Is routine screening for silent pulmonary embolism justified in patients with deep vein thrombosis? / Existe justificativa para o rastreio de embolia pulmonar silenciosa em pacientes com trombose venosa profunda?

Abstract The incidence of asymptomatic pulmonary embolism (PE) exceeds 70% in patients with deep venous thrombosis (DVT), even in cases of distal deep vein thrombosis. We report the case of a patient with a diagnosis of DVT in the lower left limb associated with asymptomatic PE who presented late symptoms due to this same PE. The absence of acute symptoms and the late onset of symptoms could have provoked doubts about the most appropriate treatment, resulting in unnecessary interventions, if pulmonary embolism had not already been diagnosed with tomography. In the present case, we demonstrate that computed tomography angiography conducted at the time of DVT diagnosis accurately diagnosed PE and prevented any misinterpretation of recurrent DVT in a patient already being medicated, which could have been mistakenly interpreted as demonstrating failure of anticoagulant therapy. Such a situation could lead to unnecessary intervention to fit an inferior vena cava filter. We cannot suggest that a classic medical conduct should be reformulated simply on the basis of a case report. However, we would be remiss not to suggest that well-designed studies should be carried out in the future to assess the need for this examination in the acute phase.

Resumo A ocorrência de embolia pulmonar assintomática em pacientes com trombose venosa profunda tem uma incidência que excede 70%, mesmo nos casos de trombose venosa profunda distal. Relatamos o caso de um paciente com diagnóstico de trombose venosa profunda no membro inferior esquerdo associado a embolia pulmonar assintomática, que apresentou sintomas tardios devido a essa mesma embolia. A ausência de sintomas agudos e o surgimento de sintomas tardios pode suscitar dúvidas quanto ao tratamento mais adequado e resultar em intervenções desnecessárias, se o diagnóstico tomográfico de embolia pulmonar não tiver sido feito anteriormente. No presente caso, demonstramos que uma angiotomografia realizada no momento do diagnóstico de trombose venosa profunda detectou a embolia pulmonar e evitou uma interpretação incorreta de um evento trombótico recorrente na vigência de anticoagulação, o que por engano demonstraria uma falha na terapia anticoagulante. Essa situação pode levar a intervenções desnecessárias, como o implante de filtro de veia cava inferior. Entendemos que apenas um relato de caso não deve mudar uma conduta médica já estabelecida; no entanto, fomenta a discussão e estimula estudos que avaliem a necessidade de um exame diagnóstico pulmonar no momento do diagnóstico de trombose venosa profunda.

Signs of impending rupture in abdominal aortic and iliac artery aneurysms by computed tomography: Outcomes in 41 patients

OBJECTIVES: This study aimed to determine the prevalence of signs of impending rupture (SIR) in asymptomatic patients with abdominal aortic and iliac artery aneurysms, and to evaluate whether these signs were associated with rupture in asymptomatic patients. METHODS: This was a retrospective study of patients with abdominal aortic and iliac artery aneurysms identified on computed tomography (CT) over a 10-year period in a single center. The CT scans were reviewed by two reviewers, and patients with SIR were assigned to one of three groups: (1) early symptomatic (ES), (2) late symptomatic (LS), and (3) always asymptomatic (AA). The four main SIR described in the literature were investigated: 1) crescent sign, 2) focal wall discontinuity of circumferential calcifications, 3) aortic bulges or blebs, and 4) aortic draping. RESULTS: From a total of 759 aortic and iliac aneurysm reports on 2226 CT scans, we identified 41 patients with at least one SIR, and a prevalence of 4.14% in asymptomatic patients. Focal wall discontinuity of circumferential calcifications was the most common sign, and it was present in 46.3% of these patients (19/41); among these, 26 were repaired (ES: 9, LS: 2, AA: 15). Eleven asymptomatic patients underwent follow-up CT. The aneurysm increased in size in 6 of the 11 (54.5%) patients, and three ruptured (all with discontinuity of calcifications), one of which had no increase in diameter. CONCLUSIONS: The presence of focal wall discontinuity of circumferential calcifications was the most common SIR. There was a prevalence of all signs in less than 5% of asymptomatic patients. In unrepaired patients, the signs could be observed on follow-up CT scans with an increase in aneurysm size, indicating that the presence of SIR alone in the absence of other clinical factors or aneurysm characteristics is an insufficient indication for surgery.