Table Of ContentPulmonary
Embolism
Eyal Herzog
Editor
123
Pulmonary Embolism
Eyal Herzog
Editor
Pulmonary Embolism
Editor
EyalHerzog
HadassahMedicalCenter
Jerusalem,Israel
ISBN978-3-030-87089-8 ISBN978-3-030-87090-4 (eBook)
https://doi.org/10.1007/978-3-030-87090-4
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Contents
Pathway for the Diagnosis and Management of Pulmonary
Embolism ......................................................... 1
EyalHerzog, GabbyElbaz-Greener, DavidPlaner, TaliKoren,
OfferAmir,JanetShapiro,andYosefKalish
Epidemiology, Pathophysiology and Predisposing Factors
ofPulmonaryEmbolismandDeepVeinThrombosis .................. 11
DeanNachman,ArthurPollack,andEyalHerzog
Non-imagingDiagnosisofPulmonaryEmbolism ..................... 23
IsraelGotsmanandEyalHerzog
ImagingModalitiesinPulmonaryEmbolism:Echocardiography ...... 35
RonenBeeri,DavidLeibowitz,EyalHerzog,andEdgarArgulian
ImagingModalitiesinVenous-Thromboembolism:Ultrasound
forLowerExtremityDeepVenousThrombosis ....................... 49
GalBen-ArieandLiatAppelbaum
ImagingModalitiesinAcutePulmonaryEmbolism:Computerized
Tomography ...................................................... 59
DotanCohenandDorithShaham
Ventilation/PerfusionScintigraphyfortheDiagnosisofPulmonary
EmbolismandChronicThromboembolicPulmonaryHypertension .... 89
YodphatKrausz,MahmoodZidan,andSimonaBen-Haim
Imaging Modalities in Pulmonary Embolism—Pulmonary
Angiography ...................................................... 107
AllanI.Bloom,DavidPlaner,RonnyAlcalai,andGabbyElbaz-Greener
IntegratingClinical,LaboratoryandImagingTestsintheDiagnosis
ofPulmonaryEmbolism ........................................... 119
NevilleBerkman
v
vi Contents
ManagementoftheHigh-RiskPulmonaryEmbolismintheAcute
Phase—Respiratory,HemodynamicandMechanicalSupport .......... 129
AsafSchwartz,MarcRomain,EyalHerzog,andSigalSviri
PharmacologicTreatmentofPulmonaryEmbolism ................... 143
BruriaHirshRaccah, YosefKalish, RefatJabara, EyalHerzog,
andBatiaRothJelinek
CatheterDirectedThrombolyticTherapyinPulmonaryEmbolism ..... 171
GabbyElbaz-Greener,RonnyAlcalai,EyalHerzog,AllanI.Bloom,
andDavidPlaner
SurgicalTreatmentofAcutePulmonaryEmbolism ................... 185
SandhyaK.BalaramandMinhQuanVu
Pulmonary Embolism Response Team: A Multidisciplinary
ApproachtoImprovePulmonaryEmbolismManagement ............. 199
JamesS.Salonia,DavidSteiger,andJanetM.Shapiro
PulmonaryEmbolisminPregnancyandthePostpartumPeriod ....... 209
JoshuaI.Rosenbloom,EyalHerzog,andDonnaR.Zwas
PulmonaryEmbolisminCancerPatients ............................ 223
ArielaArad,AronPopovtzer,andDanGilon
ChronicThromboembolicPulmonaryHypertension(CTEPH) ......... 235
RabeaAsleh,OfferAmir,andNevilleBerkman
PulmonaryThromboembolisminCOVID-19 ......................... 249
KaterynaYevdokimovaandHoomanD.Poor
TravelRelatedVenousThromboembolism ........................... 259
OrenYagel,MomenAbbasi,DavidLeibowitz,andEyalHerzog
Illustrative Cases of Multimodality Imaging in the Diagnosis
andManagementofPulmonaryEmbolism ........................... 269
EldadRahamim,DotanCohen,GabbyElbaz-Greener,DavidPlaner,
andEyalHerzog
PulmonaryEmbolism:InformationforthePatientandFamily ........ 289
SamanSetareh-ShenasandEyalHerzog
Index ............................................................. 293
Pathway for the Diagnosis
and Management of Pulmonary
Embolism
Eyal Herzog, Gabby Elbaz-Greener, David Planer, Tali Koren,
Offer Amir, Janet Shapiro, and Yosef Kalish
1 Introduction
Venous Thromboembolism (VTE), the combined syndromes of deep vein throm-
bosis (DVT) and pulmonary embolism (PE), is currently the third most frequent
acute cardiovascular syndrome globally behind myocardial infarction and stroke
[1]. In the past decade we have seen a remarkable improvement in new diagnostic
tools as well as novel therapeutic options to manage patients with VTE.
