History

With pulmonary embolism (PE), the patient often experiences acute onset of shortness of breath; sometimes the patient even pinpoints the moment of distress. Complaints related to signs of deep vein thrombosis (DVT), lower-extremity swelling, and warmth to touch or tenderness may be present. Dyspnea is the most frequent symptom of PE.

With a smaller PE near the pleura, the patient may complain of pleuritic chest pain, cough, or hemoptysis. Sometimes, massive PE can present with syncope. The patient may have a sense of impending doom, with apprehension and anxiety. History may reveal the presence of one or more causes or risk factors.

Physical Examination

Some patients have signs of DVT, lower-extremity swelling, and tenderness and warmth to touch. Clinical signs of pulmonary thromboembolism also include the following:

Tachypnea (respiratory rate exceeding 18 breaths/min) is the most common sign of PE
Tachycardia often is present
The second heart sound can be accentuated
Fever may be present
Lung examination findings frequently are normal
Cyanosis may be present

In the appropriate clinical setting, when shortness of breath, hypoxemia, and tachycardia are present, there should be a high clinical suspicion of PE until it is ruled out. Timely anticoagulation is important; 5-7% of recurrences are fatal.

The likelihood of PE in a patient in whom it is suspected may be assessed by the Wells clinical decision rule. The criteria are scored as follows:

Clinical symptoms of DVT (3 points)
Other diagnoses less likely than PE (3 points)
Heart rate higher than 100 beats/min (1.5 points)
Immobilization for at least 3 days or surgery in previous 4 weeks (1.5 points)
Previous DVT/PE (1.5 points)
Hemoptysis (1 point)
Malignancy (1 point)

In the modified Wells criteria, PE is likely when the score is greater than 4 and unlikely when the score is less than 4. Highly sensitive D-dimer is coupled into the decision algorithm.^[19]

