Jornal Vascular Brasileiro
https://www.jvascbras.org/article/doi/10.1590/1677-5449.200124
Jornal Vascular Brasileiro
Therapeutic Challenge

Is routine screening for silent pulmonary embolism justified in patients with deep vein thrombosis?

Existe justificativa para o rastreio de embolia pulmonar silenciosa em pacientes com trombose venosa profunda?

Marcela Juliano Silva; Cynthia de Almeida Mendes; Sergio Kuzniec; Mariana Krutman; Nelson Wolosker

Downloads: 0
Views: 112

Abstract

Abstract: The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase.

Keywords

venous thrombosis, vena cava filters, pulmonary embolism, embolism and thrombosis, anticoagulants

Resumo

Resumo: A ocorrência de embolia pulmonar assintomática em pacientes com trombose venosa profunda tem uma incidência que excede 70%, mesmo nos casos de trombose venosa profunda distal. Relatamos o caso de um paciente com diagnóstico de trombose venosa profunda no membro inferior esquerdo associado a embolia pulmonar assintomática, que apresentou sintomas tardios devido a essa mesma embolia. A ausência de sintomas agudos e o surgimento de sintomas tardios pode suscitar dúvidas quanto ao tratamento mais adequado e resultar em intervenções desnecessárias, se o diagnóstico tomográfico de embolia pulmonar não tiver sido feito anteriormente. No presente caso, demonstramos que uma angiotomografia realizada no momento do diagnóstico de trombose venosa profunda detectou a embolia pulmonar e evitou uma interpretação incorreta de um evento trombótico recorrente na vigência de anticoagulação, o que por engano demonstraria uma falha na terapia anticoagulante. Essa situação pode levar a intervenções desnecessárias, como o implante de filtro de veia cava inferior. Entendemos que apenas um relato de caso não deve mudar uma conduta médica já estabelecida; no entanto, fomenta a discussão e estimula estudos que avaliem a necessidade de um exame diagnóstico pulmonar no momento do diagnóstico de trombose venosa profunda.
 

Palavras-chave

trombose, veias cavas, embolia, embolia e trombose, anticoagulantes

References

1 Li F, Wang X, Huang W, et al. Risk factors associated with the occurrence of silent pulmonary embolism in patients with deep venous thrombosis of the lower limb. Phlebology. 2014;29(7):442-6. http://dx.doi.org/10.1177/0268355513487331. PMid:23761869.

2 Krutman M, Wolosker N, Kuzniec S, Campos Guerra JC, Tachibana A, Almeida Mendes C. Risk of asymptomatic pulmonary embolism in patients with deep venous thrombosis. J Vasc Surg Venous Lymphat Disord. 2013;1(4):370-5. http://dx.doi.org/10.1016/j.jvsv.2013.04.002. PMid:26992758.

3 Fleck D, Albadawi H, Wallace A, Knuttinen G, Naidu S, Oklu R. Below-knee deep vein thrombosis (DVT): diagnostic and treatment patterns. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S134-9. http://dx.doi.org/10.21037/cdt.2017.11.03. PMid:29399516.

4 García-Fuster MJ, Fabia MJ, Furió E, et al. Should we look for silent pulmonary embolism in patients with deep venous thrombosis? BMC Cardiovasc Disord. 2014;14(1):178. http://dx.doi.org/10.1186/1471-2261-14-178. PMid:25487168.

5 Jiménez D, Díaz G, Marín E, Vidal R, Sueiro A, Yusen RD. The risk of recurrent venous thromboembolism in patients with unprovoked symptomatic deep venous thrombosis and asymptomatic pulmonary embolism. Thromb Haemost. 2006;95(3):562-6. http://dx.doi.org/10.1160/TH05-10-0677. PMid:16525588.

6 Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276-315. http://dx.doi.org/10.1093/eurheartj/ehn310. PMid:18757870.

7 Krutman M, Kuzniec S, Ramacciotti E, et al. Rediscussing anticoagulation in distal deep venous thrombosis. Clin Appl Thromb Hemost. 2016;22(8):772-8. http://dx.doi.org/10.1177/1076029615627343. PMid:26787712.

8 Ruiz J, Fraile M, Bonet M, et al. Prospective study on the usefulness of lung scan in patients with deep vein thrombosis of the lower limbs. Thromb Haemost. 2001;85(5):771-4. http://dx.doi.org/10.1055/s-0037-1615716. PMid:11372666.

9 Guyatt GH, Norris SL, Schulman S, et al. Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2, Suppl):53S-70S. http://dx.doi.org/10.1378/chest.11-2288. PMid:22315256.

10 Zerati AE, Wolosker N, Yazbek G, Langer M, Nishinari K. Vena cava filters in cancer patients: experience with 50 patients. Clinics. 2005;60(5):361-6. http://dx.doi.org/10.1590/S1807-59322005000500003. PMid:16254671.

11 Spencer FA, Bates SM, Goldberg RJ, et al. A population-based study of inferior vena cava filters in patients with acute venous thromboembolism. Arch Intern Med. 2010;170(16):1456-62. http://dx.doi.org/10.1001/archinternmed.2010.272. PMid:20837832.

12 Group PS. Eight‐year follow‐up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation. 2005;112(3):416-22. http://dx.doi.org/10.1161/CIRCULATIONAHA.104.512834. PMid:16009794.

13 Skelley JW, White CW, Thomason AR. The use of direct oral anticoagulants in inherited thrombophilia. J Thromb Thrombolysis. 2017;43(1):24-30. http://dx.doi.org/10.1007/s11239-016-1428-2. PMid:27734187.

14 Elsebaie MAT, Es N, Langston A, Büller HR, Gaddh M. Direct oral anticoagulants in patients with venous thromboembolism and thrombophilia: a systematic review and meta-analysis. J Thromb Haemost. 2019;17(4):645-56. http://dx.doi.org/10.1111/jth.14398. PMid:30690830.
 


Submitted date:
05/07/2020

Accepted date:
08/24/2020

60d4c83ea9539509485eb3a2 jvb Articles
Links & Downloads

J Vasc Bras

Share this page
Page Sections