Multiple societies from around the globe have published guidelines for the
management of VTE. The most recently updated document is the 2019 European
SocietyofCardiology(ESC)guidelinesforthediagnosisandmanagementofacute
pulmonary embolism which was developed in collaboration with the European
Respiratory Society (ERS) [2]. A major limitation of the currently published
guidelines is its complexity.
To aid health care providers caring for patients with acute PE, our team
developed a novel, comprehensive yet straightforward, pathway for the manage-
ment of patients with PE, which we believe can be used in many health care
systems around the globe [3].
The necessity todevelop such apathwayat ourinstitution was compelling, and
typicaloftheneedatmanyotherlargemedicalcentres.Ithasbecomeincreasingly
difficultforallhealthcareproviderstograspallthesubtletiesinthemanagementof
VTE to rapidly, efficiently, and accurately implement clinical protocols. It should
E.Herzog(&)(cid:1)G.Elbaz-Greener(cid:1)D.Planer(cid:1)T.Koren(cid:1)O.Amir
DepartmentofCardiology,HeartInstitute,HadassahHebrewUniversityMedicalCenter,
Jerusalem,Israel
J.Shapiro
DepartmentofMedicine,MountSinaiMorningside,NewYork,NY,USA
Y.Kalish
DepartmentofHematology,HadassahHebrewUniversityMedicalCenter,Jerusalem,Israel
©TheAuthor(s),underexclusivelicensetoSpringerNatureSwitzerlandAG2022 1
E.Herzog(ed.),PulmonaryEmbolism,
https://doi.org/10.1007/978-3-030-87090-4_1
2 E.Herzogetal.
be emphasized that this pathway is the opinion of our group and may differ
somewhat from the published guidelines.
Our pathway for the diagnosis and management of pulmonary embolism is
divided into three steps as demonstrated in Fig. 1:
Step 1: Diagnosis of PE (top third of pathway)
Step 2: Acute management of patients with PE (middle third of pathway)
Step 3: Recommendations for the chronic management of patients with PE (the
bottom third of the pathway).
Ineachstepweproposekeyquestionsthatleadto“yes”and“no”answerswhich
will further aid the health care providers to easily navigate the pathway.
The Pulmonary Embolism Response Team (PERT) is a multispecialty team
involved in the decision-making for the individual patient. The ESC guidelines
recommend establishment of a team of experts to convene for every case of
intermediate or high risk pulmonary embolism. The composition of the team
depends on the local resources and expertise. The PERT team brings together
specialists from different disciplines including, but not limited to, cardiology,
pulmonology, Emergency Medicine, hematology, vascular medicine,
anaesthesiology/intensive care, cardiothoracic surgery, and interventional radiol-
ogy. The team convenes in real time (via a platform such as WhatsApp or text
messages)tocommunicateclinicaldata,discusstheoptionsandprovideconsensus
for a course of management. By directly involving the expert clinicians, the team
facilitates the immediate implementation of the care plan [4].
2 Description of the Pathway
In most cases, patients with PE present with dyspnea, chest pain, pre-syncope or
syncope, or hemoptysis. However, in other cases, the signs and symptoms may be
non-specific.
A. Acute management of hemodynamically unstable patients (Fig. 2)
The first action is to assess the hemodynamic status in any patient with suspected
PE. Hemodynamic instability is defined as one of the following:
1. Presentation following cardiac arrest or current need for cardiopulmonary
resuscitation.
2. Obstructiveshock—definedassystolicBP <90 mmHgorvasopressorsrequired
to achieve a BP >90 mmHg despite adequate filling status AND end organ
hypoperfusion(alteredmentalstatus,cold,clammyskin,oligo-anuria,increased
serum lactate).
