Arwa Adamjee – Acute Veno-Occlusive Disorders and Pulmonary Embolism: A Bedside Teaching Snapshot
Dr. Arwa Adamjee, Master of Science at Muhimbili University of Health and Allied Sciences (MUHAS), posted on LinkedIn:
”Acute Veno-Occlusive Disorders and Pulmonary Embolism: A Bedside Teaching Snapshot
Pulmonary embolism (PE) remains one of the most underdiagnosed yet potentially fatal causes of sudden collapse in hospitalized patients. Globally, PE contributes to ~300,000 deaths annually, with mortality reaching 30% if untreated – but dropping to <10% with timely anticoagulation.
Understanding the “Veno-Occlusive Spectrum”
Venous thromboembolism (VTE) includes:
1. Deep Vein Thrombosis (DVT) – thrombus formation in deep venous systems (usually lower limbs).
2. Pulmonary Embolism (PE) – embolization of thrombus fragments to pulmonary arteries.
3. Hepatic and Pulmonary Veno-Occlusive Disease (VOD/PVOD) – rare entities involving post-capillary venular obstruction, often secondary to chemotherapy, bone marrow transplantation, or fibrotic remodeling.
All share a common pathophysiologic basis – Virchow’s triad: endothelial injury, venous stasis, and hypercoagulability.
Pathophysiologic Bridge
When thrombi dislodge, they travel via the right heart to the pulmonary arteries, causing:
1. Mechanical obstruction of perfusion.
2. Vasoconstriction from serotonin, thromboxane, and endothelin release.
3. Resultant RV strain, hypoxemia, and potential hemodynamic collapse.
In PVOD, however, the obstruction is in situ – within small pulmonary venules – mimicking pulmonary hypertension but unresponsive to vasodilators.
Evidence and Clinical Pearls
The PESI score and simplified PESI (sPESI) remain validated risk-stratification tools guiding early discharge and outpatient management.
The CHEST 2021 guidelines recommend:
– DOACs (apixaban, rivaroxaban) as first-line for most VTE cases.
– Thrombolysis reserved for massive PE with hemodynamic compromise.
– Inferior vena cava filters only when anticoagulation is contraindicated.
The Hokusai-VTE trial (NEJM, 2013) demonstrated that edoxaban was non-inferior to warfarin for recurrent VTE prevention, with 19% lower major bleeding.
Bedside Teaching Points
At the ward or ED, always think of PE in:
1. Unexplained tachypnea, tachycardia, or hypoxia
2. Pleuritic chest pain or hemoptysis
3. Postoperative or immobilized patients
4. Sudden syncope in patients with right heart strain on ECG (S1Q3T3 pattern)
Initial workup:
– D-dimer (rule out in low-risk),
– CTPA (gold standard for diagnosis),
– Echocardiography (for RV dilation and strain),
– Lower limb Doppler (to confirm source).
Takeaway for Clinicians
– Always maintain a high index of suspicion; the first PE presentation can be fatal.
– Integrate risk scoring and early imaging into emergency protocols.
– For post-transplant or cytotoxic therapy patients, remember veno-occlusive disease mimics pulmonary hypertension but demands distinct management.
– Preventive strategies – early ambulation, compression stockings, LMWH prophylaxis – save lives.”
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