Anne Knisely, MS4 Diagnostic Radiology elective

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Presentation transcript:

Anne Knisely, MS4 Diagnostic Radiology elective Case Report Anne Knisely, MS4 Diagnostic Radiology elective MRN 0734588

SK, 69 y.o. F Initially admitted with heavy vaginal bleeding and severe anemia Transfused, started on Megace (megestrol) 5 cm mass on TVUS, grade 1 endometrioid adenocarcinoma on EMBx Readmitted for surgery 1 week later (robotic TLH/BSO, pelvic LND) Required 1U pRBCs, d/c’ed on PSD#2 with Foley (removed PSD#11) Presented to ED on PSD#13 with left leg pain and edema, R-sided pleuritic chest pain, mild SOB CXR, CTPA, b/l LE Doppler US, TTE PMH: Obesity (BMI 35), HTN, nec fasc of R shoulder c/b A-fib requiring debridement, trach, and PEG tube in 2015 Day after surg, Hct 29.1  23.3 31/38 mm invasion on frozen section Initial PE: R sided basilar crackles, no increased WOB on 4L NC CXR was normal!

Left pulmonary artery with occlusive thrombus (filling defect)

Right pulmonary artery with occlusive thrombus (filling defect)

Filling defects continue bilaterally Evidence of right heart strain on CT with RV:LV ratio of 1.26

Right: occlusive thrombus in R superficial femoral vein, popliteal vein, and R calf veins

Left: occlusive thrombus throughout common femoral vein, superficial femoral, profunda femoral, popliteal, and calf veins and great saphenous vein

Hospital Course TTE: RV severely dilated with reduced EF, evidence of severe pulmonary artery systolic pressure elevation Troponin peak of 0.03 Admitted to MICU with telemetry monitoring Heparin drip  enoxaparin IVC filter placed by IR HDS since admission ESBL-producing E. coli UTI  Bactrim x 7 d. Discharged on apixaban with Vascular medicine f/u in 1 mo., TTE and IVC filter removal in 3 mo. Held home Megace (can decrease effectiveness of anticoagulation) **no thrombolytics given b/c of recent surgery

Diagnosis Submassive bilateral PE Extensive bilateral pulmonary emboli with evidence of right heart strain (CT with RV:LV ratio of 1.26, TTE) Bilateral lower extremity deep vein thrombi

Radiographic Features and Ddx Pulmonary artery intraluminal filling defect(s) Thromboembolism Mass compression/tumor emboli Respiratory motion artifact Flow-related artifact/vascular bifurcation Primary pulmonary artery sarcoma Non-compressible lower extremity vein(s) Acute thrombus Chronic thrombus Proximal obstructions caused by extrinsic masses Venous distension 2/2 CHF

References Wittram C et al. (2004) CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis. RSNA RadioGraphics 24:5. DiVittorio R, Bluth E, and Sullivan M. (2002) Deep Vein Thrombosis: Diagnosis of a Common Clinical Problem. Ochsner Journal. 4(1):14-17.