Radiological Diagnostics of Pulmonary Embolism
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Date
2022
Journal Title
Journal ISSN
Volume Title
Publisher
Rīgas Stradiņa universitāte
Rīga Stradiņš University
Rīga Stradiņš University
Abstract
Šī literatūras apskata mērķis bija apkopot plaušu artēriju trombembolijas (PATE) radioloģiskās diagnostikas aspektus, un tās nozīmi PATE agrīnā patoloģijas verifikācijā un komplikāciju profilaksē. Literatūras apskatā analizēta informācija no medicīnas datu bāzēs pieejamām 49 zinātniskām publikācijām.
PATE ir trešais biežākais kardiovaskulārās nāves cēlonis pasaulē. PATE diagnostika sākas ar embolijas iespējamības klīnisku novērtējumu, izmantojot noteiktus prognostiskos klīniskos un laboratorors parametrus, pacienta anamnēzes datus un simptomus.
PATE diagnozi apstiprina radioloģiskā atradne. Datortomogrāfijas plaušu angiogrāfija (DTPA) ir zelta standarts PATE diagnosticēšanai, bet šajā literatūras apskatā iekļautas arī citas diagnostikas metodes, piemēram V/Q scintigrāfija. Magnētiskās rezonanses angiogrāfija ir pierādījusi savu potenciālu kļūt par alternatīvu pirmās izvēles radioloģiskās diagnostikas metodi, taču līdz šim tā ir ieteicama tikai kā adjuvanta metode. Plaušu artēriju digitālās subtrakcijas angiogrāfiju (DSA) joprojām var izmantot pacientiem, kuriem nepieciešama endovaskulāra ārstēšana, bet citādi to pilnībā aizstāj ar neinvazīvām metodēm. Ehokardiogrāfijā var identificēt labā kambara pārslodzes pazīmes, kas ļauj pacientiem izteikt aizdomas par PATE diagnozi. Šajā literatūras apskatā iztirzāta arī specifiskas pacientu grupas- grūtnieču- radioloģiskā izmeklēšana, ja pastāv aizdomas par PATE.
Ir izstrādāti vairāki radioloģiskie kritēriji PATE kvantitatīvai novērtēšanai, taču tie joprojām ir aprakstoši un bez būtiskas klīniskas ietekmes. Biežākās PATE komplikācijas ir akūta un hroniska plaušu hipertensija un plaušu infarkts. Minēto komplikāciju radioloģiskā diagnostika apkopota dotajā literatūras apskatā.
PATE ārstēšana balstās uz klīniski determinētu smaguma pakāpi un ietver antikoagulācijas medikamentozo terapiju. Augsta riska pacienti tiek ārstēti ar sistēmisku trombolītisku terapiju. Ja šāda terapija ir nesekmīga vai kontrindicēta, var tikt pielietotas invazīvas metodes. Pastāv vairākas endovaskulāras terapijas taktikas, lai panāktu plaušu artēriju reperfūziju, taču tehniskas un klīniskas rezultativitātes rādītāji dažādos pētījumos ir atškirīgi. Atvērta ķirurģiska plaušu artēriju embolektomija ir alternatīva pacientiem ar masīvu trombu apjomu proksimālajās plaušu artēriju daļās, taču tās iznākumi līdzinās trombolītiskajai terapijai.
Literatūras apraksta noslēgumā tiek secināts, ka agrīna diagnostika, izvēloties pareizo radioloģisko metodi, ir svarīga, jo tā ļauj agrāk uzsākt validētu un efektīvu ārstēšanu, tādējādi uzlabojot klīnisko iznākumu.