Differential Diagnoses

Merli GJ. Prevention of thrombosis with warfarin, aspirin, and mechanical methods. Clin Cornerstone. 2005. 7 (4):49-56. [QxMD MEDLINE Link].
Agnelli G, Sonaglia F, Becattini C. Direct thrombin inhibitors for the prevention of venous thromboembolism after major orthopaedic surgery. Curr Pharm Des. 2005. 11 (30):3885-91. [QxMD MEDLINE Link].
Agudelo JF, Morgan SJ, Smith WR. Venous thromboembolism in orthopedic trauma patients. Orthopedics. 2005 Oct. 28 (10):1164-71; quiz 1172-3. [QxMD MEDLINE Link].
Mismetti P, Zufferey P, Pernod G, Baylot, Estebe JP, Barrelier MT, et al. [Thromboprohylaxis in orthopedic surgery and traumatology]. Ann Fr Anesth Reanim. 2005 Aug. 24 (8):871-89. [QxMD MEDLINE Link].
Jaffer AK, Barsoum WK, Krebs V, Hurbanek JG, Morra N, Brotman DJ. Duration of anesthesia and venous thromboembolism after hip and knee arthroplasty. Mayo Clin Proc. 2005 Jun. 80 (6):732-8. [QxMD MEDLINE Link].
Lurie JM, Png CYM, Subramaniam S, Chen S, Chapman E, Aboubakr A, et al. Virchow's triad in "silent" deep vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2019 Sep. 7 (5):640-645. [QxMD MEDLINE Link].
[Guideline] Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty evidence-based guideline and evidence report. American Academy of Orthopaedic Surgeons. Available at https://www.aaos.org/globalassets/quality-and-practice-resources/vte/vte_full_guideline_10.31.16.pdf. September 23, 2011; Accessed: July 16, 2020.
Mont MA, Jacobs JJ, Boggio LN, Bozic KJ, Della Valle CJ, Goodman SB, et al. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011 Dec. 19 (12):768-76. [QxMD MEDLINE Link].
Khokhar A, Chari A, Murray D, McNally M, Pandit H. Venous thromboembolism and its prophylaxis in elective knee arthroplasty: an international perspective. Knee. 2013 Jun. 20 (3):170-6. [QxMD MEDLINE Link].
Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. American Association of Orthopedic Surgeons and American College of Chest Physicians guidelines for venous thromboembolism prevention in hip and knee arthroplasty differ: what are the implications for clinicians and patients?. Chest. 2009 Feb. 135 (2):513-520. [QxMD MEDLINE Link].
Budhiparama NC, Abdel MP, Ifran NN, Parratte S. Venous Thromboembolism (VTE) Prophylaxis for Hip and Knee Arthroplasty: Changing Trends. Curr Rev Musculoskelet Med. 2014 Jun. 7 (2):108-16. [QxMD MEDLINE Link].
Attaya H, Wysokinski WE, Bower T, Litin S, Daniels PR, Slusser J, et al. Three-month cumulative incidence of thromboembolism and bleeding after periprocedural anticoagulation management of arterial vascular bypass patients. J Thromb Thrombolysis. 2013 Jan. 35 (1):100-6. [QxMD MEDLINE Link].
Woller SC, Stevens SM, Jones JP, Lloyd JF, Evans RS, Aston VT, et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med. 2011 Oct. 124 (10):947-954.e2. [QxMD MEDLINE Link].
Liem TK, Deloughery TG. First episode and recurrent venous thromboembolism: who is identifiably at risk?. Semin Vasc Surg. 2008 Sep. 21 (3):132-8. [QxMD MEDLINE Link].
Hippisley-Cox J, Coupland C. Development and validation of risk prediction algorithm (QThrombosis) to estimate future risk of venous thromboembolism: prospective cohort study. BMJ. 2011 Aug 16. 343:d4656. [QxMD MEDLINE Link]. [Full Text].
Mahan CE, Borrego ME, Woersching AL, Federici R, Downey R, Tiongson J, et al. Venous thromboembolism: annualised United States models for total, hospital-acquired and preventable costs utilising long-term attack rates. Thromb Haemost. 2012 Aug. 108 (2):291-302. [QxMD MEDLINE Link].
Venous thromboembolism in adult hospitalizations - United States, 2007-2009. MMWR Morb Mortal Wkly Rep. 2012 Jun 8. 61(22):401-4. [QxMD MEDLINE Link]. [Full Text].
Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007 Oct. 98 (4):756-64. [QxMD MEDLINE Link].
Pasha SM, Klok FA, Snoep JD, Mos IC, Goekoop RJ, Rodger MA, et al. Safety of excluding acute pulmonary embolism based on an unlikely clinical probability by the Wells rule and normal D-dimer concentration: a meta-analysis. Thromb Res. 2010 Apr. 125 (4):e123-7. [QxMD MEDLINE Link].
[Guideline] Lim W, Le Gal G, Bates SM, Righini M, Haramati LB, Lang E, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: diagnosis of venous thromboembolism. Blood Adv. 2018 Nov 27. 2 (22):3226-3256. [QxMD MEDLINE Link]. [Full Text].
Pabinger I, Ay C. Biomarkers and venous thromboembolism. Arterioscler Thromb Vasc Biol. 2009 Mar. 29(3):332-6. [QxMD MEDLINE Link].
Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, et al. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014 Mar 19. 311 (11):1117-24. [QxMD MEDLINE Link]. [Full Text].
La Vecchia L, Ottani F, Favero L, Spadaro GL, Rubboli A, Boanno C, et al. Increased cardiac troponin I on admission predicts in-hospital mortality in acute pulmonary embolism. Heart. 2004 Jun. 90 (6):633-7. [QxMD MEDLINE Link]. [Full Text].
