Οξεία & Χρόνια Πνευμονική Εμβολή: Αναστασία Ανθη Β Κλινική Εντατικής Θεραπείας & Ιατρείο Πνευμονικής Υπέρτασης Π.Γ.Ν. «ΑΤΤΙΚΟΝ»

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1 Οξεία & Χρόνια Πνευμονική Εμβολή: Ο βασικός ρόλος της καρδιαγγειακής απεικόνισης Αναστασία Ανθη Β Κλινική Εντατικής Θεραπείας & Ιατρείο Πνευμονικής Υπέρτασης Π.Γ.Ν. «ΑΤΤΙΚΟΝ»

2 Disclosures Sponsored to attend scientific meetings, or honoraria by: Actelion Bayer Galenica GSK MSD Pfizer

3 Epidemiology of pulmonary embolism Venous thrombo-embolism (VTE) which includes deep-vein thrombosis and pulmonary embolism is the third most common cause of vascular disease related deaths after myocardial infarction and stroke 30-day all-cause mortality : 9% - 11% three-month mortality : 8.6% - 17% Registries and hospital discharge datasets of unselected patie

4 Epidemiology of pulmonary embolism Venous thrombo-embolism (VTE) which includes deep-vein thrombosis and pulmonary embolism is the third most common cause of vascular disease related deaths after myocardial infarction and stroke with an annual incidence of 1-2 cases / 1000 in the general population is increasingly prevalent despite efforts to prevent the disease

5 Prevalence of clinical venous thromboembolism in the USA ( ) Am J Hematol 2011; 86 (2):

6 Prevalence of clinical venous thromboembolism in the USA ( ) Am J Hematol 2011; 86 (2):

7 Prevalence of clinical venous thromboembolism in the USA Am J Hematol 2011; 86 (2):

8 Initial risk stratification of acute PE PE guidelines 2014

9 Proposed diagnostic algorithm for patients with suspected not high-risk pulmonary embolism CT angiography has been established as the imaging gold standard for confirmation or exclusion of the disease

10 CTPA Rim sign Ελλείμματα που περιβάλλονται από σκιαγραφικό

11 CTPA Railroad track sign Ελλείμματα που περιβάλλονται από σκιαγραφικό

12 CTPA Ελλείμματα σε επαφή με το τοίχωμα (σχηματισμός οξείας γωνίας)

13 CTPA Απόφραξη του αγγείου - απουσία σκιαγράφησης - ΠΙΘΑΝΗ ΔΙΑΤΑΣΗ σε σύγκριση με τα αντίστοιχης τάξης αγγεία

14 CTPA Riding or saddle embolus

15 CTPA Vessel cut-off sign

16 CTPA Οξεία

17 CTPA Οξεία Χρόνια

18 CTPA

19 CTPA Παρουσία εμφράκτων σε ποσοστό 10-30%

20 Vascular sign CTPA

21 CTPA RV / LV 0,9-1 The RV and LV diameter from inner wall to inner wall at their widest point is measured on axial images at the level of the tricuspid and mitral valves, respectively. 4 chamber view

22 CTPA RV L V Martine Remy-Jardin,, François Pontana, Jean-Baptiste Faivre et al. New Insights in Thromboembolic Disease Radiol Clin N Am 2014; 52:

24 Patients without right ventricular dysfunction at MDCT have a low risk of in-hospital death or clinical deterioration

25 Proposed diagnostic algorithm for patients with suspected high-risk PE PE guidelines 2014

26 Proposed diagnostic algorithm for patients with suspected high-risk PE PE guidelines 2014

27 Proposed diagnostic algorithm for patients with suspected high-risk PE The absence of echocardiographic signs of RV overload or dysfunction practically excludes PE as the cause of haemodynamic instability. PE guidelines 2014

Proposed diagnostic algorithm for patients with suspected high-risk PE Echocardiography may be of further help in the differential diagnosis of the cause of

28 Proposed diagnostic algorithm for patients with suspected high-risk PE Echocardiography may be of further help in the differential diagnosis of the cause of shock, by detecting pericardial tamponade, acute valvular dysfunction, severe global or regional LV dysfunction, aortic dissection, or hypovolaemia PE guidelines 2014

29 perfusion V/Q scan ventilation

Westermark sign: dilatation of pulmonary vessels proximal to

30 Hampton s Hump: a pleura based shallow wedge shaped consolidation in the lung periphery with the base against the pleural surface Westermark sign: dilatation of pulmonary vessels proximal to embolism along with collapse of distal vessels, often with a sharp cut off

31 MR Angiography

32 MR Angiography

Νέες Εφαρμογές: Dual Energy CT Perfusion Dual Energy: Χάρτες κατανομής ιωδίου που επιτρέπουν απεικόνιση αιμάτωσης Konstantin Nikolaou, Sven Thieme,

35 Νέες Εφαρμογές: Dual Energy CT Perfusion Dual Energy: Χάρτες κατανομής ιωδίου που επιτρέπουν απεικόνιση αιμάτωσης Konstantin Nikolaou, Sven Thieme, Wieland Sommer, Thorsten Johnson, and Maximilian F. Reiser. Diagnosing Pulmonary Embolism. New Computed Tomography Applications J Thorac Imaging 2010;25:

36 Classification of patients with acute PE based on early mortality risk PE guidelines 2014

37 Imaging & laboratory tests for prediction of early mortality in acute PE

38 Chronic thromboembolic pulmonary hypertension Epidemiology long-term complication of PE incidence : % within the first two years after a symptomatic PE event

39 Chronic thromboembolic pulmonary hypertension Epidemiology long-term complication of PE incidence : % within the first two years after a symptomatic PE event 80% of patients with CTEPH have clinical history of VTE (recent international registry) routine screening for CTEPH after PE is not supported by current evidence

40 Algorithm for the diagnosis of chronic thromboembolic pulmonary hypertension PE guidelines 2014

41 Algorithm for the diagnosis of chronic thromboembolic pulmonary hypertension V/Q lung scan is the main firstline imaging test for CTEPH 96 97% sensitivity 90 95% specificity PE guidelines 2014

42 Algorithm for the diagnosis of chronic thromboembolic pulmonary hypertension V/Q lung scan is the main firstline imaging test for CTEPH 96 97% sensitivity 90 95% specificity PE guidelines 2014

43 Algorithm for the diagnosis of chronic thromboembolic pulmonary hypertension PE guidelines 2014

44 CTEPH Vascular Signs

45 CTEPH Vascular Signs

46 CTEPH Vascular Signs Systemic collateral supply

47 CTEPH Vascular Signs Systemic collateral supply

48 CTEPH RV / LV > 1 Right ventr. myocardial thickness > 4 mm Διάμετρος ΠΑ > 29 mm Διάμετρος ΠΑ > ΑΑ

49 CTEPH Parenchymal signs Mosaic perfusion

50 RadioGraphics 2009; 29:31 53

51 1 year later RadioGraphics 2010; 30: RadioGraphics 2009; 29:31 53

55 Clinical classification of Pulmonary Hypertension (ESC/ERS guidelines 2015)

57 CTEPH J A C C : C A R D I O V A S C U L A R I M A G I N G, :

58 CTEPH PAH J A C C : C A R D I O V A S C U L A R I M A G I N G, :

59 Ευχαριστώ πολύ τον ακτινολόγο του διακλινικού ιατρείου πνευμονικής υπέρτασης του Π.Γ. Ν. «ΑΤΤΙΚΟΝ», κ. Στέλιο Αργέντο για τη βοήθεια του.

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