Abstract
Background
Current pulmonary embolism treatment options rely heavily on anatomical clot location.
However, anatomical location does not necessarily determine adverse outcomes; rather,
clinical severity is secondary to the degree of perfusion impairment. Dual-energy
computed tomography pulmonary angiogram (DE-CTPA) can map perfusion at the time of
pulmonary embolism diagnosis. Single-photon emission computed tomography ventilation-perfusion
scans allow for perfusion tracking similar to DE-CTPA.
Methods
We present 3 patients with intermediate-risk pulmonary embolism treated with mechanical
thrombectomy using the Inari FlowTriever System (Inari Medical, Irvine, Calif). Lung
perfusion scoring was applied to pre-procedure and post-procedure imaging. We graded
perfusion of each lobe in 3 planes. If the entire lobe was perfused, a score of 3
was assigned. If lung perfusion is normal, total perfusion score is 15. All patients
had pre-procedure and follow-up transthoracic echocardiograms.
Results
All 3 patients were diagnosed with pulmonary embolism via DE-CTPA that showed right
ventricle strain and had deep venous thrombosis. Following mechanical thrombectomy,
patients immediately experienced improvement in perfusion score; scores continued
to improve at follow-up. All patients also had improvement in right ventricle size
or function on follow-up echocardiogram.
Discussion
Intermediate-risk pulmonary embolism often has large initial clot burden that predicts
residual pulmonary vascular obstruction. Residual pulmonary vascular obstruction is
associated with increased risk of death, recurrent thrombus, and chronic thromboembolic
pulmonary hypertension. Clot removal via thrombectomy may decrease the prevalence
of residual pulmonary vascular obstruction by improving lung perfusion. We found that
mechanical thrombectomy increased lung perfusion immediately and at follow-up assessments.
Keywords
Abbreviations:
DE-CTPA (Dual-energy computed tomography pulmonary angiogram), DOAC (Direct oral anticoagulant), SPECT V/Q (Single-photon emission computed tomography ventilation-perfusion), TTE (Transthoracic echocardiogram)To read this article in full you will need to make a payment
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References
- Early anticoagulation is associated with reduced mortality for acute pulmonary embolism.Chest. 2010; 137: 1382-1390
- 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): the Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC).Eur Heart J. 2019; 41: 543-603
- Pulmonary embolism and gas exchange.Respiration. 2019; 98: 253-262
- Dual-energy CT for imaging of pulmonary hypertension: challenges and opportunities.Radiographics. 2014; 34: 1769-1790
- Dual Energy CT lung perfusion imaging–correlation with SPECT/CT.Eur J Radiol. 2012; 81: 360-365
- Predictors of residual pulmonary vascular obstruction after pulmonary embolism: results from a prospective cohort study.Thromb Res. 2020; 194: 1-7
- Long-term prognostic value of residual pulmonary vascular obstruction at discharge in patients with intermediate- to high-risk pulmonary embolism.Eur Heart J. 2013; 34: 693-701
- Residual pulmonary embolism as a predictor for recurrence after a first unprovoked episode: results from the REVERSE cohort study.Thromb Res. 2018; 162: 104-109
- Detection of residual pulmonary vascular obstruction by ventilation-perfusion lung scan late after a first pulmonary embolism.Am J Cardiol. 2017; 119: 1883-1889
- What's next after the clot? Residual pulmonary vascular obstruction after pulmonary embolism: from imaging finding to clinical consequences.Thromb Res. 2019; 184: 67-76
Article Info
Publication History
Published online: April 21, 2022
Footnotes
Funding: This manuscript has no relevant disclosures in the form of grants, gifts, or other forms of financial support.
Conflicts of Interest: The authors have no conflicts of interest to disclose. The authors have no relationships with industry.
Authorship: All authors had access to the data and a role in writing the manuscript. SG: Investigation, Data curation, Formal analysis, Writing – original draft, review, & editing; VU: Investigation, Writing – original draft; MK: Resources, Investigation, Methodology; RB: Methodology, Writing – review & editing; VL: Conceptualization, Writing – review & editing; JP: Visualization, Writing – review & editing; GC: Supervision, Writing – review & editing; SD: Resources, Investigation, Methodology, Project administration; PR: Conceptualization, Methodology, Formal analysis, Visualization, Supervision, Project administration, Writing – review & editing.
Identification
Copyright
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