Klok FA, Mos IC, Huisman MV. Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis. Am J Respir Crit Care Med. 2008 Aug 15. 178 (4):425-30. [QxMD MEDLINE Link].
Ray P, Maziere F, Medimagh S, Lefort Y, Arthaud M, Duguet A, et al. Evaluation of B-type natriuretic peptide to predict complicated pulmonary embolism in patients aged 65 years and older: brief report. Am J Emerg Med. 2006 Sep. 24 (5):603-7. [QxMD MEDLINE Link].
Duman H, Özyurt S, Erdoğan T, Kara BY, Durakoğlugil ME. The role of serum bilirubin levels in determining venous thromboembolism. J Vasc Surg Venous Lymphat Disord. 2019 Sep. 7 (5):635-639. [QxMD MEDLINE Link].
Bauer KA. New anticoagulants. Curr Opin Hematol. 2008 Sep. 15(5):509-15. [QxMD MEDLINE Link].
[Guideline] Witt DM, Nieuwlaat R, Clark NP, Ansell J, Holbrook A, Skov J, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv. 2018 Nov 27. 2 (22):3257-3291. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020 Oct 13. 4(19):4693-738. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Farge D, Debourdeau P, Beckers M, et al. International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost. 2013 Jan. 11 (1):56-70. [QxMD MEDLINE Link].
[Guideline] Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2019 Aug 5. JCO1901461. [QxMD MEDLINE Link]. [Full Text].
Akl EA, Gunukula S, Barba M, Yosuico VE, van Doormaal FF, Kuipers S, et al. Parenteral anticoagulation in patients with cancer who have no therapeutic or prophylactic indication for anticoagulation. Cochrane Database Syst Rev. 2011 Apr 13. 4:CD006652. [QxMD MEDLINE Link].
Akl EA, Vasireddi SR, Gunukula S, Yosuico VE, Barba M, Terrenato I, et al. Oral anticoagulation in patients with cancer who have no therapeutic or prophylactic indication for anticoagulation. Cochrane Database Syst Rev. 2011 Jun 15. 6:CD006466. [QxMD MEDLINE Link].
Boutitie F, Pinede L, Schulman S, Agnelli G, Raskob G, Julian J, et al. Influence of preceding length of anticoagulant treatment and initial presentation of venous thromboembolism on risk of recurrence after stopping treatment: analysis of individual participants' data from seven trials. BMJ. 2011 May 24. 342:d3036. [QxMD MEDLINE Link]. [Full Text].
Merli G, Spyropoulos AC, Caprini JA. Use of emerging oral anticoagulants in clinical practice: translating results from clinical trials to orthopedic and general surgical patient populations. Ann Surg. 2009 Aug. 250 (2):219-28. [QxMD MEDLINE Link].
[Guideline] Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141 (2 Suppl):7S-47S. [QxMD MEDLINE Link]. [Full Text].
Akl EA, Labedi N, Barba M, Terrenato I, Sperati F, Muti P, et al. Anticoagulation for the long-term treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev. 2011 Jun 15. 6:CD006650. [QxMD MEDLINE Link].
EINSTEIN Investigators., Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010 Dec 23. 363 (26):2499-510. [QxMD MEDLINE Link]. [Full Text].
Büller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012 Apr 5. 366(14):1287-97. [QxMD MEDLINE Link]. [Full Text].
Cohen AT, Dobromirski M. The use of rivaroxaban for short- and long-term treatment of venous thromboembolism. Thromb Haemost. 2012 Jun. 107(6):1035-43. [QxMD MEDLINE Link].
Romualdi E, Donadini MP, Ageno W. Oral rivaroxaban after symptomatic venous thromboembolism: the continued treatment study (EINSTEIN-extension study). Expert Rev Cardiovasc Ther. 2011 Jul. 9(7):841-4. [QxMD MEDLINE Link].
Janssen Pharmaceuticals. FDA approves new 10 mg dosing for XARELTO® (rivaroxaban) to reduce the continued risk of venous thromboembolism (VTE). October 30, 2017. Available at http://www.janssen.com/us/sites/www_janssen_com_usa/files/fda-approves-new-10mg-dosing-for-xarelto-rivaroxaban-to-reduce-the-continued-risk-of-venous-thromboembolism-vte.pdf.
Cohen AT, Spiro TE, Büller HR, Haskell L, Hu D, Hull R, et al. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med. 2013 Feb 7. 368 (6):513-23. [QxMD MEDLINE Link]. [Full Text].
Spyropoulos AC, Ageno W, Albers GW, Elliott CG, Halperin JL, Hiatt WR, et al. Rivaroxaban for Thromboprophylaxis after Hospitalization for Medical Illness. N Engl J Med. 2018 Sep 20. 379 (12):1118-1127. [QxMD MEDLINE Link]. [Full Text].
Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med. 2013 Aug 29. 369 (9):799-808. [QxMD MEDLINE Link].
Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009 Dec 10. 361(24):2342-52. [QxMD MEDLINE Link].
Schulman S, Kakkar AK, Goldhaber SZ, Schellong S, Eriksson H, Mismetti P, et al. Treatment of acute venous thromboembolism with dabigatran or warfarin and pooled analysis. Circulation. 2014 Feb 18. 129(7):764-72. [QxMD MEDLINE Link].