This literature review presents the diagnostic approach in pulmonary embolism and points out the importance and relevance of radiologic imaging in early diagnosis and prevention of complications of pulmonary embolism. To perform this literature review, 49 relevant scientific articles were referenced. Pulmonary embolism is the third most common cause of cardiovascular death. In many cases it remains undiagnosed, which is why highly sensitive diagnostic methods should be used and improved. Diagnosis starts with clinical evaluation of likelihood of pulmonary embolism, using established probability scores for typical patient history and symptoms, and laboratory testing. Diagnosis is confirmed by radiologic imaging. CT-pulmonary angiography (CTPA) is the gold-standard for diagnosing pulmonary embolism, but V/Q scintigraphy is a reliable alternative. Both are highly sensitive for detecting pulmonary embolism in combination with clinical and laboratory assessment. MRA has shown its potential to become an alternative first choice imaging method, but so far is only recommended as adjuvant imaging method. Pulmonary digital subtraction angiography might still be used in patients requiring endovascular treatment, but is otherwise completely replaced by non-invasive methods. Echocardiography can identify signs of right ventricular overload which allows to rule in patients for pulmonary embolism diagnosis and can thereby increase diagnostic sensitivity for pulmonary embolism, especially in the hospital setting. In pregnant patients, a chest X-ray and duplex-sonography of the deep veins of the legs should be performed before confirmatory imaging. If available, V/Q scintigraphy should be preferred over CTPA. Severity staging of pulmonary embolism bases clinical presentation of the patient and his risk of early death. Several radiological criteria for quantification of embolism have been developed, but remain descriptive and without clinical impact. Common complications of pulmonary embolism include acute and chronic pulmonary hypertension and pulmonary infarction. They can be identified by specific radiographic signs, best visible on CTPA. Treatment bases on clinically determined stage of severity and includes anticoagulation with low molecular weight heparin. High-risk patients are treated with systemic thrombolytic therapy. If such therapy failed or contraindicated, interventional approaches can be applied. Several endovascular approaches to achieve reperfusion exist and success rates differ among the methods. Open surgical pulmonary embolectomy is an alternative in patients with extensive proximal thrombus burden with an outcome similar to thrombolytic therapy. In a conclusion, early diagnosis by choosing the right imaging modality is important, as it allows to initiate validated and effective treatment earlier and might thereby improve the patients outcome.
This literature review presents the diagnostic approach in pulmonary embolism and points out the importance and relevance of radiologic imaging in early diagnosis and prevention of complications of pulmonary embolism. To perform this literature review, 49 relevant scientific articles were referenced. Pulmonary embolism is the third most common cause of cardiovascular death. In many cases it remains undiagnosed, which is why highly sensitive diagnostic methods should be used and improved. Diagnosis starts with clinical evaluation of likelihood of pulmonary embolism, using established probability scores for typical patient history and symptoms, and laboratory testing. Diagnosis is confirmed by radiologic imaging. CT-pulmonary angiography (CTPA) is the gold-standard for diagnosing pulmonary embolism, but V/Q scintigraphy is a reliable alternative. Both are highly sensitive for detecting pulmonary embolism in combination with clinical and laboratory assessment. MRA has shown its potential to become an alternative first choice imaging method, but so far is only recommended as adjuvant imaging method. Pulmonary digital subtraction angiography might still be used in patients requiring endovascular treatment, but is otherwise completely replaced by non-invasive methods. Echocardiography can identify signs of right ventricular overload which allows to rule in patients for pulmonary embolism diagnosis and can thereby increase diagnostic sensitivity for pulmonary embolism, especially in the hospital setting. In pregnant patients, a chest X-ray and duplex-sonography of the deep veins of the legs should be performed before confirmatory imaging. If available, V/Q scintigraphy should be preferred over CTPA. Severity staging of pulmonary embolism bases clinical presentation of the patient and his risk of early death. Several radiological criteria for quantification of embolism have been developed, but remain descriptive and without clinical impact. Common complications of pulmonary embolism include acute and chronic pulmonary hypertension and pulmonary infarction. They can be identified by specific radiographic signs, best visible on CTPA. Treatment bases on clinically determined stage of severity and includes anticoagulation with low molecular weight heparin. High-risk patients are treated with systemic thrombolytic therapy. If such therapy failed or contraindicated, interventional approaches can be applied. Several endovascular approaches to achieve reperfusion exist and success rates differ among the methods. Open surgical pulmonary embolectomy is an alternative in patients with extensive proximal thrombus burden with an outcome similar to thrombolytic therapy. In a conclusion, early diagnosis by choosing the right imaging modality is important, as it allows to initiate validated and effective treatment earlier and might thereby improve the patients outcome.
Description
Medicīna
Medicine
Veselības aprūpe
Health Care
Medicine
Veselības aprūpe
Health Care
Keywords
"Plaušu embolija", "Diagnostiskā attēlveidošana", "Radioloģiskā attēlveidošana", "CTPA", "V/Q scintigrāfija", "Plaušu scintigrāfija", "Plaušu angiogrāfija", "Magnētiskās rezonanses angiogrāfija", "Plaušu infarkts", "Plaušu hipertensija", "Plaušu embolijas ārstēšana", "CTPA smaguma pakāpe", "Pulmonary embolism", "Diagnostic imaging", "Radiologic imaging", "CTPA", "V/Q scintigraphy", "Lung scintigraphy", "Pulmonary Angiography", "Magnetic resonance angiography", "Pulmonary infarction", "Pulmonary hypertension", "Pulmonary embolism treatment", "CTPA Severity score"