Assessment of severity and prognosis in patients with pulmonary embolism attending to clot load score on MDCT pulmonary angiography

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1 Assessment of severity and prognosis in patients with pulmonary embolism attending to clot load score on MDCT pulmonary angiography Award: Certificate of Merit Poster No.: C-0890 Congress: ECR 2018 Type: Scientific Exhibit Authors: M. S. Fernández López-Peláez, E. Zabía Galíndez, M. J. Garcia Isidro, E. Ayerbe Unzurrunzaga ; Madrid/ES, Boadilla del Monte, Madrid/ES Keywords: Cardiovascular system, Lung, Pulmonary vessels, CTAngiography, Computer Applications-General, Computer Applications-Detection, diagnosis, Contrast agent-intravenous, Embolism / Thrombosis DOI: /ecr2018/C-0890 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. Page 1 of 22

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3 Aims and objectives Despite advances in prophylaxis, diagnostic modalities or therapeutic options in acute pulmonary embolism (PE), 8% - 15% mortality rate is still reported in hemodynamically stable patients, which increases up to 50% - 58% in patients with hemodynamic instability (1, 2). Other series have reported mortality rates from 2% in patients with nonmassive embolus to a 95% in patients with cardiorespiratory arrest (3, 4). As many of those deaths frequently occur within the first hours after admission, a rapid and specific diagnosis is still required (5). Thus, risk stratification for patients with acute PE is important to establish appropriate treatment and management (6). Current risk prediction rules for patients with acute PE have been mainly based on clinical and laboratory parameters (7, 8). Among the commonly used clinical imaging modalities, multidetector computed tomography (MDCT) of pulmonary arteries has been established as the main imaging method for diagnosis of acute PE (9-11). But also MDCT of pulmonary arteries allows more comprehensive assessment of the clot burden and signs of right ventricular (RV) dysfunction than echocardiography, as well as additional information of the underlying lung parenchimal disease (12,13). In the literature, several studies have addressed the role of MDCT pulmonary angiographic parameters for helping predict intermediate and long-term prognosis in patients with acute PE (14-20). In base of this, the purpose of this work is to determine whether quantification of clot burden in pulmonary arteries can be considered a useful method for predicting a poor prognosis (short and long term mortality or cardiopulmonary complications), based on the MDCT pulmonary angiographic findings from acute PE-hospitalized patients, and to compare our results with those reported in the literature. Methods and materials - Data Source Page 3 of 22

4 From 400 patients registered in our institution between November 2010 and June 2015 with suspiction of acute PE, 70 patients were included for this analysis attending to positive findings at MDCT, from which clinical and imaging data were retrospectively reviewed. All patients were aged #16 years (adults) and underwent at least one MDCT pulmonary angiographic examination with a suggestive PE event. Subjects were initially identified by means of procedure codes, then radiology reports were retrieved and reviewed by a trained radiologist with 10 years of experience in chest CT to confirm PE diagnosis. a) Clinical data included information attending on demographic characteristics, admission dates, pre-test clinical risk factors (PESI scale) (Fig.1), discharge dates, laboratory results, therapeutic procedures, outcomes or deaths during hospitalization, by using the institutional medical archive system (HOSMA ). b) Radiological data included imaging findings attending on MDCT pulmonary angiography studies, such as clot location, presence of RV dilatation, morfology of IV septum, PA hypertension, contrast reflux to IVC, pleural effusion and pulmonary infarctation among others, and they were retrieved and reviewed from our picture archiving and communication system (PACS). PA clot load score: The presence, number and location of pulmonary arterial clots were scored from MDCT pulmonary angiography images, basing on parameters of Qanadli Score system (Fig.2). For our work, however, we did not assess the residual perfusion distal to the embolus as Qanadli score does, so that no weighting factor was needed to apply to the scoring results in any case. Thus, our resulting score system remained basically as shown in Fig.3. Patients were categorized into the following three groups, according to the results of our clot burden quantification score: - GROUP 1 (Low clot burden): score 1-5 points (Fig. 4) - GROUP 2 (Moderate clot burden): score 6-14 points (Fig. 5) - GROUP 3 (High clot burden): score 5-20 points (Fig. 6) c) Follow-up data were retrieved and reviewed by a trained clinical physician with more than 10 years of experience, according to time of response to anticoagulant therapy, onset of complications, deaths, recurrences or secuelae. As secuelae-related data, Page 4 of 22

5 chronic pulmonary hypertension (PH), chronic PE and chronic right heart failure events were reviewed. - Statistical Analysis: Normal distribution of measures of the clot burden was tested by using Kolmogorov - Smirnov test. The correlation between clot burden score and patients prognosis and the correlation between clot volumen and MDCT signs of right heart dysfunction were assessed with the Pearson coefficient for normally distributed data and with the Spearman rank coefficient for nonnormally distributed data. Pairwise comparison among groups was conducted by using the Mann-Whitney U test and Student s t-test for assessing the statistical significance and the construction of 95% confidence intervals (CI). Statistical significance was defined as P < X² test / Yates X² test and Fisher's exact test were used for the analysis of contingency tables. All analyses were conducted by using SPSS STATISTICS, version Images for this section: Page 5 of 22

