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Introduction: The pulmonary arterial morphology of patients with pulmonary embolism (PE) is diverse and it is unclear how the different vascular lesions evolve after initiation of anticoagulant treatment. A better understanding of the evolution of CTPA findings after the start of anticoagulant treatment may help to better identify those PE patients prone to develop CTEPH. We aimed to assess the evolution of various thromboembolic lesions on CTPA over time after the initiation of adequate anticoagulant treatment in individual acute PE patients with and without an ultimate diagnosis of CTEPH. Methods: We analyzed the CTPA at diagnosis of acute PE (baseline) and at follow-up in 41 patients with CTEPH and 124 patients without an ultimate diagnosis of CTEPH, all receiving anticoagulant treatment. Central and segmental pulmonary arteries were scored by expert chest radiologists as normal or affected. Lesions were further sub-classified as: 1. central thrombus, 2. total thrombotic occlusion, 3. mural thrombus, 4. web or 5. tapered pulmonary artery. Results: Central thrombi resolved after anticoagulant treatment, while mural thrombi and total thrombotic occlusions either resolved or evolved into webs or tapered pulmonary arteries. Only patients with an ultimate diagnosis of CTEPH exhibited webs and tapered pulmonary arteries on the baseline scan. Moreover, such lesions always persisted after follow-up. Conclusion: Webs and tapered pulmonary arteries at the time of PE diagnosis strongly indicate a state of chronic PE and should raise awareness for possible CTEPH, particularly in patients with persistent dyspnea after anticoagulant treatment for acute PE.

Supplemental material, sj-pdf-1-pul-10.1177_2045894020907883 for Dynamic vascular changes in chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy by Dieuwertje Ruigrok, Natalia J. Braams, Esther J. Nossent, Peter I. Bonta, Anco Boonstra, Rutger J. Lely, Frederikus A. Klok, Anton Vonk Noordegraaf, Petr Symersky, Harm-Jan Bogaard and Lilian J. Meijboom in Pulmonary Circulation

Chronic thromboembolic pulmonary hypertension (CTEPH), characterised by pulmonary hypertension and persistent perfusion defects despite adequate anticoagulation, causes significant morbidity and mortality. Persistent dyspnoea after acute pulmonary embolism is frequent and an indication for additional diagnostics. Only a minority of these patients develop CTEPH. Echocardiography and perfusion scintigraphy are the cornerstone of diagnostics when suspecting CTEPH. Right-heart catheterisation and pulmonary angiography should confirm the diagnosis. The diagnostic phase is preferably carried out in an expert centre in order to optimise the diagnosis and choose the optimal treatment for each individual patient. Treatment of patients with CTEPH is a multidisciplinary team effort. Pulmonary endarterectomy is the only potentially curative treatment; perioperative mortality is less than 5% in experienced centres. Inoperable patients can be treated with medication that specifically targets pulmonary arterial hypertension, but a survival benefit has not yet been shown for this medication. Balloon pulmonary angioplasty has recently become available in the Netherlands as a treatment option, but the exact role of this new technique in the treatment of patients with CTEPH still needs to be investigated.

Chronic thromboembolic pulmonary hypertension (CTEPH), characterised by pulmonary hypertension and persistent perfusion defects despite adequate anticoagulation, causes significant morbidity and mortality. Persistent dyspnoea after acute pulmonary embolism is frequent and an indication for additional diagnostics. Only a minority of these patients develop CTEPH. Echocardiography and perfusion scintigraphy are the cornerstone of diagnostics when suspecting CTEPH. Right-heart catheterisation and pulmonary angiography should confirm the diagnosis. The diagnostic phase is preferably carried out in an expert centre in order to optimise the diagnosis and choose the optimal treatment for each individual patient. Treatment of patients with CTEPH is a multidisciplinary team effort. Pulmonary endarterectomy is the only potentially curative treatment; perioperative mortality is less than 5% in experienced centres. Inoperable patients can be treated with medication that specifically targets pulmonary arterial hypertension, but a survival benefit has not yet been shown for this medication. Balloon pulmonary angioplasty has recently become available in the Netherlands as a treatment option, but the exact role of this new technique in the treatment of patients with CTEPH still needs to be investigated.