Dec 19, 2019
Episode 4: Dr. Rosenfield interviews Dr. Richard
Channick on Post PE care!
Dr Channick is the current PERT Consortium president and is the
Director of the Acute and Chronic Thromboembolic Disease Program
within the David Geffen School of Medicine at UCLA.
Dr. Rosenfield is Section Head of Vascular Medicine and
Intervention at Mass General Hospital and past PERT president and
What happens after a PE?
- Following acute pulmonary embolism some patients do not return
to their baseline and may suffer from what is called post PE
- Some of these unfortunate patients develop chronic
thromboembolic disease or chronic thromboembolic pulmonary
Follow Up Clinic
- In clinic it's important to assess if patients have returned to
their baseline of physical acitivity. If the answer is no, then go
for objective testing
- First step may be getting a follow-up echocardiogram or repeat
- CTA is extremely helpful for acute pulmonary embolism. CTA is
less revealing for chronic pulmonary embolism. VQ scan is the most
sensitive test for the chronic pulmonary embolism. If VQ scan
is normal 8 to 10 weeks following acute PE rhythm you do not have
any chronic pulmonary embolism
- Following an abnormal VQ scan next steps should be -->
evaluated for CTED or CTEPH.
Define chronic thromboembolic pulmonary hypertension and
- CTED or CTEPH is a scar tissue forming in pulmonary vessels is
not an acute clot. à higher degree of such vascular obstruction
will lead to increase in PVR and eventually PHTN and RV
- CTED or CTEPH has distinct appearance on imaging: Chronic clot
may have appearance of fibrous bands, webs or bands. Appearance is
quite different than acute clot.
- Extremely high pulmonary artery pressure of about 80 or 90
millimeters of Hg suggest chronic right ventricular pressure
- Bronchial collaterals on CTA may suggest a chronic process.
Acute Vs Chronic Clot on Imaging:
- Acute clot will have a central occlusive appearance.
- Sometimes it is hard to differentiate. If patient has not been
anticoagulated in the past you anticoagulate and do a follow-up in
8 to 10 weeks.
- Signs of RV hypertrophy on the echocardiogram also suggests a
Treatment of chronic thromboembolic pulmonary
- First-line of treatment is surgical. [It is complicated cardiac
surgery that involves expert surgical team. It involves
cardiopulmonary bypass, deep hypothermic arrest and needs and
- Balloon pulmonary angioplasty growing evidence.
- RIOCIGUAT is the only approved drug for CTEPH. Macitentan has
been studied but not approved. PDE inhibitors also have
- Upfront medical therapy should not delay the referral for the
patients who potentially are surgical candidates.
Types of chronic thromboembolic pulmonary disease
and surgical classification
- Four levels depend on whether the disease starts
- If the disease starts proximally it is easier for the surgeon
to dissect. It depends where the chronic clots are involving the
Level 1 disease: Proximal
Level 2 disease: Lobar disease
Level 3 disease segmental disease
Level 4 disease sub-segmental disease
Basics Concepts of Balloon Pulmonary Angioplasty
- It involves dilating the narrowed pulmonary segments and
improve with the primary pulmonary perfusion and reducing the
- First step is to do the pulmonary angiogram. Then match the
perfusion defects with the VQ scan. Work as a team.
- Goal is not to over distend the pulmonary vasculature. Goal is
just to break up the scar or the fibrous tissue and increase distal
perfusion. Vascular stenting is not performed usually.
- BPA is a staged procedure. The session can last anywhere
between 2-3 to 12-13 sessions.
- Each session is 2 to 3 hours involves fair amount of radiation
and the contrast.
- Pulmonary hemorrhage is a very serious complication; BPA has a