A 75-year-old with abdominal pain, hypoxia, and weak pulses in the left leg

Cleveland Clinic Journal of Medicine. 2018 February;85(2):145-154 | 10.3949/ccjm.85a.16069
February 1, 2018|Cleveland Clinic Journal of Medicine
Maya Serhal, MD;Natalie Evans, MD, RPVI;Heather L. Gornik, MD, RVT, RPVI
Author and Disclosure Information

Maya Serhal, MD
Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic

Natalie Evans, MD, RPVI
Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Heather L. Gornik, MD, RVT, RPVI
Medical Director, Non-Invasive Vascular Laboratory, Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Maya Serhal, MD, Department of Vascular Medicine, J3-5, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195; Serhalm@ccf.org

Dr. Gornik has disclosed she was a site principal investigator in the Examining Use of Ticagrelor in Peripheral Artery Disease (EUCLID) trial, funded by AstraZeneca.

ECHOCARDIOGRAPHIC SIGNS OF PULMONARY EMBOLISM

2. Which of the following findings on transthoracic echocardiography would not suggest acute pulmonary embolism?

  • Midright ventricular wall hypokinesis with apical sparing
  • Severe tricuspid regurgitation
  • Left ventricular dilation
  • Lack of respiratory variation of the inferior vena cava
  • Septal wall motion toward the left ventricle

Left ventricular dilation does not suggest acute pulmonary embolism. Echocardiograms of patients with acute submassive pulmonary embolism typically show evidence of right ventricular strain, such as the other entities listed above (midright ventricular hypokinesis with apical sparing, severe tricuspid regurgitation, lack of respiratory variation of the inferior vena cava, and septal wall motion toward the left ventricle).

The degree of right ventricular dysfunction is related to the extent of acute pulmonary vascular occlusion and aids in risk-stratification of patients with acute pulmonary embolism. Midright ventricular wall hypokinesis with apical sparing has been termed the McConnell sign.2

In our patient, transthoracic echocardiography showed:

  • Normal left ventricular ejection fraction
  • Mild diastolic dysfunction
  • Right ventricular dilation with moderately decreased right ventricular systolic function and apical sparing
  • Right ventricular systolic pressure 54 mm Hg, consistent with moderate pulmonary hypertension
  • Right atrial pressure 10 mm Hg
  • No inspiratory collapse of a dilated inferior vena cava
  • Mild tricuspid valve regurgitation.

CLASSIFICATION OF ACUTE PULMONARY EMBOLISM

3. Given the above information, how would you classify the patient’s pulmonary embolism?

  • Massive
  • Submassive
  • Low-risk
  • Clinically stable

The patient’s pulmonary embolism is submassive.

Classification of pulmonary embolism
Many classification schemes exist for acute pulmonary embolism. That of the American Heart Association is shown in Table 2.3

Historically, the classification of pulmonary embolism was determined by the angiographic thrombus burden. However, this has limited utility because clinical factors (eg, hypotension on initial presentation) have been shown to be better predictors of short-term mortality risk.3

Our patient is characterized as having a submassive pulmonary embolism based on elevated biomarkers (troponin T, N-terminal pro-B-type natriuretic peptide) and right ventricular dysfunction in the absence of hypotension.

ULTRASONOGRAPHY FOR DIAGNOSIS OF DEEP VEIN THROMBOSIS

Example of lower-extremity duplex ultrasonography.
Figure 3. Example of lower-extremity duplex ultrasonography. Arteries and veins are labeled. Veins without deep vein thrombosis are compressible, as seen on the left. A vein is shown that is not compressible, suggesting deep vein thrombosis.
Duplex ultrasonography can show evidence of deep vein thrombosis if a venous segment is not compressible (Figure 3). Of note, approximately 70% of patients with pulmonary embolism have evidence of deep vein thrombosis on imaging studies.4

Venous duplex ultrasonography has become the standard for diagnosis of lower extremity deep vein thrombosis. However, its quality and diagnostic accuracy depend on the skill of the person performing the examination. It is further limited by certain patient characteristics, including severe obesity, edema, and wounds and dressings at the site being examined.5

Our patient underwent duplex ultrasonography of the lower extremities, which demonstrated acute proximal and calf deep vein thrombosis in the right femoral, popliteal, and peroneal veins and no deep vein thrombosis in the left leg.