Difficulties of timely diagnosis of the Pulmonary Embolism of patients with chronic obstructive lung disease: possibility MSCT.

Transcription

1 Difficulties of timely diagnosis of the Pulmonary Embolism of patients with chronic obstructive lung disease: possibility MSCT. Poster No.: C-2618 Congress: ECR 2012 Type: Scientific Exhibit Authors: I. Koroleva, I. Sokolina; Moscow/RU Keywords: Contrast agents, Lung, Vascular, CT, CT-Angiography, Contrast agent-intravenous, Chronic obstructive airways disease DOI: /ecr2012/C-2618 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 15

2 Purpose The cause of acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) is often difficult to determine. The prevalence of Pulmonary Embolism (PE) in patients with COPD was 20-25% [1, 2].The factors, predisposing to the PE in patients with COPD was: the pulmonary heart with the presence of mural blood clots in the right ventricle; the violation of aggregation of platelets, fibrinolysis, polycythemia; decreased physical activity; systemic inflammatory reaction the body; smoking [3,4]. The goal of our report to show wide possibility MSCT in diagnosis of Pulmonary Embolism of patients with chronic obstructive pulmonary disease (COPD). Methods and Materials During the 3 years were examined 258 patients with acute exacerbation of COPD (186 man and 72 females). Pulmonary embolism was found in 46 patients (17,8%). The examinations were produced on multislice CT Light Speed VCT-64 General Electric and Aquillion-320 Toshiba. Patients received ml of contrast material (iohexol, iodixanol, ioversol) an injection rate of 3,5-4,0 ml/sec. The US-doppler scan, perfusion scintigraphy, Ehocardiography and D-dimer were fulfilled also. Table 1 show the characteristics of the 43 included patients. Table 1. Characteristics of the patients. Characteristics n=46 Sex (m/f) 33/13 Age (years) mean 59±7 years Smoker 46 (100%) Duration of smoking 48±12 pack-years Duration of COPD 8±3 years Exacerbations during the last years 3.3±2 Severity of COPD 27 (58,5%) Severe 19 (41,3%) Page 2 of 15

3 Very severe Phenotype of COPD 25 (54,4%) Bronchitic 21 (45,6%) Emphysematic Results Clinical symptoms: expressed shortness of breath (3-4 degree on a scale MRCDS) and chest pain (74,3%). Blood gas analyses:## - 7,36±0,9; ##2-46,2±12,1; ###2-50,1±10,3. The values of the gas composition of the blood in patients with PE authentically did not differ from those of the other causes of an exacerbation of COPD. In patients with PE were observed lower rates of vital lung capacity (VLC) (42,4 ±3%), while the FEV1 authentically did not differ. Thrombosis of deep veins of the legs (DVT)(fig.1, 2) has been revealed in for 91.3% of patients. Localization of DVT: ileo-caval segment %, femoro-popliteal segment - 30,1%, several venous segments -15.2%, the veins of legs - 7,1%. In 54.7% of the patients DVT proceeded asymptomatic. By echocardiography of blood clots in the right atrium (fig.3) was detected in 1 patient with PE and COPD. #-ray of the chest: the findings of PE was suspected in only 36.9% of patients. The signs of PE (fig.4) included: subpleural infiltrates, pleural effusion, elevated hemidiaphragm, band atelectasis, cardiomegaly. 99# Have we examined patients discrepancy data MSCT with perfusion scintigraphy ( ##) was 3 cases (6,5%): false positive - 1, false-negative - 2. Pulmonary perfusion may be impaired as a result of a reactive vasoconstriction due to obstruction of the bronchi. Specific to PE perfusion defects - hypo- and aperfusion areas (fig.5) can be attributed to the areas of fibrosis, the presence of effusion in the pleural cavity and emphysema. Therefore, the data perfusion scintigraphy of the lungs in COPD more frequently than in other pathological conditions diagnostically unreliable (>30%). Excess of a level of D-dimer was celebrated in almost all patients with DVT (from 0,5 mcg/ml and 3.5 mcg/ml). In 2 patients the indicators of D-dimer were below or at the level of 0,5 mcg/ml when there is direct evidence of Pulmonary Embolism when MSCT. One patient indicators of D-dimer were above 0,5 mcg/ml at negative data MSCT, even at 3 patients indicators of D-dimer were normal in the absence of signs PE when MSCT. MSCT showed vascular and parenchymal signs of PE. Vascular signs included intraluminal thromboembolic masses at different levels of the pulmonary artery (fig.6, 7, Page 3 of 15

