2025 Volume 32 Issue 6 Pages 673-675
See article vol. 32: 688-702
Acute pulmonary thromboembolism (PTE) is a potentially life-threatening condition caused by the obstruction of pulmonary arteries, most commonly by thrombi originating from deep vein thrombosis (DVT) in the lower extremities1). The clinical spectrum ranges from asymptomatic cases to severe embolism resulting in hemodynamic instability or cardiac arrest. In the United States, PTE affects approximately 370,000 individuals annually, contributing to 60,000–100,000 deaths1). Clinical presentation often includes acute chest pain, dyspnea, or syncope1). Its diagnosis relies on clinical probability scores (e.g. Wells score), D-dimer testing, and imaging confirmation via computed tomography pulmonary angiography (CTPA), the gold standard2, 3).
CTPA not only identifies pulmonary thromboemboli at segmental and subsegmental levels, but also evaluates right ventricular (RV) enlargement as a marker of RV dysfunction, a key determinant of disease severity3). Management strategies are tailored to the patient’s hemodynamic status. Anticoagulation, typically with direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, and dabigatran, remains the cornerstone of therapy1, 4). Thrombolysis is reserved for patients with persistent hypotension (systolic blood pressure ＜90 mm Hg)1).
Follow-up CT imaging plays a pivotal role in monitoring thrombus resolution, guiding therapeutic decisions, and identifying complications such as chronic thromboembolic pulmonary hypertension (CTEPH). Patients are typically reassessed at six months to evaluate their return to the baseline respiratory function and exercise tolerance5). Persistent dyspnea or exercise intolerance warrants further investigation with cardiopulmonary exercise testing, ventilation-perfusion scanning, and echocardiography to detect residual obstruction or alternative pathologies5). While routine imaging is not universally recommended, it is crucial in specific scenarios, including suspected recurrence or evaluation of long-term sequelae. However, given the risk of radiation exposure, particularly in younger populations, alternative imaging modalities should be considered6).
In the current issue of the Journal of Atherosclerosis and Thrombosis, Migita et al. provided real-world evidence supporting the efficacy and safety of DOACs in the management of PTE7). Their study highlights that rivaroxaban was preferentially prescribed to patients with lower body weight and a higher thrombus burden, reflecting physicians’ focus on balancing bleeding risk with the need for intensive therapy. Notably, 35.8% of patients receiving intensive rivaroxaban therapy transitioned to standard doses within 2 weeks, following follow-up CT demonstrating adequate thrombus resolution. This early de-escalation of therapy did not increase the risk of recurrence or mortality, emphasizing the potential for individualized, risk-adapted treatment approaches7). However, the decision to terminate intensive therapy early should be carefully evaluated on a case-by-case basis.
From a different perspective, a critical diagnostic challenge lies in distinguishing PTE from other conditions such as pulmonary artery sarcoma (Fig.1). Pulmonary artery intimal sarcoma (PAIS), a rare malignancy, often mimics PTE due to its nonspecific clinical presentation and imaging findings. Notably, pulmonary intimal sarcoma is frequently associated with pericardial effusion, a distinguishing feature8). Furthermore, follow-up CT often reveals a persistently low rate of thrombus resolution. Pulmonary artery sarcoma typically occurs in middle-aged individuals with no significant sex predilection, although its diagnosis is often delayed due to overlapping symptoms with more common conditions9-13). Serial CT imaging or 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) can facilitate early detection, emphasizing the importance of vigilant follow-up while carefully balancing the risks associated with radiation exposure8, 14).
A: Thrombus in the main pulmonary artery (PA) trunk detected on computed tomography (CT) in a patient with acute pulmonary thromboembolism. B: Calcified mass in the main PA trunk detected on CT in a patient with pulmonary artery intimal sarcoma. C: Surgically resected white, craggy mass from the main pulmonary artery. D: Histopathological findings are consistent with intimal sarcoma.
Early imaging follow-up in acute PTE is crucial for optimizing therapy, monitoring thrombus resolution, and distinguishing PTE from other rare vascular tumors. The findings of Migita et al. reinforce the safety and effectiveness of DOACs, including risk-adapted early termination of intensive therapy in appropriate patients. Future research should refine the diagnostic algorithms and explore low-radiation imaging modalities to enhance safety and diagnostic accuracy.
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