CTEPH vs. Pulmonary Embolism: Practice Pearls for Diagnosis and Management (Video)

When a patient presents with dyspnea and other symptoms suggestive of pulmonary embolism (PE) or chronic thromboembolic pulmonary hypertension (CTEPH), a host of questions arise:

• What criteria best distinguish these two entities?
• Which tests to order?
• If PE is suspected, is it subacute? Which medications are indicated? Is outpatient treatment safe?
• If the diagnosis is acute PE, what’s the best treatment — catheter-directed lysis, thromboendarterectomy or surgical clot excision — and who decides?
• Which patients are most likely to have CTEPH? How are they identified and managed?

Cleveland Clinic approaches the diagnosis and treatment of these complex patients with multidisciplinary teams that include specialists in pulmonary medicine, cardiothoracic surgery, nuclear medicine, interventional radiology, cardiovascular medicine, anesthesiology and critical care medicine.

In the video below, a panel of several such specialists — pulmonologist Gustavo Heresi, MD; cardiothoracic surgeons Nicholas Smedira, MD, MBA, and Michal Tong, MD; interventional radiologist Ihab Haddadin, MD; and vascular medicine specialist John Bartholomew, MD — share their experience and insights relative to the following issues:

Differentiating between PE and CTEPH

• Length of symptoms: days versus weeks
• What to look for on chest CT, including the clot’s position in the pulmonary artery and involvement of distal branches

Treating subacute PE

• How to know whether urgent intervention is required
• Which tests can confirm chronic versus acute PE
• Optimal first-line treatment
• Choosing an anticoagulant
• Criteria for discharging patients on medical therapy
• What type of follow-up is necessary

Treating acute PE

• Which advanced therapies are effective in stabilizing hemodynamically unstable patients
• Criteria for evaluating treatment options
• Pros and cons of catheter-directed thrombolytic therapy versus mechanical thrombectomy versus surgical clot extraction

When to consider CTEPH, including:

• In survivors of acute PE who continue to have symptoms and right heart dysfunction after 6 to 12 weeks of anticoagulation
• In patients with established pulmonary hypertension
• In patients without pulmonary hypertension who exhibit chronic blood clots and shortness of breath
• When disease is unilateral

Surgical and postoperative management of CTEPH

• Optimal surgical approach
• Operative mortality rates
• Postoperative medications that limit lung injury and improve pulmonary hypertension
• Optimal choice of anticoagulants

Bottom line

Due to the complexity of these entities, the optimal management approach for these patients is best decided by a multidisciplinary team. Surgical treatment, in particular, is largely dependent on volume and experience.