Schulman S, Kearon C, Kakkar AK, Schellong S, Eriksson H, Baanstra D, et al. Extended use of dabigatran, warfarin, or placebo in venous thromboembolism. N Engl J Med. 2013 Feb 21. 368(8):709-18. [QxMD MEDLINE Link].
Büller HR, Décousus H, Grosso MA, Mercuri M, Middeldorp S, Prins MH, et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med. 2013 Oct 10. 369(15):1406-15. [QxMD MEDLINE Link]. [Full Text].
Raskob GE, van Es N, Verhamme P, Carrier M, Di Nisio M, Garcia D, et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med. 2018 Feb 15. 378 (7):615-624. [QxMD MEDLINE Link].
Cohen AT, Harrington RA, Goldhaber SZ, Hull RD, Wiens BL, Gold A, et al. Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients. N Engl J Med. 2016 Aug 11. 375 (6):534-44. [QxMD MEDLINE Link]. [Full Text].
Gibson CM, Chi G, Halaby R, Korjian S, Daaboul Y, Jain P, et al. Extended-Duration Betrixaban Reduces the Risk of Stroke Versus Standard-Dose Enoxaparin Among Hospitalized Medically Ill Patients: An APEX Trial Substudy (Acute Medically Ill Venous Thromboembolism Prevention With Extended Duration Betrixaban). Circulation. 2017 Feb 14. 135 (7):648-655. [QxMD MEDLINE Link].
Goldhaber SZ, Haire WD, Feldstein ML, Miller M, Toltzis R, Smith JL, et al. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion. Lancet. 1993 Feb 27. 341 (8844):507-11. [QxMD MEDLINE Link].
DeYoung E, Minocha J. Inferior Vena Cava Filters: Guidelines, Best Practice, and Expanding Indications. Semin Intervent Radiol. 2016 Jun. 33 (2):65-70. [QxMD MEDLINE Link].
Bikdeli B, Wang Y, Jimenez D, Ross JS, Monreal M, Goldhaber SZ, et al. Association of Inferior Vena Cava Filter Use With Mortality Rates in Older Adults With Acute Pulmonary Embolism. JAMA Intern Med. 2019 Feb 1. 179 (2):263-265. [QxMD MEDLINE Link].
Phillips D. IVC filters may increase mortality risk in patients with PE. Medscape Medical News. Available at https://www.medscape.com/viewarticle/906330. December 11, 2018; Accessed: July 16, 2020.
Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet. 2011 Jul 2. 378 (9785):41-8. [QxMD MEDLINE Link].
Kahn SR, Comerota AJ, Cushman M, Evans NS, Ginsberg JS, Goldenberg NA, et al. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation. 2014 Oct 28. 130 (18):1636-61. [QxMD MEDLINE Link].
Enden T, Haig Y, Kløw NE, Slagsvold CE, Sandvik L, Ghanima W, et al. Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. Lancet. 2012 Jan 7. 379 (9810):31-8. [QxMD MEDLINE Link].
Makris M, Van Veen JJ, Tait CR, Mumford AD, Laffan M. Guideline on the management of bleeding in patients on antithrombotic agents. Br J Haematol. 2013 Jan. 160(1):35-46. [QxMD MEDLINE Link].
Lanzarotti S, Weigelt JA. Heparin-induced thrombocytopenia. Surg Clin North Am. 2012 Dec. 92(6):1559-72. [QxMD MEDLINE Link].
Kang M, Alahmadi M, Sawh S, Kovacs MJ, Lazo-Langner A. Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study. Blood. 2015 Feb 5. 125 (6):924-9. [QxMD MEDLINE Link].
Bilen O, Teruya J. Complications of anticoagulation. Dis Mon. 2012 Aug. 58(8):440-7. [QxMD MEDLINE Link].
Iorio A, Kearon C, Filippucci E, Marcucci M, Macura A, Pengo V, et al. Risk of recurrence after a first episode of symptomatic venous thromboembolism provoked by a transient risk factor: a systematic review. Arch Intern Med. 2010 Oct 25. 170 (19):1710-6. [QxMD MEDLINE Link].
Brighton TA, Eikelboom JW, Mann K, Mister R, Gallus A, Ockelford P, et al. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med. 2012 Nov 22. 367 (21):1979-87. [QxMD MEDLINE Link]. [Full Text].
Warkentin TE. Aspirin for dual prevention of venous and arterial thrombosis. N Engl J Med. 2012 Nov 22. 367(21):2039-41. [QxMD MEDLINE Link]. [Full Text].
Schulman S. Current strategies in prophylaxis and treatment of venous thromboembolism. Ann Med. 2008. 40(5):352-9. [QxMD MEDLINE Link].
Prevention of venous thromboembolism in orthopedic surgery. Med Lett Drugs Ther. 2008 Nov 3. 50 (1298):86-8. [QxMD MEDLINE Link].
Jaffer AK, Brotman DJ. Prevention of venous thromboembolism after surgery. Clin Geriatr Med. 2008 Nov. 24(4):625-39, viii. [QxMD MEDLINE Link].
Piazza G, Goldhaber SZ. Physician alerts to prevent venous thromboembolism. J Thromb Thrombolysis. 2010 Jul. 30 (1):1-6. [QxMD MEDLINE Link].
Wittkowsky AK. New oral anticoagulants: a practical guide for clinicians. J Thromb Thrombolysis. 2010 Feb. 29 (2):182-91. [QxMD MEDLINE Link].
Lu JP, Knudson MM, Bir N, Kallet R, Atkinson K. Fondaparinux for prevention of venous thromboembolism in high-risk trauma patients: a pilot study. J Am Coll Surg. 2009 Nov. 209(5):589-94. [QxMD MEDLINE Link].
Muntz J. Thromboprophylaxis in orthopedic surgery: how long is long enough?. Am J Orthop. 2009 Aug. 38(8):394-401. [QxMD MEDLINE Link].
Huo MH, Muntz J. Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients: a review. Clin Ther. 2009 Jun. 31 (6):1129-41. [QxMD MEDLINE Link].
