Blocking of the pulmonary
artery by foreign matter such as a blood
clot, fat, air, tumor tissue.
The third most common cause of death in
Most patients with DVT develop PE (Majority
of cases are unrecognized clinically).
Untreated, approximately 1/3 of patients who
survive an initial PE die of a future
In the US:
► 60% of patients who died in hospitals had PE.
The diagnosis was missed in up to 70%.
Prospective studies demonstrated DVT in:
► 10-13% of all medical patients placed on bed rest for 1
► 29-33% of all patients in medical ICUs,
► 20-26% of patients with pulmonary diseases who stays at bed for ≥3 days,
► 27-33% of those admitted to a critical care unit after MI,
► 48% of patients who are asymptomatic after CABG.
Pathphysiology of PE:
► VIRCHOW’S TRIAD
Local trauma to vessel wall
► Hypercoagulable state
► Primary Hypercoagulable states
► Acquired Hypercoagulable states
Non-imaging Diagnostic Methods:
► PLASMA D-DIMER ELISA
• Natural Break down of fibrin to D-Dimers
• Sensitive but not specific as it
• Increases in MI, repsis, cancer, any other systemic
• No difference between average PaO2 in patients with and without PE
• Not part of diagnostic strategy
• Exclude AMI
• Raise suspicion of PE
• Confirm the diagnosis
Imaging Diagnostic Methods:
• Abnormal CXR in ¼ of patients.
• Focal oligemia (Westermark’s sign)
indicates massive central embolic occlusion.
• Peripheral wedge shaped density above the
diaphragm (Hampton’s hump) indicates
• Small pleural effusion.
Spiral or the new multi-detector CT:
► Replacing V/Q scan
► Replacing pulmonary Angio in Dx
► More specific, more accessible
► Provides alternative diagnosis in 30% of cases
► May miss sub segmental emboli
► Give information about the size and function of RV
► Requires a high dose of injected contrast (can use non iodinated contrast) - check creatinine
► Diagnostic even in the presence of an abnormal chest radiograph
► Perfusion scan:
• Technetium 99m-labeled macro aggregated albumin (MAA).
• injected intravenously.
► Ventilation scan:
• Technetium 99m DTPA aerosol.
► Second choice imaging test.
► 70% of patients have an indeterminate result and need another test to make the diagnosis.
► Good in the presence of a normal chest radiograph.
► Not helpful in the presence of an abnormal chest radiograph, in patients with COPD or cardiac disease.
► Does not provide an alternative diagnosis.
► Was the Gold standard, replaced by the new multidetector CT scanning
► Invasive -
catheter inserted into femoral vein, up the
IVC through into right-sided cardiac
chambers and into pulmonary
injected directly into pulmonary arteries.
► Required when
interventions are planned as:
• Suction catheter embolectmy.
• Mechanical clot fragmentation.
• Catheter directed thrombolysis.
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