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LETTER TO THE EDITOR |
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| Year : 2014 | Volume
: 9
| Issue : 2 | Page : 127-128 |
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| Endobronchial ultrasound as a confirmatory tool for the diagnosis of pulmonary embolism |
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Kassem Harris, Michel Chalhoub
Department of Medicine, Staten Island University Hospital, Staten Island, New York, USA
| Date of Web Publication | 14-Mar-2014 |
Correspondence Address:
Kassem Harris
Department of Medicine, Staten Island University Hospital, Staten Island, New York
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1817-1737.128863
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How to cite this article:
Harris K, Chalhoub M. Endobronchial ultrasound as a confirmatory tool for the diagnosis of pulmonary embolism. Ann Thorac Med 2014;9:127-8 |
Sir,
Pulmonary embolism (PE) is a life-threatening condition that requires prompt diagnosis and treatment to achieve a favorable outcome. In cases where imaging study of the chest is essential to make the diagnosis of PE, computed tomography angiography (angio-CT) is the preferred imaging modality which is based on locating a filling defect inside one of the pulmonary arteries and has the advantage of diagnosing other possible chest abnormalities. [1] Ventilation perfusion scan is Another method of diagnosing PE, and ultrasounds provide images of the thrombus inside a vessel in real time. Such ultrasounds enable diagnosticians to identify the extension of the thrombus as well as to observe the degree of vascular obstruction. Convex probe endobronchial ultrasound (CP-EBUS), first described in 1992, has become broadly useful. Not only are these types of ultrasounds applicable in staging and restaging lung cancers, CP-EBUS have also recently been used in diagnosing mediastinal and extra-mediastinal lesions.
The tracheal and bronchial walls lay in proximity to mediastinal vascular structures, particularly the pulmonary arteries. Due to this anatomical fact, the use of CP-EBUS in evaluating the pulmonary arteries for the presence of clots and other vascular abnormalities seems appropriate. [2] Aumiller, et al. [3] evaluated 32 patients in the intensive care unit who were diagnosed with PE using angio-CT of the chest. Angio-CT was followed by CP-EBUS, which allowed for the diagnosis of PE in all patients and identified 97 out of 101 thrombi. In this study, CP-EBUS provided the means to locate all central thrombi; the four missed thrombi were in the middle lobe artery and left upper lobe artery. The diagnosis of PE was not affected by the instances of the CP-EBUS not locating the thrombi in these patients, since one thrombus at any pulmonary arterial site is sufficient to make the diagnosis of PE.
Egea Santaolalla, et al. [4] reported a case where CP-EBUS identified a left main pulmonary artery thrombus that was not seen on images obtained using angio-CT. Casoni, et al. [5] also used CP-EBUS to differentiate between pulmonary artery thrombus and vascular sarcoma, therefore confirming the diagnosis of PE.
Our own experience using CP-EBUS to confirm a diagnosis of PE further supports the notion that CP-EBUS is a useful confirmatory diagnostic tool. An elderly patient was referred to our service with an abnormal angio-CT performed as part of an out-patient work-up for dyspnea on exertion [Figure 1]. The angio-CT was officially read to show the right hilar abnormality, which can represent right main PE, rather than a right hilar mass draping over the pulmonary artery. Under moderate sedation, we performed CP-EBUS (using the model BF-UC160F-OL8; Olympus, Tokyo, Japan), which revealed a clot in the proximal right pulmonary artery and thus excluded hilar lesions as a diagnosis [Figure 2]. The procedure time was about 5 min and there were no complications.
Based on our own experience as well as the preponderance of other reports supporting the usage of CP-EBUS in diagnostic confirmations, we can conclude that CP-EBUS is a safe, useful tool in diagnosing PE especially in patients who are unstable to be transferred for diagnostic imaging. CP-EBUS can be performed at bedside in the intensive care unit. In occasional incidences, CP-EBUS can be successfully used as a confirmatory test when the diagnosis of central PE is highly suspected based on angio-CT of the chest. A new vascular mediastinal role ought to be counted as one of the most promising applications of CP-EBUS. | Figure 1: Axial angiography-computed tomography (CT) of the chest showing right hilar abnormalities described as right pulmonary artery thrombus versus a hilar lesion draping over the pulmonary artery (left image). Coronal angiography-CT of the chest (right image)
Click here to view |
 | Figure 2: Convex probe endobronchial ultrasound (EBUS) image with the scope at the level of the right main stem bronchus showing a clot in the proximal right pulmonary artery (a-c). EBUS image with Doppler mode of the right pulmonary artery (d)
Click here to view |
 References | |  |
| 1. | Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006;354:2317-27. 
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| 2. | Le Rouzic O, Tercé G, Jardin C, Blanc AL, Santangelo T, Ramon PP, et al. Pulmonary embolism diagnosed during an endobronchial ultrasound procedure. Rev Mal Respir 2010;27:775-7.
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| 3. | Aumiller J, Herth FJ, Krasnik M, Eberhardt R. Endobronchial ultrasound for detecting central pulmonary emboli: A pilot study. Respiration 2009;77:298-302.
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| 4. | Egea Santaolalla CJ, Ribas Solis FJ, Juste Carne M. Pulmonary thromboembolism observed by endobronchial ultrasound (EBUS). Arch Bronconeumol 2011;47:164-5.
[PUBMED] |
| 5. | Casoni GL, Gurioli C, Romagnoli M, Poletti V. Diagnosis of pulmonary thromboembolism with endobronchial ultrasound. Eur Respir J 2008;32:1416-7.
[PUBMED] |
[Figure 1], [Figure 2] |
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