Sharma A, Chatterjee S, Lichstein E, Mukherjee D. Extended thromboprophylaxis for medically ill patients with decreased mobility: does it improve outcomes?. J Thromb Haemost. 2012 Oct. 10 (10):2053-60. [QxMD MEDLINE Link].
Goldhaber SZ, Leizorovicz A, Kakkar AK, Haas SK, Merli G, Knabb RM, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med. 2011 Dec 8. 365(23):2167-77. [QxMD MEDLINE Link].
Anderson DR, Dunbar MJ, Bohm ER, Belzile E, Kahn SR, Zukor D, et al. Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial. Ann Intern Med. 2013 Jun 4. 158(11):800-6. [QxMD MEDLINE Link].
Anderson DR, Dunbar M, Murnaghan J, Kahn SR, Gross P, Forsythe M, et al. Aspirin or Rivaroxaban for VTE Prophylaxis after Hip or Knee Arthroplasty. N Engl J Med. 2018 Feb 22. 378 (8):699-707. [QxMD MEDLINE Link].
Brown T. FDA OKs Pradaxa for thromboprophylaxis after hip surgery. Medscape Medical News. Available at http://www.medscape.com/viewarticle/854972. November 24, 2015; Accessed: July 16, 2020.
Kabrhel C, Varraso R, Goldhaber SZ, Rimm E, Camargo CA Jr. Physical inactivity and idiopathic pulmonary embolism in women: prospective study. BMJ. 2011 Jul 4. 343:d3867. [QxMD MEDLINE Link].
Izumi M, Ikeuchi M, Aso K, Sugimura N, Kamimoto Y, Mitani T, et al. Less deep vein thrombosis due to transcutaneous fibular nerve stimulation in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2015 Nov. 23 (11):3317-23. [QxMD MEDLINE Link].
Gonzalez Della Valle A, Shanaghan KA, Nguyen J, Liu J, Memtsoudis S, Sharrock NE, et al. Multimodal prophylaxis in patients with a history of venous thromboembolism undergoing primary elective hip arthroplasty. Bone Joint J. 2020 Jul. 102-B (7_Supple_B):71-77. [QxMD MEDLINE Link].
Merkow RP, Bilimoria KY, McCarter MD, Cohen ME, Barnett CC, Raval MV, et al. Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Ann Surg. 2011 Jul. 254 (1):131-7. [QxMD MEDLINE Link].
[Guideline] Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb. 141 (2 Suppl):e278S-e325S. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Kozek-Langenecker S, Fenger-Eriksen C, Thienpont E, Barauskas G, ESA VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the elderly. Eur J Anaesthesiol. 2018 Feb. 35 (2):116-122. [QxMD MEDLINE Link].
Markel DC, York S, Liston MJ Jr, Flynn JC, Barnes CL, Davis CM 3rd, et al. Venous thromboembolism: management by American Association of Hip and Knee Surgeons. J Arthroplasty. 2010 Jan. 25 (1):3-9.e1-2. [QxMD MEDLINE Link].
Turpie AG, Lassen MR, Davidson BL, Bauer KA, Gent M, Kwong LM, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty (RECORD4): a randomised trial. Lancet. 2009 May 16. 373 (9676):1673-80. [QxMD MEDLINE Link].
Turpie AG, Lassen MR, Eriksson BI, Gent M, Berkowitz SD, Misselwitz F, et al. Rivaroxaban for the prevention of venous thromboembolism after hip or knee arthroplasty. Pooled analysis of four studies. Thromb Haemost. 2011 Mar. 105 (3):444-53. [QxMD MEDLINE Link].
[Guideline] Qaseem A, Chou R, Humphrey LL, Starkey M, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Venous thromboembolism prophylaxis in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011 Nov 1. 155 (9):625-32. [QxMD MEDLINE Link].
[Guideline] Kakkos SK, Gohel M, Baekgaard N, et al. Editor's Choice - European Society for Vascular Surgery (ESVS) 2021 clinical practice guidelines on the management of venous thrombosis. Eur J Vasc Endovasc Surg. 2021 Jan. 61(1):9-82. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Kaufman JA, Barnes GD, Chaer RA, et al. Society of Interventional Radiology Clinical practice guideline for inferior vena cava filters in the treatment of patients with venous thromboembolic disease: developed in collaboration with the American College of Cardiology, American College of Chest Physicians, American College of Surgeons Committee on Trauma, American Heart Association, Society for Vascular Surgery, and Society for Vascular Medicine. J Vasc Interv Radiol. 2020 Oct. 31(10):1529-44. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Diagnosis of venous thromboembolism - clinical practice guideline. American Academy of Family Physicians. Available at https://www.aafp.org/patient-care/clinical-recommendations/all/venous-thromboembolism1.html. March 2019; Accessed: July 16, 2020.
[Guideline] Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb. 149 (2):315-352. [QxMD MEDLINE Link].
Lachiewicz PF. Prevention of symptomatic pulmonary embolism in patients undergoing total hip and knee arthroplasty: clinical guideline of the American Academy of Orthopaedic Surgeons. Instr Course Lect. 2009. 58:795-804. [QxMD MEDLINE Link].
Johanson NA, Lachiewicz PF, Lieberman JR, Lotke PA, Parvizi J, Pellegrini V, et al. Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Am Acad Orthop Surg. 2009 Mar. 17 (3):183-96. [QxMD MEDLINE Link].

