels were found to be statistically significantly higher in high-risk patients compared with high-intermediate-risk patients (P=.016, .001). VEGF-D level was moderately correlated with mean pulmonary artery pressure and PAOI (r=.481, P=.01; r=.404, P=.01). In ROC curve analysis, a cut-off of 370.1pg/mL for VEGF-D had 91.4% sensitivity and 67% specificity in the differentiation of high-intermediate-risk and high-risk PE patients. This study showed that plasma VEGF-D level was more reliable than troponin-I and NT-proBNP in clinical risk scoring and demonstrating thrombus burden. VEGF-D can be used as a biomarker in clinical risk scoring and estimation of thrombus burden in patients with acute PE.

Índice de obstrucción de la arteria pulmonar, diámetro de la arteria pulmonar y strain del ventrículo derecho como hallazgos pronósticos de la tomografía computarizada en el paciente con embolia pulmonar aguda

ObjectiveThis study was designed to determine predictors of pulmonary hypertension and signs of right heart dysfunction caused by pulmonary embolism (PE) that may lead to early detection of high-risk patients. So the predictive value of pulmonary artery obstruction index (PAOI), measured by pulmonary CT angiography (PCTA) in the acute setting, in predicting the patients susceptible to PE cardiac complications was evaluated. Also two other PCTA indices, pulmonary artery diameter (PAD), and right ventricle (RV) strain, in these patients were investigated and their predictive value for cardiac complications on follow up echocardiography were demonstrated. Materials and methodsIn the study 120 patients with a definite diagnosis of PE were included. The PAOI, PAD and RV strain were measured using PCTA at the time of the initial diagnosis. Transthoracic echocardiography was done 6 months after the diagnosis of PE and RV echocardiographic indices were measured. Pearson correlation was used to investigate correlation between PAOI, PAD, RV strain and signs of right heart dysfunction. ResultsPAOI was strongly correlated with systolic pulmonary artery pressure (SPAP) (r=0.83), RV systolic pressure (r=0.78) and RV wall thickness (r=0.61) in long-term follow up echocardiography. A higher rate of RV dysfunction and RV dilation was detected among the patients with higher PAOI (P<0.001). PAOI≥18 was strongly predictive for development of RV dysfunction. Also developments of pulmonary hypertension, RV systolic hypertension, RV dilation, RV dysfunction, and RV hypertrophy were significantly more common among patients with higher PAD and RV strain (P<0.001). ConclusionsPAOI, PAD and RV strain are sensitive and specific PCTA indices that can predict the development of long-term complications such as pulmonary hypertension and right heart dysfunction, at the time of initial PE diagnosis.

Clinical and angiopulmonographic association in pulmonary embolism

To detect the effect of the feature of the pulmonary vascular obstruction on the clinical manifestations of pulmonary embolism (PE). The 127 patients with PE were included in this study. PE verified with multidetector computed tomography with pulmonary angiography. Among them were 57 patients with high-risk PE, and 39 patients with intermediate-risk PE and 31 patients with low-risk PE. The pulmonary artery obstruction index and the obstruction level were determined. The mean values of the pulmonary artery obstruction index in high and intermediate risk patients were 42.5%, and in low risk patients 12.5% (p0.001). The trunk or main branches obstruction was in 80.7% of high-risk PE patients, the main or lobar branches obstruction in 92.3% of intermediate-risk patients and lobar or segmental branches obstruction in 93.5% of low-risk patients. Pulmonary infarction was detected in 89.2% of patients with the segmental branches obstruction and with another level of obstruction in 28.0% of patients only (p0.001). The hemodynamic disorder in pulmonary embolism associate with the pulmonary artery obstruction index of more than 30%. The development of obstructive shock is associated with the pulmonary artery trunk obstruction, and the development of pulmonary infarction associated with the segmental branches obstruction.

Quantitative measurement of cross-sectional area of small pulmonary vessels in pulmonary embolism

Objective: The relationship between the percentage of total cross-sectional area (% CSA) of small pulmonary vessels for the lung area in CTPA and the right ventricular function parameters in patients with pulmonary embolism. Methods: 120 patients with PE and 72 healthy subjects underwent CTPA and all date were analyzed Retrospectively. The main pulmonary artery diameter (mPA), the ratio of the main pulmonary artery to the ascending aorta diameter (rPA), right ventricle/left ventricular diameter ratio (RVd/LVd), and the pulmonary artery obstruction index (PAOI) in the PE group were measured for all subjects. The %CSA<5 mm(2) and 5-10 mm(2) for the lung area (%CSA(<5) and %CSA(5-10)) of small pulmonary vessels were measured with Image J image-processing program. According to the risk stratification of the 2018 Guidelines for the Diagnosis and Treatment of Pulmonary Thromboembolism, PE patients were divided into medium-high risk group (RVd/LVd>1) and low-risk group (RVd/LVd<1). The indexes of PE in medium-high risk group, low risk group and control group were compared by ANOVA, and the indexes among PE subgroups were compared by independent sample t-test. Spearman correlation method was used to analyze the correlation between %CSA and right ventricular function parameters of PE patients. Results: %CSA(<5) of medium-high risk group, low-risk group and control group were (0.69±0.19)%, (0.95±0.27)% and (0.99±0.30)% (P<0.01), respectively. %CSA(5-10) of three groups were (0.63±0.15)%, (0.84±0.18)%, and (0.85±0.25)% (P<0.01), respectively; %CSA(<5) and %CSA(5-10) of medium-high risk group were lower than low-risk group and control group. %CSA(<5) and %CSA(5-10) in PE patients correlated negatively with RVd/LVd, rPA and mPA (r=-0.545/-0.549, -0.235/-0.352, -0.239/-0.298, respectively). Conclusion: The measurement of % CSA<(5) and %CSA (5-10) in CTPA were negatively correlated with RVd/LVd in patients with pulmonary embolism, which indirectly reflected the severity of the pulmonary embolism patients.

Efficacy of Computed Tomography Pulmonary Angiography as Non-invasive Imaging Biomarker for Risk Stratification of Acute Pulmonary Embolism.

Objectives:Massive and sub-massive pulmonary embolisms (PEs) are associated with high mortality and morbidity. The mainstay of treatment for PE is anticoagulation. However, high- and intermediate-risk patients may benefit from interventional thrombolytic therapy. Computed tomography pulmonary angiography (CTPA) is widely available, fast, and non-invasive technique, and it can identify pulmonary thrombus down to at least a segmental level. In this study, we attempt to evaluate the efficacy of CTPA as a non-invasive imaging biomarker for risk stratification of acute PE (APE) patients.Material and Methods:This is a prospective study conducted on 150 patients who proved to have APE by CTPA. The simplified PE severity index score was obtained. The pulmonary artery obstruction index (PAOI) using and right to left ventricular (RV/LV) diameter ratios were calculated.Results:The patients were divided into (1) high risk (shocked) and (2) non-high risk groups. There was a significant difference between the 1st and 2nd groups regarding PAOI. Hemodynamically stable patients were further subclassified according to the right ventricular dysfunction (RVD) into Group Ia (intermediate risk) and Group Ib (low risk). There was a significant difference between subgroups regarding PAOI (P < 0.0001, r = 0.385). Receiver operating characteristic curve analysis revealed PAOI >47% associated with RV/LV ratio >1.Conclusion:Our results support the use of CTPA as a surrogate imaging biomarker for both diagnosis and risk stratification of APE patients. CTPA allows assessment of clot burden through PAOI calculation and identification of intermediate-risk PE through the assessment of RVD.