Modern aspects of MSCT diagnostics of acute massive pulmonary embolism

Introduction: The growing importance of the MSCT method in the case of acute massive pulmonary embolism forms new diagnostic directions  — the determination of objective MSCT markers of right ventricular dysfunction and the search for new, previously ignored, MSCT parameters of angiographic severity of embolic load.
The purpose of the study: to evaluate the prognostic role and predictivity of the results of MSCT angiopulmonography in the case of choosing a surgical method for the treatment of pulmonary embolism.
Research objectives. Тo analyze the influence of the volume of preserved peripheral arterial pulmonary blood flow on the results of surgical treatment of acute massive PE and the dependence of the average pressure in the pulmonary artery on the MSCT parameters.
Materials and methods: this work examines the surgical approach to the treatment and possibilities of preoperative MSCT diagnosis of acute massive pulmonary embolism. The 7-year analysis included the analysis of more than 1,200 MSCT studies for acute massive pulmonary embolism. 147 patients were selected for surgical treatment and successfully operated on, the remaining patients received conservative therapy with dynamic MSCT observation. According to international classifiers, the analysis of classes and categories of intraoperative and postoperative complications of emergency surgical treatment was performed in comparison with the initial MSCT parameters of acute massive PE.
Results. The smaller the number of segmental branches of the pulmonary artery is determined at the preoperative stage, the higher the risks of mortality and complications of emergency surgical treatment of acute massive PE (p<0,001). A direct relationship between the average pressure in the pulmonary artery and the MSCT parameter-the diameter of the unpaired vein (p<0,001) was confirmed. An increase in the number of visualized bronchial arteries corresponds to an increase in the average pressure in the pulmonary artery (p<0,05).
Discussion. The lightning speed of the course of pulmonary embolism dictates an exceptional approach to the completeness of the diagnosis of the disease, and the change in treatment tactics due to the increasing demand for surgical methods of treatment changes the diagnostic approach to acute pulmonary embolism in general. The success of surgical treatment of PE directly depends on the completeness and speed of preoperative MSCT diagnostics, in particular, on the quality of analysis of intra-pulmonary and intracardiac hemodynamics.
Conclusion: For acute massive PE with obstruction at the level of the trunk and / or main branches of the pulmonary artery, with a sharp and often uncontrolled progression of right ventricular failure, risk stratification in «real time» becomes the most relevant, the time factor becomes of paramount importance for determining treatment tactics. The inclusion of previously ignored MSCT parameters in the algorithm of preoperative diagnosis allows us to modify the algorithm of preoperative diagnosis, to form and introduce the concept of the reference MSCT status of a patient with acute massive PE. 

1. Khubulava G.G., Gavrilov E.K., Shishkevich A.N., Larin I.A., Alborov Yu.R., Sadovoy S.V. Diagnostics and surgical treatment of ascending deep phlebothrombosis of the lower extremities and pelvis. Bulletin of Surgery, 2018, Vol. 177, No. 2, рр. 46–51 (In Russ.).

2. Medvedev A.P., Maksimov A.L., Nemirova S.V., Pichugin V.V., Demarin O.I., Kalinina M.L., Kozina M.B., Chiginev V.A. Experience of diagnosis and surgical treatment of pulmonary embolism in pregnant women. Modern technologies in medicine, 2017, No 9 (4), рр. 143–155 (In Russ.)].

3. Russian clinical recommendations for the diagnosis, treatment, prevention of venous thromboembolic complications. Phlebology, 2015, Vol. 9, No. 4 (2), рр. 4–46 (In Russ.)

4. Konstantinides S.V., Torbicki A., Agnelli G., Danchin N., Fitzmaurice D., Galiè N., Gibbs J.S. 2014 ESC 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. 2014. Vol. 35, No. 43. P. 3033–3069. doi: 10.1093/eurheartj/ehu283.