6 Fig. 1: Clinical prognostic data from PESI scale. Wicki J. Perrier A. Perneger TV. et al. Predicting adverse in patients with acute pulmonary embolism: a risk score. Thromb Haemost 2000; 84: Page 6 of 22

7 Fig. 2: Qanadli score system of the clot burden in PAs of patients with acute PE. Qanadli SD. El Hajjam M. 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: Page 7 of 22

8 Fig. 3: Our score system of clot burden quantification at MDCT images from patients with acute PE. Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 8 of 22

9 Fig. 4: Fig. 4. MDCT imaging findings in a patient with low clot burden score (GROUP 1). Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 9 of 22

10 Fig. 5: Fig.5. MDCT imaging findings in a patient with moderate clot burden score (GROUP 2). Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 10 of 22

11 Fig. 6: Fig. 6. Imaging MDCT findings in a patient with high clot burden score (GROUP 3). Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 11 of 22

12 Results - Prevalence of acute PE and demographic characteristics. From 400 adult patients who underwent acute PE-suspected pulmonary MDCT between , a total of 70 (17,5%) were included in our study with PE positive findings. From the remaining 330 studies, 16 patients (4%) were excluded because of inadequate image quality to assess an accurate quantification of clot burden, and 314 patients (78,5%) were excluded because they were diagnostic for other conditions rather than acute PE, like chronic vascular disease (3,3%) or acute processes (75,2% of PE suspictions), such as congestive heart failure or pneumonia (Fig. 7). Attending to the gender and age from patients with acute PE, the mean rate of hospitalizations was significantly higher among males than females (54,2% vs.45,7%). Additionally, patients aged # 80 years exhibited significantly higher rates compared with those patients aged under 80 years (81,4% vs.18, 5%) (Fig. 8). - MDCT angiographic findings. The distribution of embolus along the pulmonary arterial tree is displayed in Fig. 9. The most proximally affected pulmonary artery branch was the trunk in 3 patients (4,2 %), followed by principal pulmonary arteries in 23 (32,8%) patients, lobar arteries in 32 (45%) patients, segmental pulmonary arteries in 59 (84,2%) patients, and subsegmental pulmonary arteries in 39 (55,7%) patients. Isolated PE in subsegmental arteries was only found in 8 (11,4%) patients. According to our results of quantification of the clot burden (Fig.10), patients scoring groups were displayed as follows: Group 1, 35 patients (50%); group 2, 14 patients (20%) and group 3, 21 patients (30%). The frequency of prognostic events in hospitalized patients according to the quantification of clot burden is shown in Fig. 11. Patients with the highest scores of clot burden (group 3) were related to have the highest incidence of recurrences (5%) and cardiopulmonary complications (14,2%) and patients of groups 2 and 3 were most related to have long-stay hospitalizations; however, rates of ICU incomes and mortality rates were similarly found in patients of the three groups. Page 12 of 22

13 Signs of right heart dysfunction on MDCT angiographic images are summarized in Fig. 12, where the most commonly found were pulmonary hypertension (34,2%), reflux of contrast medium into the IVC (27%) and dilatation of right ventricle (17%) of patients with acute PE. Their frequencies, attending to the clot burden scoring groups at MDCT, are displayed in Fig. 13, which shows the highest rates of RV dilatation (75%) and pulmonary hypertension (71%) in the highest clot burden scoring group (group 3). Images for this section: Fig. 7: Prevalence of acute PE in the population of study. Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 13 of 22

14 Fig. 8: Prevalence of acute PE according to age and gender of patients. Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 14 of 22

15 Fig. 9: Distribution of PE in the pulmonary arteries (PAs) on MDCT images. Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 15 of 22

16 Fig. 10: Distribution of the scoring groups of quantification of clot burden at MDCT pulmonary angiography images. Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 16 of 22

17 Fig. 11: Distribution of prognostic events in hospitalized patients with acute PE according to the clot burden scores on MDCT images. Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 17 of 22

18 Fig. 12: Distribution of signs of right heart dysfunction on MDCT images from patients with acute PE. Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 18 of 22

19 Fig. 13: Signs of RV dysfunction and pulmonary infarctation attending to clot burden scoring groups at MDCT. Radiology, Hospital Madrid Monteprincipe - Madrid/ES Page 19 of 22

20 Conclusion Radiological risk stratification of patients with acute PE is very important because optimal management, monitoring, and therapeutic strategies depend on the prognosis. In our study, in patients with acute PE, quantification of clot burden in PAs at MDCT did not show significant correlation with short or long term mortality at the follow-up; in most cases, it was directly related with patient s basal clinical status (underlying cancer disease). However, the highest clot burden MDCT scores showed strong correlation (p <0.05) with the presence of signs of right heart dysfunction (because of RV overload) in the male population, and this correlation was more pronounced in the subgroup of patients with normal cardiorrespiratory reserve. Finally, patients with acute PE and signs of right heart dysfunction, were found to have a strong significant correlation (p< 0.05) with the development of cardiopulmonary sequelae in the male population along the follow up. We conclude that quantification of PA clot load still remains controversial for predicting prognosis in patients with acute PE. Many other MDCT findings that may allow refinement of the risk stratification are still under evaluation. Personal information References 1. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353: Kasper W, Konstantinides S, Geibel A, et al. Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry. J Am Coll Cardiol 1997; 30: Page 20 of 22

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