18th February 2025

Complications of PE

Chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of PE. Emboli are replaced by fibrous tissue, causing chronic obstruction of the pulmonary vasculature, increased pulmonary artery pressure and pulmonary hypertension. Inadequate anticoagulation, large thrombus mass, residual thrombi and recurrence of VTE may contribute to the development of CTEPH.

Patients typically present with worsening chronic breathlessness after their acute PE and signs of right heart dysfunction including cyanosis, raised JVP, loud P2 heart sound, right ventricular heave, possible tricuspid regurgitation murmur and peripheral oedema. Further testing at a specialist pulmonary hypertension centre would include right heart catheter studies, lung function testing, exercise testing and further imaging (echocardiography, CTPA, MRA, VQ scan and invasive pulmonary angiography).

Treatment options include pulmonary vasculature vasodilators, diuretics for symptom relief, anticoagulation, and more invasive options such as balloon pulmonary angioplasty and pulmonary endarterectomy.

Pulmonary infarction

Pulmonary infarction may complicate PE. Pleuritic chest pain and haemoptysis are more common in these cases. CT thorax is diagnostic – findings include a wedge-shaped focus of consolidation that may not have air bronchograms.

Paradoxical embolism

Deep vein thrombosis in the presence of right-to-left shunts (e.g. patent foramen ovale) may cause paradoxical embolism. Sites of embolisation include the cerebrovasculature causing ischaemic stroke, cardiac vessels causing myocardial infarction, gastrointestinal tract or extremities.