Download PDF
Thromb Haemost 2015; 114(01): 26-34
DOI: 10.1160/TH14-10-0842
Coagulation and Fibrinolysis
Schattauer GmbH

Thromboembolic resolution assessed by CT pulmonary angiography after treatment for acute pulmonary embolism

Paul L. den Exter   *
1   Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
,
Josien van Es   *
2   Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
,
Lucia J. M. Kroft
3   Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
,
Petra M. G. Erkens
4   Department of Clinical Epidemiology, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre, the Netherlands
,
Renée A. Douma
2   Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
,
Inge C. M. Mos
1   Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
,
Gé Jonkers
5   Department of Internal Medicine, Rijnland Hospital, Leiderdorp, the Netherlands
,
Marcel M. C. Hovens
6   Department of internal medicine, Rijnstate Hospital, Arnhem, the Netherlands
,
Marc F. Durian
7   Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
,
Hugo ten Cate
8   Department of Internal Medicine and Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
,
Ludo F. M. Beenen
9   Department of Radiology; Academic Medical Center, Amsterdam, the Netherlands
,
Pieter Willem Kamphuisen
10   Department of Vascular Medicine, University Medical Center Groningen, Groningen, the Netherlands
,
Menno V. Huisman
1   Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
,
for the Prometheus Follow-Up Investigators › Author Affiliations
Further Information

Publication History

Received: 10 October 2014

Accepted after major revision: 13 February 2015

Publication Date:
22 November 2017 (online)

    Permissions and Reprints

Summary

The systematic assessment of residual thromboembolic obstruction after treatment for acute pulmonary embolism (PE) has been under-studied. This assessment is of potential clinical importance, should clinically suspected recurrent PE occur, or as tool for risk stratification of cardiopulmonary complications or recurrent venous thromboembolism (VTE). This study aimed to assess the rate of PE resolution and its implications for clinical outcome. In this prospective, multi-center cohort study, 157 patients with acute PE diagnosed by CT pulmonary angiography (CTPA) underwent follow-up CTPA-imaging after six months of anticoagulant treatment. Two expert thoracic radiologists independently assessed the presence of residual thromboembolic obstruction. The degree of obstruction at baseline and follow-up was calculated using the Qanadli obstruction index. All patients were followed-up for 2.5 years. At baseline, the median obstruction index was 27.5 %. After six months of treatment, complete PE resolution had occurred in 84.1 % of the patients (95 % confidence interval (CI): 77.4–89.4 %). The median obstruction index of the 25 patients with residual thrombotic obstruction was 5.0 %. During follow-up, 16 (10.2 %) patients experienced recurrent VTE. The presence of residual thromboembolic obstruction was not associated with recurrent VTE (adjusted hazard ratio: 0.92; 95 % CI: 0.2–4.1). This study indicates that the incidence of residual thrombotic obstruction following treatment for PE is considerably lower than currently anticipated. These findings, combined with the absence of a correlation between residual thrombotic obstruction and recurrent VTE, do not support the routine use of follow-up CTPA-imaging in patients treated for acute PE.

Keywords

Pulmonary arteries - pulmonary circulation - pulmonary embolism - multidetector computed tomography

* These authors contributed equally.


 

