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Pulmonary Embolism

Baylor Scott & White Medical Center – Temple

Types of pulmonary embolism

Acute massive pulmonary embolism is a leading cause of death in patients admitted to the hospital

Pulmonary embolism (PE) is a condition where clots that originate elsewhere in the body break off and travel to the vasculature of the lungs to cause obstruction of the blood flow from the right side of the heart to the left side.

Pulmonary embolism can be minor when a small portion of the lung vasculature is involved, or it may be massive if the majority of the vasculature is involved and circulation is compromised. 

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Pulmonary embolism symptoms

Patients with pulmonary embolism present with a variety of symptoms, including chest pain and shortness of breath. However, these symptoms are not specific for pulmonary embolism and the diagnosis depends on the clinician having a high index of suspicion.

  • Patients with PE who have reduced blood pressure are referred to as having a massive PE
  • Patients who have normal blood pressure, but whose right heart is under strain, are said to have sub-massive PE
  • Patients with neither are stable PE

Testing for pulmonary embolism

The most common test for pulmonary embolism is a venous phase CT angiogram. This quick and accurate test provides all the information needed for initial treatment. Unfortunately, the need for contrast dye makes the test risky in patients with renal dysfunction.

A VQ scan is an alternative test but does not distinguish between acute and chronic pulmonary embolism. An echocardiogram is important to look at the function of the right heart and see if any thrombus is present in the heart that could cause additional compromise to the lung circulation and may constitute an indication for emergency surgery.

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Pulmonary Embolism Response Team (PERT)

Time is of the essence in dealing with acute massive pulmonary embolism. The management of pulmonary embolism involves multiple specialists with a wide range of expertise. The PERT is organized to simultaneously communicate to all the specialists and promptly activate the required resources to manage acutely ill patients.

Options include blood thinners (anticoagulation and fibrinolysis), catheter-based therapies and emergent surgery. We are happy to transfer patients from other institutions for these advanced therapies

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CTEPH

Many Chronic Thromboembolic Pulmonary Hypertension (CTEPH) patients are unaware they had an acute pulmonary embolism.

  • About
  • Symptoms
  • Diagnosis
  • Treatment

About

About 2-4% of all patients with pulmonary embolism do not resolve their acute thrombus. They then enter a chronic phase where the vascular pressures in the lung elevate, putting a strain on the right ventricle and eventually causing it to fail. Many patients with Chronic Thromboembolic Pulmonary Hypertension (CTEPH) are unaware they had an acute pulmonary embolism. CTEPH is a common cause of unexplained pulmonary hypertension (elevated vascular pressure in the lungs). 

Symptoms

Common presenting symptoms include chest pain, palpitations, syncope and shortness of breath. Patients often have signs of right heart failure, including leg swelling. Any patient whose symptoms do not resolve within three months of an acute pulmonary embolism needs to be worked up for CTEPH.

Diagnosis

The initial screening test is an echocardiogram to look for evidence of elevated lung pressures and right heart failure. Any patient with unexplained pulmonary hypertension should undergo a VQ scan. If the scan shows normal perfusion, CTEPH is ruled out. If the VQ scan is positive, patients undergo a CT Angiogram and a right heart catheterization.

Treatment

CTEPH is managed by a multi-disciplinary team. The entire team reviews each patient to attain consensus before management. CTEPH is surgically curable. In patients who have favorable anatomy, a procedure called Pulmonary Thrombo-endarterectomy (PTE) can reduce pressures and reverse the patient’s symptoms. Patients who have residual hypertension after surgery, and those who are not candidates for surgery, are managed by our pulmonary hypertension specialists. There are now medications and combinations of medications designed specifically for patients with CTEPH.

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