CHEST

CHEST

Volume 150, Issue 2, August 2016, Pages e41-e47
Journal home page for CHEST

Chest Imaging and Pathology for Clinicians
A 57-Year-Old Man With Insidious Dyspnea and Nonpleuritic Chest and Back Pain

https://doi.org/10.1016/j.chest.2016.02.680Get rights and content

A 57-year-old man with a history of DVT and pulmonary embolism, transient ischemic attacks, prior 60 pack-year smoking history, and oxygen-dependent COPD presented with insidiously worsening dyspnea associated with new pleuritic chest and back pain.

Section snippets

Case Presentation

Three years before presentation, the patient developed left lower extremity edema shortly following air travel and he was ultimately diagnosed with a DVT and concomitant pulmonary embolism (PE). Additional evaluation revealed emphysema, COPD, and hypoxemia necessitating 3 to 4 L/min of supplemental oxygen. He was anticoagulated with Coumadin until 1 year before presentation when he suffered a mechanical fall with multiple rib fractures and anticoagulation was discontinued. He was otherwise

Clinical Discussion

The history of significant hypoxemia and significant pulmonary hypertension should raise suspicion for alternative diagnoses other than COPD. A comprehensive evaluation for additional etiologies of persistent hypoxemia and pulmonary hypertension following VTE and PE was warranted, including consideration for CTEPH. In review of the patient’s chart, an echocardiogram that had been performed at the time of initial PE several years before presentation revealed elevated estimated pulmonary artery

Conclusions

The patient in our study exhibited a spectrum of acute, subacute, and chronic PE, representing thromboembolic events hours, days to weeks, and years after initial VTE, respectively. Initial management focused on hemodynamic stabilization and prophylactic retrieval of a right- to left-sided thrombus that posed a catastrophic risk of both pulmonary and systemic embolization. Suspected by history and confirmed at the time of surgery, CTEPH was appropriately considered, and the patient underwent

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following: J. R. S. has received payments for expert witness testimony involving cases of PE. None declared (K. N., G. A. A., N. M M., G. J. V., C. D. W., B. B. G., D. M. D.).

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: The Video can be found in the Multimedia section of the online article.

References (31)

  • N. Galie et al.

    Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT)

    Eur Heart J

    (2009)
  • M.R. Jaff et al.

    Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association

    Circulation

    (2011)
  • S.V. Konstantinides et al.

    2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism

    Eur Heart J

    (2014)
  • G. Athappan et al.

    Comparative efficacy of different modalities for treatment of right heart thrombi in transit: a pooled analysis

    Vasc Med

    (2015)
  • D.M. Dudzinski et al.

    Multidisciplinary pulmonary embolism response teams

    Circulation

    (2016)

    • Cited by (3)

    • Interventional Therapies for Acute Pulmonary Embolism

      2022, Surgical Clinics of North America
      Citation Excerpt :

      Additional maneuvers for improved exposure and clot extraction include making a second incision in the right PA exposed between aorta and superior vena cava,52 gentle compression of the lung to dislodge small distal clots (except if the patient received antecedent ST), and clot extraction from the segmental arteries using a small videoscope.70,71 Other loci of thrombus-in-transit can be addressed surgically, including right heart thrombi and impending paradoxic embolism of PE, for which SPE is considered first-line therapy.9,72 Before PA closure, the catheter in the superior vena-cava is advanced into the right PA under direct vision.

    • Saddle Pulmonary Embolus Caught in Transit across a Patent Foramen Ovale

      2019, Case Reports in Pulmonology

    • Interventional Treatment of Pulmonary Embolism

      2017, Circulation: Cardiovascular Interventions
    View full text
    Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.