  • References

  • 1 Klok FA, Zondag W, van Kralingen KW. et al. Patient outcomes after acute pulmonary embolism. A pooled survival analysis of different adverse events. Am J Respir Crit Care Med 2010; 181: 501-506.
    CrossrefPubMedGoogle Scholar
  • 2 Baglin T, Douketis J, Tosetto A. et al. Does the clinical presentation and extent of venous thrombosis predict likelihood and type of recurrence? A patient-level meta-analysis. J Thromb Haemost 2010; 08: 2436-2442.
    CrossrefPubMedGoogle Scholar
  • 3 Kline JA, Steuerwald MT, Marchick MR. et al. Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest 2009; 136: 1202-1210.
    CrossrefPubMedGoogle Scholar
  • 4 Klok FA, Tijmensen JE, Haeck ML. et al. Persistent dyspnea complaints at long-term follow-up after an episode of acute pulmonary embolism: results of a questionnaire. Eur J Intern Med 2008; 19: 625-629.
    CrossrefPubMedGoogle Scholar
  • 5 Klok FA, van Kralingen KW, van Dijk AP. et al. Quality of life in long-term survivors of acute pulmonary embolism. Chest 2010; 138: 1432-1440.
    CrossrefPubMedGoogle Scholar
  • 6 den Exter PL, van der Hulle T, Lankeit M. et al. Long-term clinical course of acute pulmonary embolism. Blood Rev 2013; 27: 185-192.
    CrossrefPubMedGoogle Scholar
  • 7 Hoeper MM, Mayer E, Simonneau G.. et al. Chronic Thromboembolic Pulmonary Hypertension. Circulation 2006; 113: 2011-2020.
    CrossrefPubMedGoogle Scholar
  • 8 Hamadah A, Alwasaidi T, Le Gal G. et al. Baseline imaging after therapy for un-provoked venous thromboembolism: a randomized controlled comparison of baseline imaging for diagnosis of suspected recurrence. J Thromb Haemost 2011; 09: 2406-2410.
    CrossrefPubMedGoogle Scholar
  • 9 Kearon C, Akl EA, Comerota AJ. et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141: e419S-e494S.
    CrossrefPubMedGoogle Scholar
  • 10 Nijkeuter M, Hovens MM, Davidson BL. et al. Resolution of thromboemboli in patients with acute pulmonary embolism: a systematic review. Chest 2006; 129: 192-197.
    CrossrefPubMedGoogle Scholar
  • 11 Remy-Jardin M, Louvegny S, Remy J. et al. Acute central thromboembolic disease: posttherapeutic follow-up with spiral CT angiography. Radiology 1997; 203: 173-180.
    CrossrefPubMedGoogle Scholar
  • 12 Van Rossum AB, Pattynama PM, Tjin AT. et al. Spiral CT appearance of resolving clots at 6 week follow-up after acute pulmonary embolism. J Comput Assist Tomogr 1998; 22: 413-417.
    CrossrefPubMedGoogle Scholar
  • 13 Wartski M, Collignon MA. Incomplete recovery of lung perfusion after 3 months in patients with acute pulmonary embolism treated with antithrom-botic agents. THESEE Study Group. Tinzaparin ou Heparin Standard: Evaluation dans l’Embolie Pulmonaire Study. J Nucl Med 2000; 41: 1043-1048.
    PubMedGoogle Scholar
  • 14 Schoepf UJ, Goldhaber SZ, Costello P. Spiral Computed Tomography for Acute Pulmonary Embolism. Circulation 2004; 109: 2160-2167.
    CrossrefPubMedGoogle Scholar
  • 15 Castaner E, Gallardo X, Ballesteros E. et al. CT diagnosis of chronic pulmonary thromboembolism. Radiographics 2009; 29: 31-50.
    CrossrefPubMedGoogle Scholar
  • 16 Wittram C, Kalra MK, Maher MM. et al. Acute and chronic pulmonary emboli: angiography-CT correlation. AJR Am J Roentgenol 2006; 186: S421-S429.
    CrossrefPubMedGoogle Scholar
  • 17 Qanadli SD, El HM, Vieillard-Baron A. et al. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol 2001; 176: 1415-1420.
    CrossrefPubMedGoogle Scholar
  • 18 van der Meer RW, Pattynama PM, Van Strijen MJ. et al. Right ventricular dys-function and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology 2005; 235: 798-803.
    CrossrefPubMedGoogle Scholar
  • 19 Hvid-Jacobsen K, Fogh J, Nielsen SL. et al. Scintigraphic control of pulmonary embolism. Eur J Nucl Med 1988; 14: 71-72.
    CrossrefPubMedGoogle Scholar
  • 20 Sanchez O, Helley D, Couchon S. et al. Perfusion defects after pulmonary embolism: risk factors and clinical significance. J Thromb Haemost 2010; 08: 1248-1255.
    CrossrefPubMedGoogle Scholar
  • 21 PIOPED.. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. J Am Med Assoc 1990; 263: 2753-2759.
    CrossrefPubMedGoogle Scholar
  • 22 van EJ, Douma RA, Kamphuisen PW. et al. Clot resolution after 3 weeks of anticoagulant treatment for pulmonary embolism: comparison of computed tomography and perfusion scintigraphy. J Thromb Haemost 2013; 11: 679-685.
    CrossrefPubMedGoogle Scholar
  • 23 Stein PD, Yaekoub AY, Matta F. et al. Resolution of pulmonary embolism on CT pulmonary angiography. AJR Am J Roentgenol 2010; 194: 1263-1268.
    CrossrefPubMedGoogle Scholar
  • 24 Pesavento R, Filippi L, Pagnan A. et al. Unexpectedly High Recanalisation Rate in Patients with Pulmonary Embolism Treated with Anticoagulants Alone. Am J Respir Crit Care Med 2014; 189: 1277-1279.
    CrossrefPubMedGoogle Scholar
  • 25 Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. J Am Med Assoc 2007; 298: 317-323.
    CrossrefPubMedGoogle Scholar
  • 26 Huisman MV, Klok FA. Diagnostic management of acute deep vein thrombosis and pulmonary embolism. J Thromb Haemost 2013; 11: 412-422.
    CrossrefPubMedGoogle Scholar
  • 27 Prandoni P, Lensing AW, Prins MH. et al. Residual venous thrombosis as a predictive factor of recurrent venous thromboembolism. Ann Intern Med 2002; 137: 955-960.
    CrossrefPubMedGoogle Scholar
  • 28 Stevinson BG, Hernandez-Nino J, Rose G. et al. Echocardiographic and functional cardiopulmonary problems 6 months after first-time pulmonary embolism in previously healthy patients. Eur Heart J 2007; 28: 2517-2524.
    CrossrefPubMedGoogle Scholar
  • 29 Nijkeuter M, Sohne M, Tick LW. et al. The natural course of hemodynamically stable pulmonary embolism: Clinical outcome and risk factors in a large prospective cohort study. Chest 2007; 131: 517-523.
    CrossrefPubMedGoogle Scholar
  • 30 van der Bijl N, Klok FA, Huisman MV. et al. Measurement of right and left ventricular function by ECG-synchronized CT scanning in patients with acute pulmonary embolism: usefulness for predicting short-term outcome. Chest 2011; 140: 1008-1015.
    CrossrefPubMedGoogle Scholar
  • 31 Vedovati MC, Becattini C, Agnelli G. et al. Multidetector CT scan for acute pulmonary embolism: embolic burden and clinical outcome. Chest 2012; 142: 1417-1424.
    CrossrefPubMedGoogle Scholar
  • 32 Meyer G, Planquette B, Sanchez O. Long-term outcome of pulmonary embolism. Curr Opin Hematol 2008; 15: 499-503.
    CrossrefPubMedGoogle Scholar