Rapid Clinical Updates: Navigating the Management of Incidental/Subsegmental Pulmonary Emboli-Handout

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Subsegmental pulmonary embolism (SSPE), especially isolated subsegmental PE (ISSPE), presents uncertain clinical significance. Advancements in CT imaging now detect emboli as small as 3mm, increasing PE diagnoses without changing overall clinical outcomes; radiologist agreement on these findings is often low. Traditionally, all PE—including ISSPE—has been anticoagulated, but routine anticoagulation may not benefit all ISSPE patients.<br /><br />Recurrence risk after ISSPE without anticoagulation is roughly 3% at 90 days. However, patients with multiple ISSPE lesions have over twice the recurrence risk compared to those with single lesions. Interestingly, patients with single ISSPE managed without anticoagulation tend to have fewer recurrent venous thromboembolism (VTE) events at 90 days than those treated for proximal PE.<br /><br />Current guidelines show variability but increasingly recommend active surveillance instead of immediate anticoagulation for low-risk ISSPE patients. Low risk typically excludes those with active cancer, hemodynamic instability, or concurrent proximal deep vein thrombosis (DVT), who are generally anticoagulated. Despite guideline support, active surveillance adoption remains limited in the community.<br /><br />For patients not anticoagulated, serial ultrasounds to monitor for proximal DVT are advised, though optimal monitoring intervals and duration remain unclear. Ongoing clinical trials aim to clarify best management pathways.<br /><br />In summary, while small and isolated subsegmental pulmonary emboli can often be managed without anticoagulation in selected low-risk patients, careful patient selection and surveillance are key. Those with multiple emboli or higher-risk conditions like cancer still warrant anticoagulant therapy. Future research will better define management to balance treatment benefits against bleeding risks.

Keywords

Subsegmental pulmonary embolism

Isolated subsegmental PE

CT imaging

Anticoagulation

Recurrence risk

Venous thromboembolism

Active surveillance

Deep vein thrombosis

Clinical guidelines

Patient selection