Thrombosis of the pulmonary

artery
By Butranova O.I.
2011
Radiographic Eponyms
- Hampton’s Hump, Westermark’s Sign

Westermark’s
Sign
Hampton’s Hump
Risk Factors

Hypercoagulability
Malignancy
Nonmalignant thrombophilia
Pregnancy
Postpartum status (<4wk)
Estrogen/ OCP’s
Genetic mutations (Factor V Leiden, Protein C & S deficiency, Factor
VIII, Prothrombin mutations, anti-thrombin III
deficiency)
Venous Statis
Bedrest > 24 hr
Recent cast or external fixator
Long-distance travel or prolong automobile travel

Venous Injury
Recent surgery requiring endotracheal intubation
Recent trauma (especially the lower extremities and pelvis)
3
 Clinical Presentation
 The Classic Triad: (Hemoptysis, Dyspnea, Pleuritic Pain)

 Not very common!

 Occurs in less than 20% of patients with documented PE

 Three Clinical Presentations

 Pulmonary Infarction
 Submassive Embolism
 Massive Embolism
Clinical Features
Symptoms in Patients with Angio Proven PTE

Symptom Percent
Dyspnea 84
Chest Pain, pleuritic 74
Anxiety 59
Cough 53
Hemoptysis 30
Sweating 27
Chest Pain, nonpleuritic 14
Syncope 13
Clinical Features
Signs with Angiographically Proven PE
Sign Percent

Tachypnea > 20/min 92

Rales 58
Accentuated S2 53
Tachycardia >100/min 44
Fever > 37.8 43
Diaphoresis 36
S3 or S4 gallop 34
Thrombophebitis 32
Lower extremity edema 24
 Diagnostic Test
 Imaging Studies
 CXR
 V/Q Scans
 Spiral Chest CT
 Pulmonary Angiography
 Echocardiograpy

 Laboratory Analysis
 CBC, ESR, Hgb/Hct,

 D-Dimer

 ABG’s

 Ancillary Testing
 EKG

 Pulse Oximetry
Diagnostic Testing
- CXR’s
Chest radiograph findings in patient with pulmonary
embolism
Result Percent
Cardiomegaly 27%
Normal study 24%
Atelectasis 23%
Elevated Hemidiaphragm 20%
Pulmonary Artery Enlargement 19%
Pleural Effusion 18%
Parenchymal Pulmonary Infiltrate 17%
Chest X-ray Eponyms of PE
 Westermark's sign

 A dilation of the pulmonary vessels proximal to the

embolism along with collapse of distal vessels,
sometimes with a sharp cutoff.

 Hampton’s Hump

 A triangular or rounded pleural-based infiltrate with the

apex toward the hilum, usually located adjacent to the
hilum.
Radiographic Eponyms
- Hampton’s Hump, Westermark’s Sign

Westermark’s
Sign
Hampton’s Hump
Diagnostic Testing
– EСG’s
 E СG

 Most Common Findings:

 Tachycardia or nonspecific ST/T-wave changes

 Acute cor pulmonale or right strain patterns

 Tall peaked T-waves in lead II (P pulmonale)

 Right axis deviation
 RBBB
 S1-Q3-T3 (occurs in only 20% of PE patients)
D-dimer Test
 Fibrin split product

 Circulating half-life of 4-6 hours

 Quantitative test have 80-85% sensitivity, and 93-100% negative predictive

value

 False Positives:

Pregnant Patients Post-partum < 1 week

Malignancy Surgery within 1 week
Advanced age > 80 years Sepsis
Hemmorrhage CVA
AMI Collagen Vascular Diseases
Hepatic Impairment
 V/Q Scan

 Technique

 Interpretation
 Normal
 Low probability/”nondiagnostic” (most common)
 High Probability

 Simplified approached to the interpretation of results:

High probability  Treat for PE

Normal Scan  If low pre-test, your done
Everything else  Purse another study (CT,
Angio)
 Pulmonary Angiography

 “Gold Standard”
 Performed in an

Interventional Cath
Lab

 Positive result is a
“cutoff” of flow or
intraluminal filling defect

 “Court of Last Resort”

Treatment
 Anticoagulants
 Heparin

 Provides immediate thrombin inhibition, which prevents

thrombus extension

 Does not dissolve existing clot

 Will not work in patients with antithrombin III def.

• In this case use hirudins

 Few absolute contraindications

 Treatment
 Anticoagulants
 Heparin

 Available as Unfractionated or LMW Heparin

• FDA approved dosing:

– Unfractionated: 80 units/kg bolus, 18 units/kg/hr

– LMWH: 1 mg/kg Q 12 or 1.5mg/kg Q D

 LMWH (Lovenox) prefered in pregnant patients

Treatment
 Anticoagulants
 Warfarin (Coumadin)

 Interferes with the action of Vit-K dependent factors: II, VII,

IX, and X, as well as protein C & S

 Causes temporary hypercoagulable state in first 5 days of

treatment

• Important a patient is anticoagulated with heparin before

initiating warfarin therapy

 Target INR is 2.5 – 3.0

Treatment
 Fibrinolytic Therapy (Alteplase)
 Indications:

 Documented PE with:

• Persistent hypotension
• Syncope with persistent hemodynamic compromise
• Significant hypoxemia
• +/- patient with acute right heart strain

 Approved Altivase regimen is 100mg as a continuous IV

infusion.
Treatment
 Embolectomy
 Prefininolytic therapy this was only

therapy for massive PE

 Carries a 40% operative mortality

 Alternative is Transvenous Catheter

Embolectomy
 A Simplified Algorithm

 Pre-test probability
 D-dimer (VIDAS-
DD)
 CT angiography
Special Circumstances
 Morbid Obesity

 Pregnancy
 V/Q has considerable less radiation

• 50 mrem vs. 800 mrem

 Almost all will have positive D-Dimer

 Heparin safe in pregnancy

 Witnessed Cardiac Arrest

 Standard ACLS, if known PE, the lytics.