1. Contemporary Management of Pulmonary Embolism Lowell I. Gerber M.D. Associate Professor of Medicine KCOM

4. PULMONARY EMBOLISM PATHOLOGY

5. PULMONARY EMBOLISM PATHOPHYSIOLOGY

6. THE SPECTRUM OF PULMONARY EMBOLISM Right Ventricular Dysfunction Hemodynamic Instability Stable Hemodynamics and Cardiac Function

10. RISK STRATIFICATION VARIABLE HAZARD RATIO (95% CI) Age >70 years 1.6 (1.1-2.3) COPD 1.8 (1.2-2.7) Systolic blood pressure <90mmHg 2.9 (1.7-5.0) Right ventricular hypokinesis 2.0 (1.3-2.9) Congestive Heart Failure 2.4 (1.5-3.7) Cancer 2.3 (1.5-3.5) Respiratory rate <20/min 2.0 (1.2-3.2) Goldhaber, et al. Lancet. 353:1386-89; 24 Apr 1999

12. MORTALITY PE/DVT IN ELDERLY INHOSPITAL 1 YEAR 21% / 3% 39% / 21% Kniffin et al. Arch Intern Med . 1994 Apr 25

13. CLINICAL PROFILE PE STEIN, P.D. ET AL. CHEST 100:598, 1991 SYMPTOMS FREQUENCY (%) DYSPNEA 73 PLEURITIC PAIN 66 COUGH 37 LEG SWELLING / PAIN 28 / 26 SIGNS FREQUENCY (%) TACHYPNEA (>20/MIN) 70 RALES 51 TACHYCARDIA 30 S4 / INCREASED S2 24 / 23

14. CXR PULMONARY VASCULATURE ENLARGED RIGHT DESCENDING PULMONARY ARTERY WEDGE-SHAPED INFILTRATE OFTEN NORMAL

15. ELECTROCARDIOGRAM PULMONARY EMBOLISM T-wave inversion in leads III, aVF, or in leads V1-V4 QS in leads III and aVF Incomplete or complete right bundle branch block QRS axis > 90 or indeterminate axis Transition zone shift to V5

18. LABORATORY TESTING BioMarkers in Pulmonary Embolism

20. LABORATORY TESTING BioMarkers in Pulmonary Embolism Troponin

21. LABORATORY TESTING BioMarkers in Pulmonary Embolism Troponin

23. V/Q SCAN NORMAL PERFUSION ABNORMAL PERFUSION NORMAL- AND HIGH-PROBABILITY SCANS ARE CONSIDERED DIAGNOSTIC

24. PIOPED: PREDICTIVE VALUE V/Q SCAN SCAN CATEGORY CLINICAL SUSPICION 80-100% 20-79% 0-19% HIGH 96% 88% 56% INTERMEDIATE 66% 28% 16% LOW 40% 16% 4% PIOPED INVESTIGATORS. JAMA. 1990; 263: 2753-2759

26. ANGIOGRAPHIC SEVERITY SCORING Miller, et al. Amer Journ Roent,Rad Therapy & Nuc Med. 125(4):895-9, 1975 Dec.

27. Multi Slice CT 92 % SENSITIVITY , 95% SPECIFICITY COMPARED TO ANGIOGRAPHY OR TO HIGH-PROB OR NORMAL SCINTIGRAM (3 rd generation scanner, 1mm slice thickness) van Rossum,et al. Radiology. 1996;201:467-70

28. Multi Slice CT

29. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography JAMA 2006; 295:172-179 January 11, 2006 Writing Group for the Christopher Study Investigators

30. Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer and CT

34. RV OVERLOAD DIASTOLE SYSTOLE RV DILATATION & ABNORMAL SEPTAL MOTION

35. MORTALITY RV DYSFUNCTION Goldhaber, et al. Lancet. 353: 1386-89;24 April 1999 RV HYPOKINESIS NO RV HYPOKINESIS

36. PRIMARY THERAPY VS SECONDARY PREVENTION HEPARIN NORMAL BP RV DYSFUNCTION SBP<90 THROMBOLYSIS MECHANICAL INTERVENTION

39. Low Molecular Weight Heparins

40. THROMBOLYSIS UNSTABLE PATIENTS Jerges-Sanchez et al. J Thromb Thrombolysis 1995;2:227-229

41. Cardiac CT

42. Cardiac CT

43. THROMBOLYSIS RV DYSFUNCTION Goldhaber et al. The Lancet 341:8844; 507-511, Feb 27 1993

44. THROMBOLYSIS STABLE MAJOR PE Konstantinides S et al. Circulation. 1997;96:882-888

45. THROMBOLYSIS STABLE MAJOR PE ONLY INDEPENDENT PREDICTOR OF SURVIVAL (719 PATIENTS) Konstantinides et al. Circulation. 1997;96:882-888

52. PERCUTANEOUS

55. PULMONARY INTRATHROMBUS INFUSION

56. THROMBOLYSIS AND FRAGMENTATION

59. CURRENT PERMANENT IVC FILTERS Greenfield Bird’s Nest Simon Nitinol Vena Tech Stainless steel Titanium

62. Gunther Tulip Filter (Cook Inc., Bloomington, IN) has perhaps the widest experience in both the US and Europe. There are several reports in the literature supporting its value as a temporary filter It has the capability of deployment from either a femoral or jugular route. It must be retrieved from a jugular vein approach. Most authors recommended retrieval within 14 days.

63. OptEase Filter Cordis Endovascular, a Johnson & Johnson company, Miami, FL Has a unique self-centering design that provides dual-level filtration. It can be deployed from both the transfemoral and transjugular approaches using the same kit. It is the only potentially retrievable filter that is recovered from a femoral vein approach and requires a small retrieval system (10F guiding catheter)

67. FUTURE APPLICATIONS OF IVC FILTERS . Patent Foramen Ovale Recognized as a major contributor to morbidity and mortality Combined procedures of IVC filter and PFO closure may become more frequent

68. RHEOLYTIC THROMBECTOMY CATHETER

69. RHEOLYTIC THROMBECTOMY CATHETER

70. RHEOLYTIC THROMBECTOMY CATHETER

74. PATIENT CHARACTERISTICS PATIENT AGE GENDER CLINICAL STATUS CONTRAINDICATION 1 25 M ORTHOPNEA, LOW BP SKULL INJURY 2 70 M CARDIOGENIC SHOCK RECENT SURGERY 3 72 M CARDIOGENIC SHOCK CRITICAL BLEEDING 4 72 M ORTHOPNEA, LOW BP ACTIVE ULCER 5 52 F CARDIOGENIC SHOCK SURGERY 14 D AGO Voigtlander et al. Cath Card Interv . 47:91-96 1999

76. ANGIOGRAPHIC RESULTS TOTAL MILLER SCORE INVOLVEMENT REDUCTION OF FLOW (X/34) (X/16) (X/18) Voigtlander et al. Cath Card Interv. 47:91-96 1999

77. HEMODYNAMIC RESULTS Voigtlander et al. Cath Card Interv .47:91-96 1999

81. THROMBOENDARTERECTOMY HEMODYNAMIC VALUES PREOP POSTOP 3 moFOLLOW-UP Moser et al. Circulation 81: 1735,1990

88. Protocol for the Treatment of Massive Pulmonary Embolism in Patients Who Have Contraindications to Thrombolytic Therapy using the Possis AngioJet System

93. Contemporary Management of Pulmonary Embolism Lowell I. Gerber M.D.