Pulmonary Embolism

Summary

Our diagnostic approach to the embolic suspect involves a high index of suspicion based on the clinical context. Next, study of the lower extremity veins; if such a study (IPG, Duplex, venogram) discloses proximal DVT, the patient needs treatment and a search for embolism may or may not be required. If it is, perfusion and ventilation scans are performed next. If this test is non-diagnostic, pulmonary angiography is the final step. As noted, other technics are under investigation. It will take time to assess whether their promise is fulfilled since it is well-known that “early reports” are usually the most positive and may not translate into clinical, non-investigative use.

• REFERENCES

• 1 Foster CS, Genton E, Henderson MD, Sherry S, Wessler S. (eds) The epidemiology of venous thrombosis. Millbank Memorial Fund Quarterly 1972; L: 1-285.
• 2 National Institutes of Health Consensus Conference:. Prevention of venous thrombosis and pulmonary embolism. JAMA 1986; 256: 744-8.
• 3 Sevitt S, Gallagher NG. Venous thrombosis and pulmonary embolism. Br J Surg 1961; 48: 1475-2489.
• 4 Havig O. Source of pulmonary emboli. Acta Chir Scand 1977; 478: 42-7.
• 5 Moser KM, Lemoine JR. Is embolic risk conditioned by location of deep venous thrombosis?. Am Int Med 1981; 94: 439-44.
• 6 Kakkar VV, Howe CT, Nicolaides AW. et al. Deep vein thrombosis: Is there a high risk group?. Am J Surg 1970; 120: 527-31.
• 7 Hull R, Hirsh J, Carter CJ. et al. Pulmonary angiography, ventilation lung scanning and venography for clinically-suspected pulmonary embolism with abnormal perfusion scans. Ann Int Med 1983; 98: 891-9.
• 8 Hull R, Hirsh J, Sackett DL. et al. Replacement of venography in suspected venous thrombosis by impedance plethysmography and ¹²⁵I fibrinogen. N Engl J Med 1989; 320: 342-5.
• 9 Hull R, Taylor DW, Hirsh J. et al. Impedance plethysmography: the relationship between venous filling and sensitivity and specificity for proximal vein thrombosis. Circulation 1978; 58: 896-906.
• 10 Hull RD, Hirsh J, Carter C. et al. Diagnostic efficacy of impedance plethysmography for clinically suspected deep vein thrombosis. Am Int Med 1985; 102: 21-8.
• 11 Monreal M, Rey-Joly BC, Ruis MD. et al. Asymptomatic pulmonary embolism in patients with deep vein thrombosis. J Cardio-vasc Surg 1989; 30: 104-7.
• 12 Moser KM, Fedullo PF, Littlejohn SK, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis. JAMA 1994; 271: 223-5.
• 13 Dalen JE, Alpert JS. Natural history of pulmonary embolism. Prog Cardiovasc Dis 1975; 17: 259-70.
• 14 Moser KM. Venous thromboembolism: State of the art. Am Rev Resp Dis 1990; 141: 235-49.
• 15 The PIOPED Investigators.. Value of the ventilation/perfusion scan in acute pulmonary embolism. JAMA 1990; 263: 2753-9.
• 16 Griffin JH, Evatt B, Zimmerman TS. et al. Deficiency of protein C in congenital throm-bolic disease. J Clin Invest 1981; 68: 1370-3.
• 17 Comp PC, Esman CT. Recurrent venous thromboembolism in patients with a partial deficiency of protein S. N Engl J Med 1984; 311: 1525-8.
• 18 Demers C. et al. Thrombosis in anti-thrombin III deficient persons. Report of a large kindred and literature review. Ann Int Med 1992; 116: 754-61.
• 19 Elias M, Eldor A. Thromboembolism in patients with the lupus type circulating anticoagulant. Ann Int Med 1984; 144: 510-5.
• 20 Hull R. et al. Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. JAMA 1990; 263: 2313-7.
• 21 An international multicentre Trial:. Prevention of fatal postoperative pulmonary embolism by low doses of heparin. Lancet 1975; 2: 45-51.
• 22 Anderson FA, Wheeler HB, Goldberg RJ. et al. Physician practices in the prevention of venous thromboembolism. Am Int Med 1991; 115: 591-5.
• 23 Bounameaux H, Cirafici P, De Muerloose P. et al. Measurement of D-dimer in plasma as diagnostic aid in suspected pulmonary embolism. Lancet 1991; 337: 196-200.
• 24 Anderson DR, Lensing AW, Wells PS. et al. Limitations of impedance plethysmography in the diagnoses of clinically-suspected deep vein thrombosis. Ann Int Med 1993; 118: 25-30.
• 25 Heijboer H, Cogo A, Buller HR, Ten Cate JW. Detection of deep vein thrombosis with impedance plethysmography and real-time compression ultrasonography in hospitalized patients. Arch Int Med 1992; 152: 1901-3.
• 26 Davidson BC, Elliott CC, Lensing AW. Low accuracy of color Doppler ultrasound in the detection of proximal leg vein thrombosis in asymptomatic high risk patients. Ann Int Med 1992; 117: 735-8.
• 27 Kanke M, Matsueda GR, Strauss HW. et al. Localization and visualization of pulmonary emboli with radiolabeled fibrin – specific monoclonal antibody. J Nucl Med 1991; 32: 1254-60.
• 28 Morris T, Marsh J, Konopka R. et al. Anti-fibrin monoclonal antibodies detect deep vein thrombosis in a canine model. Chest 1993; 104: 245.
• 29 Greenspan R. et al. Accuracy of the chest radiograph in diagnosis of pulmonary embolism. Invest Radiol 1982; 17: 5395-543.
• 30 Stein PD. et al. The electrocardiogram in acute pulmonary embolism. Prog Cardiovasc Dis 1975; 17: 247-57.
• 31 Overton DT, Bucka JJ. The alveolo-arterial oxygen gradient in patients with documented pulmonary embolism. Arch Int Med 1988; 1617-9.
• 32 Mercandetti AJ, Kipper MS, Moser KM. Influence of perfusion and ventilation scans on therapeutic decision-making and outcome in cases of possible embolism. West J Med 1985; 142: 208-13.
• 33 Hull R, Raskob GE. Low probability lung scan findings: a need for change. Ann Int Med 1991; 114: 142-3.
• 34 Kipper MS. et al. Long-term follow-up of patients with suspected pulmonary embolism and a normal lung scan. Chest 1982; 82: 411-5.
• 35 Hull R. et al. Clinical validation of a normal perfusion lung scan in patients with suspected pulmonary embolism. Chest 1990; 97: 23-6.
• 36 Nicod P. et al. Pulmonary angiography in severe chronic pulmonary hypertension. Ann Int Med 1987; 107: 565-8.
• 37 Kipper MS, Alazaraki N. The feasibility of performing ¹³³Xe ventilation imaging following the perfusion study. Radiology 1982; 144: 581-6.
• 38 Shure D, Moser KM, Harrell HJ. Identification of pulmonary emboli in the dog. comparison of angioscopy and perfusion scanning. Circulation 1981; 64: 618-21.