5. Yudin A.L., Uchevatkin A.A., Afanasyeva N.I., Yumatova E.A., Kulagin A.L. The role of multidetector computed tomography in the diagnosis of venous thromboembolism. Russian Medical Journal, 2015, No. 21 (1), рр. 40–43 (In Russ.).

6. Mean M., Tritschler T., Limacher A., Breault S., Rodondi N., Aujesky D., Qanadli SD. Association between computed tomography obstruction index and mortality in elderly patients with acute pulmonary embolism: A prospective validation study // PLoS ONE. 2017. Vol. 12, No. 6. P. 1–13 . doi: 10.1371/journal.pone.0179224.

7. John G., Marti C., Poletti P.A., Perrier A. Hemodynamic Indexes Derived from Computed Tomography Angiography to Predict Pulmonary Embolism Related Mortality // BioMed Research International. 2014. P. 8. doi: 10.1155/2014/363756

8. Sukhova M.B. Acute massive pulmonary embolism. A modern view on the analysis of the results of the MSCT study. Modern standards of radiation research and principles of drawing conclusions: a guide for doctors, ed. by T.N.Trofimova. St. Petersburg, 2021, 440 р. (In Russ.).

9. Sinelnikov R.D., Sinelnikov Ya.R. Atlas of human anatomy. In 4 volumes. Vol. 2. The doctrine of the entrails. Splanchnologiya. 2nd еd., ster. Moscow, 1996. P. 157–160 (In Russ.).

10. Aviram G., Rogowski O., Gotler Y., Bendler A., Steinvil A., Goldin Y., Graif M., Berliner S. Real Time Risk Stratification of Patients with Acute Pulmonary Embolism by Grading the Reflux of Contrast into the Inferior Vena Cava on Computerized Tomographic Pulmonary Angiography // Journal of Thrombosis and Haemostasis. 2008. Vol. 6, No. 9. P. 1488–1493. doi: 10.1111/j.1538–7836.2008.03079.

11. Yeh B.M., Kurzman P., Foster E., Qayyum A., Joe B., Coakley F. Clinical relevance of retrograde inferior vena cava or hepatic vein opacification during contrast-enhanced CT // Am. J. Roentgenol. 2004. Vol. 183, No. 5. P. 1227– 1232. doi: 10.2214/ajr.183.5.1831227.

12. Kazaryan A.M., Akopov A.L., Rosok B., Postriganova N.D., Edwin B. The Russian edition of the classification of complications in surgery. Bulletin of Surgery named after Grekov I.I., 2014, Vol. 173, No. 2, рр. 86–91 (In Russ.).

13. Tyurin V.P., Pronin A.G. Comparison of criteria for stratification of the risk of death in pulmonary embolism, taking into account the volume of damage to the pulmonary arteries. International Journal of Heart and Vascular Diseases, 2018, Vol. 6, No. 18, рр. 36–47 (In Russ.).

14. Савельев В.С., Яблоков Е.Г., Кириенко А.И. Тромбоэмболия легочных артерий. М.: Медицина, 1979. С. 264 [Savelyev V.S., Yablokov E.G., Kiriyenko A.I. Pulmonary embolism. Moscow: Publishing house Medicine, 1979, рр. 264 (In Russ.)].

15. Khubulava G.G., Gavrilov E.K., Tarasov V.A. Immediate and long-term results of open thrombectomy from deep veins of the lower extremities with floating phlebotrobosis with and without preliminary implantation of a cava filter. Annals of Surgery, 2016, Vol. 21, No. 1–2, рр. 139–144 (In Russ).

16. Alyokhin M.N. Possibilities and limitations of echocardiography in the assessment of pressure in the pulmonary artery and right chambers of the heart. Ultrasound and functional diagnostics, 2012, No. 6, рр. 106–116 (In Russ.).

17. Yudin A.L., Uchevatkin A.A., Afanasyeva N.I., Yumatova E.A., Rudaya A.I. Bronchial arteries-anatomical features and ways of remodeling. Radiation diagnostics and therapy, 2015, Vol. 1, No. 6, рр. 32–38 (In Russ.).