Subsegmental PEs and Anticoagulation

Our approach to anticoagulating patients with SSPE is the following:

●We believe that most patients with SSPE should be anticoagulated similarly to those who present with symptomatic or large lobar defects [5,32]. This is particularly important when VTE is unprovoked and persistent risk factors for VTE such as active cancer and acute hospitalization with prolonged immobility, are present; defects are multiple; symptoms are present; and/or when patients have limited cardiorespiratory reserve.

The optimal duration of anticoagulation is unknown but similar to patients with segmental or lobar PE, patients with SSPE should be treated for a minimum of three months. Anticoagulant therapy beyond that period should be individualized, the details of which are discussed separately.

Experts also agree that a small subset of patients with a single small defect (ie, seen on one image) in whom there is no evidence of proximal lower extremity DVT or evidence of thrombus elsewhere (eg, upper extremity clot) may reasonably opt for no anticoagulation, provided the risk of recurrence is considered low [32].

Additional findings that may support this decision include those in whom a false positive test is suspected, the absence of persistent risk factors, those with preserved baseline cardiorespiratory function, and/or those in whom a low pretest probability and normal D-dimer is present.

When clinical surveillance is chosen, we suggest serial testing with bilateral proximal compression ultrasonography (CUS) of the lower extremities in two weeks to look for evidence of proximal thrombus. We also have a low threshold to repeat diagnostic imaging for PE should symptoms persist or recur. This strategy is based upon the rationale that serial CUS has been reported to be safe in patients with nondiagnostic testing for PE (eg, indeterminate or low probability ventilation perfusion scanning)
Retrospective studies have also reported that no recurrence was observed in a small number of patients with SSPE in whom no proximal DVT was identified by compression ultrasonography of the lower extremities [34,35]. In contrast, in another small retrospective study, the rate of recurrence during anticoagulant therapy was no different in patients with SSPE than in those who had larger PE (ie, segmental or lobar) and was higher than in those in whom PE was excluded [36].
– From UpToDate, accessed 10/2016

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