3. Persistent hypotension- defined as systolic BP <90 mmHg or systolic BP drop
>40 mmHg from baseline, lastinglonger than 15 min and notcaused byanew
onset arrhythmia, hypovolemia or sepsis.
PathwayfortheDiagnosisandManagementofPulmonaryEmbolism 3
SuspectedPE (Dyspnea,Chestpain,Pre-syncopeorSyncope,Hemoptysis)
Evidenceofhemodynamicinstability? 1.Cardiacarrest
2.Obstructiveshock Searchfor
3.Persistenthypotension otherdiagnosis
NO
YES
AssessclinicalprobabilityofPE
s SignificantRVdysfunctiononTTE NO
si
on YES
g LoworIntermediateClinicalProbability HighClinicalProbability
a CTPAimmediatelyavailableandfeasible
Di
Positive YES
DDimertest EvidenceofPEonCTPA EvidenceofPEonCTPA NO
NO
Negative NO YES YES
Searchforother HighriskPE
diagnosis
PERTactivation
ConsiderAPLAtesting
Coumadin LMWH DOAC Heparin Anticoagulation
PEactivation
Hemodynamicsupport
AssessseverityofPE
sPESI 1.Simplified PESI Score>=1 or
mnetge C8ASBag0Pne,<>c9e18r000 0 C ,SmH1amFt0<, H09Cg0O, %,1P H D1R0> ,1NC1O,0C 23..R TVr odpyosfnuinn c(tcioonnsi doenr BYTNETSPE o or Nr TC PTrPoA BNP) SystemicThromRboeClypastiehsertfeurdsiiroecntesdtraEmteboglieectsoSmuyrgical
na Negative Positive
a
m
tue LowriskPE IntermediateLowriskPE IntermediateHighriskPE
c
A
Evaluateifalltrue PERTactivation
1.No other reasons for hospitalization
2.Family or social support
3.Easy access to medical care ConsiderCatheterDirectedTherapy
NO
YES
CardiologyorMedicalFloor CriticalCareUnit
DischargeHomeonDOACexceptpatientswithtriple+APLA
Continueanticoagulationfor3-6monthsandF/UCoagulationClinic
tn At 3-6 month: any positive testing? 1. Doppler US of legs 2. RV dysfunction on TTE 3. Positive D Dimer
e
m NO
e
g DoesthepatienthasANYofthefollowing?
ana YES 12.. NSyom epvtidoemnsc (ed oyfs pmnaejao ro pr rfouvnocctiaotnioanl l(i>m3it daatiyosn isn) b ed, malignancy, major surgery or trauma)
m 3. Evidence of severe thrombophilia.
c
in YES NO
o
hr ContinueA/CanddetermineprobabilityofPH/CTEPH StopA/Candconsiderprophylaxisinhighriskpopulation
C
Fig.1 Pathwayforthediagnosisandmanagementofpulmonaryembolism
In patients with hemodynamic instability, the most useful initial test is bedside
transthoracic echocardiography (TTE). The bedside TTE will show evidence of
4 E.Herzogetal.
Fig.2 Acutemanagementofhemodynamicallyunstablepatientswithpulmonaryembolism
significant acute RV dysfunction if acute PE is the cause of the patient’s hemo-
dynamicdecompensation.Thishemodynamicallyunstablepatientisdefinedinour
pathway as a “High Risk PE” and the PE Response Team (PERT team) should be
activated.Inahighlyunstablepatient,whocannotbemobilizedtoCTangiography,
TTEevidenceofRVdysfunctionissufficienttopromptinitiationofanticoagulation
withheparinandinitiationofreperfusionstrategywithoutfurthertesting.Incentres
where computed tomography pulmonary angiogram (CTPA) is immediately
availableandfeasible,adiagnosisofPEshouldbeconfirmedbeforeproceedingto
a reperfusion strategy.
PrimaryreperfusionisthetreatmentofchoiceforpatientswithhighriskPEand
can be achieved by thrombolysis and/or embolectomy. Thrombolysis can be
achieved by a systemic treatment or preferably by a catheter directed treatment.
Embolectomy can be performed surgically or by a catheter directed approach.
Following reperfusion treatment and hemodynamic stabilization, the patient
should be hospitalized in a critical care unit. As patients continue to recover, they
can be switched from parenteral to oral anticoagulation before discharge home.