4 8), often bilateral (56,7%). Parenchymal signs of PE were lung infarction (41,3%) and mosaic perfusion (15,2%). Chronic pulmonary embolism was found at 8.6% of the patients. CT signs of chronic pulmonary embolism (fig.9) recorded in the present study include: organized thrombi, calcified thrombi, reanalyzed thrombi, dilatation of pulmonary artery, mosaic perfusion. To assess the status of venous bed successfully used CT-flebography: in the venous vessels clearly render blood clots different localization and length (fig.10). Images for this section: Fig. 1: US-dopplerography: Mural blood clot in the right popliteal vein Page 4 of 15

5 Fig. 2: Sonography: Occlusive thrombosis of the common femoral vein Page 5 of 15

6 Fig. 3: Echocardiography: prolapse of thrombus in right atrium to the oval foramen Page 6 of 15

7 Fig. 4: Chest X-ray:subpleural infiltrat in right lung, pleural effusion, cardiomegaly. Page 7 of 15

8 Fig. 5: Perfusion scintigraphy(99###)in patient with COPD:polysegmental multiple perfusion defects. Page 8 of 15

9 Fig. 6: MSCT-angiography: bilateral thromboembolic masses in inferior lobar artery. Page 9 of 15

10 Fig. 7: MSCT-angiography: thromboembolic masses in the right pulmonary artery Page 10 of 15

11 Fig. 8: MSCT-angiography: bilateral thromboembolic masses in the segmental artery, bilateral lung infarctions, bilateral pleural effusion. Page 11 of 15

12 Fig. 9: MSCT-angiography: In the lumen of the right pulmonary artery is visualized massive calcified and recanalized embolic mass; dilatation of the pulmonary artery. Page 12 of 15

13 Fig. 10: CT-flebography: blood clots in the femoral vein Page 13 of 15

14 Conclusion Pulmonary embolism is one of the causes of an exacerbation of COPD and its frequency have we examined patients was 17.8%. MSCT is highly effective method of early diagnostics of pulmonary embolism in patients with COPD. The peculiarity of PE in this category of patients is predominantly combined bilateral defeat of various segments of the pulmonary artery and the highest percentage of lung infarctions. CT-venography of the low extremity is effective method of identifying the causes of venous thrombosis. This method may by used as independent procedure rapid and complex MSCT diagnostic of pulmonary embolism in patients with COPD. The most significant clinical signs of PE in patients with COPD are expressed unmotivated shortness of breath (3-4 degree on a scale MRCDS) and pain in the chest due lung infarctions. Perfusion scintigraphy in patients with COPD often, than in other diseases diagnostic unreliable (>30%), which is caused by the violation of pulmonary perfusion as a result of a reactive vasoconstriction due to bronchial obstruction. References Sharma GVRK, Sasahara AA. Diagnosis of pulmonary embolism in patients with chronic obstructive pulmonary disease. J Chronic Dis. 1975; 28: Winter J H, Buckler P W, Bautista A P.et alfrequency of venous thrombosis in patients with an exacerbation of chronic obstructive lung disease. Thorax Tillie#Leblond I, Marquette C H, Perez T.et alpulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors. Ann Intern Med Erelel M, Cuhadaroglu C, Ece T.et althe frequency of deep venous thrombosis and pulmonary embolus in acute exacerbation of chronic obstructive pulmonary disease. Respir Med Personal Information Section: Personal Information I.M. Koroleva, MD, I.A. Sokolina Page 14 of 15

15 ADRESS CORRESPONDENCE TO: Department of Radiology, First Moscow State Medical University I.M. Sechenov Moscow, Russia, Trubetskaya street, 8-2 tel. (499) ; tel./fax (499) ; Page 15 of 15