Media Gallery

Venous Thromboembolism (VTE). Pulmonary embolism within the pulmonary artery.
Venous Thromboembolism (VTE). Ventilation-perfusion scan. Left image: Posterior view of normal findings on ventilation scan. Right image: Posterior view of a perfusion scan that reveals a perfusion defect in the left upper quadrant. The defect in the middle of the image is due to the position of the heart.
Venous Thromboembolism (VTE). Helical CT scan of the pulmonary arteries. A filling defect in the right pulmonary artery is present, consistent with a pulmonary embolism.

of 3

Author

Vera A De Palo, MD, MBA, FCCP Medical Director/Consultant, Respiratory Therapy Program, New England Institute of Technology; Consulting Physician, TruCare

Vera A De Palo, MD, MBA, FCCP is a member of the following medical societies: American College of Chest Physicians, Massachusetts Medical Society, Rhode Island Thoracic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Abdallah E Kharnaf, MD Resident Physician, Department of Medicine, Memorial Hospital of Rhode Island, The Warren Alpert Medical School of Brown University

Abdallah E Kharnaf, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor, Department of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Acknowledgements

Michael J Belanger, MD Clinical Instructor, Department of Orthopedics, Harvard Medical School

Disclosure: Nothing to disclose.

Jegan Krishnan, MBBS, FRACS, PhD Professor, Chair, Department of Orthopedic Surgery, Flinders University of South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; Private Practice, Orthopaedics SA, Flinders Private Hospital

Jegan Krishnan, MBBS, FRACS, PhD, is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, and Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jerome D Wiedel, MD Chair, Professor, Department of Orthopedics, University of Colorado Health Sciences Center

Disclosure: Nothing to disclose.