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

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This educational presentation, moderated by Dr. Jagriti Chadha and featuring Drs. Adrian Umpierrez and W. Graham Carlos, focuses on the management of incidental and isolated subsegmental pulmonary embolism (ISSPE). ISSPE refers to emboli confined to the subsegmental branches of the pulmonary arteries, detected increasingly from computed tomography pulmonary angiography (CTPA), and typically measuring 2-3 mm. The incidence of pulmonary embolism (PE) in the U.S. is approximately 60 to 120 cases per 100,000 annually, with ISSPE comprising about 3.8% to 10% of cases.<br /><br />ISSPE generally presents as a less severe form of PE; patients are often hemodynamically stable with lower serum biomarkers and fewer deep vein thromboses (DVT). High-risk groups include patients with active malignancy, age over 65, those without reversible risk factors (e.g., recent surgery), hospitalized or immobile patients, and those with multiple subsegmental emboli.<br /><br />Management of ISSPE has evolved over recent years. Earlier guidelines recommended anticoagulation broadly, but current (2021 CHEST) guidelines suggest clinical surveillance rather than routine anticoagulation in low-risk patients without DVT, citing weak recommendations based on low-certainty evidence. Surveillance includes patient education, serial lower extremity ultrasounds (LE-US), and close monitoring for symptoms. Studies show a 90-day venous thromboembolism risk of about 2.1% in single ISSPE and 5.7% in multiple ISSPE cases without anticoagulation, rates comparable to treated proximal PE.<br /><br />Key management steps include confirming or excluding DVT by LE-US; anticoagulation is advised if DVT or high-risk features (e.g., cancer, advanced age, multiple emboli) exist. Conversely, low-risk patients may be managed safely with surveillance. However, real-world adherence to surveillance strategies remains low, and further trials like SAFE SSPE and STOPAPE are underway to establish evidence.<br /><br />In clinical cases presented, the preferred next step for a young, otherwise healthy patient with a single ISSPE is to start anticoagulation with a direct oral anticoagulant for 6 months. For incidental ISSPE in stable hospitalized patients, initial LE Doppler is recommended before making anticoagulation decisions.<br /><br />In summary, ISSPE management balances risks of bleeding from anticoagulation against VTE recurrence. Evidence supports individualized approaches guided by risk stratification, imaging, and clinical vigilance rather than automatic anticoagulation for all ISSPE detected incidentally.

Keywords

Incidental Subsegmental Pulmonary Embolism

ISSPE

Pulmonary Embolism Management

Computed Tomography Pulmonary Angiography

Deep Vein Thrombosis

Anticoagulation Guidelines

Clinical Surveillance

Venous Thromboembolism Risk

Risk Stratification

Direct Oral Anticoagulants