Clinical significance and management of subsegmental pulmonary embolism
- 1.5k Downloads
Computed tomographic pulmonary angiography (CTPA) has a high sensitivity for diagnosing filling defects in subsegmental pulmonary arteries. The adoption of CTPA as the prefered diagnostic modality for the diagnosis of pulmonary embolism (PE) has led to an increased rate of PE diagnosis. However, the case fatality rate is lower and the mortality rate of PE has remained unchanged despite this rise in PE diagnosis suggesting that the disease is of lesser severity. There continues to be clinical equipoise on whether patients diagnosed with isolated subsegmental PE (SSPE) require anticoagulation or can be managed conservatively if the presence of deep vein thrombosis (DVT) has been excluded. Recent recommendations from the European Society of Cardiology suggest an individualized approach for the management of patients with newly diagnosed SSPE based on the risk/benefit ratio of anticoagulation and the presence of lower limb DVT. Prospective data evaluating the safety and efficacy of management strategies for SSPE is needed in order to determine the optimal management of these patients.
KeywordsPulmonary embolism Venous thromboembolism Venous thrombosis Computed tomography
Dr. Carrier is a recipient of a New Investigator Award from the Heart and Stroke Foundation of Canada and holds a T2 Research Chair in Cancer and Thrombosis form the University of Ottawa.
Conflict of interest
No relevant conflict of interest to declare.
- 1.Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B, Forcier A, Dalen JE (1991) A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester study. Arch Intern Med 151:933–938CrossRefPubMedGoogle Scholar
- 4.Carrier M, Righini M, Wells PS, Perrier A, Anderson DR, Rodger MA, Pleasance S, Le GG (2010) Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost 8:1716–1722CrossRefPubMedGoogle Scholar
- 6.Auer RC, Schulman AR, Tuorto S, Gonen M, Gonsalves J, Schwartz L, Ginsberg MS, Fong Y (2009) Use of helical CT is associated with an increased incidence of postoperative pulmonary emboli in cancer patients with no change in the number of fatal pulmonary emboli. J Am Coll Surg 208:871–878CrossRefPubMedGoogle Scholar
- 14.Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, Leeper KV, Popovich J Jr, Quinn DA, Sos TA, Sostman HD, Tapson VF, Wakefield TW, Weg JG, Woodard PK, for the PIOPED II Investigators (2006) Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 354:2317–2327CrossRefPubMedGoogle Scholar
- 18.Perrier A, Bounameaux H, Morabia A, de Moerloose P, Slosman D, Didier D, Unger PF, Junod A (1996) Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study. Arch Intern Med 156:531–536CrossRefPubMedGoogle Scholar
- 21.Anderson DR, Kahn SR, Rodger MA, Kovacs MJ, Morris T, Hirsch A, Lang E, Stiell I, Kovacs G, Dreyer J, Dennie C, Cartier Y, Barnes D, Burton E, Pleasance S, Skedgel C, O’Rouke K, Wells PS (2007) Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA 298:2743–2753CrossRefPubMedGoogle Scholar
- 26.Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR (2012) Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141:e419S–e494SCrossRefPubMedCentralPubMedGoogle Scholar
- 27.Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galie N, Gibbs JS, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk NA, Zamorano JL, Zompatori M (2014) 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)Endorsed by the European Respiratory Society (ERS). Eur Heart J 35:3033–3073CrossRefPubMedGoogle Scholar
- 32.van der Hulle T, den Exter PL, Meyer G, Planquette B, Soler S, Monreal M et al. (2014) Risk of recurrent venous thromboembolism and major bleeding in cancer-associated incidental pulmonary embolism amongst treated and untreated patients: a pooled analysis of 926 patients. Blood 124(21):590Google Scholar
- 34.O’Connell C, Razavi P, Ghalichi M, Boyle S, Vasan S, Mark L, Caton A, Duddalwar V, Boswell W, Grabow K, Liebman HA (2011) Unsuspected pulmonary emboli adversely impact survival in patients with cancer undergoing routine staging multi-row detector computed tomography scanning. J Thromb Haemost 9:305–311CrossRefPubMedGoogle Scholar