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Pulmonary embolism at the emergency department during the COVID-19 pandemic. A comparative cohort study from a tertiary level hospital in southern Spain

  • Antonio Jesús Láinez-Ramos-Bossini1,2,3,*,
  • Beatriz Moraleda Cabrera1,3
  • Francisco Garrido Sanz1,3
  • Elvira Ruiz Castellano1,3
  • Mónica Crespo Balbuena1,3
  • Francisco Javier Pérez García1,3
  • Carlos Jiménez Mascuñán1,3
  • Mario Rivera Izquierdo3,4

1Department of Radiology, Virgen de las Nieves University Hospital, 18014 Granada, Spain

2Department of Radiology, University of Granada, 18012 Granada, Spain

3Instituto de Investigación Biosanitaria de Granada (ibs.GRANADA), 18012 Granada, Spain

4Department of Preventive Medicine and Public Health, University of Granada, 18012 Granada, Spain

DOI: 10.22514/sv.2022.067

Submitted: 19 January 2022 Accepted: 08 March 2022

Online publish date: 12 October 2022

*Corresponding Author(s): Antonio Jesús Láinez-Ramos-Bossini E-mail:


Several studies have been published showing a significant increase in thrombotic complications in coronavirus disease 2019 (COVID-19) patients, including acute pulmonary embolism (PE). However, there is significant variability regarding published data on the number of computed tomography pulmonary angiography (CTPA) orders to rule out PE, frequency and characteristics of PE, and other factors that could have magnified the actual incidence of PE. The aim of this work is to analyze these factors during the first year of the pandemic. A longitudinal retrospective observational study was designed comparing two cohorts (preCOVID and COVID) of patients for whom an emergency CTPA was requested to rule out PE at the emergency department of our institution. Information was collected regarding the number of CTPAs requested, patient demographics, presence and extension of PE, and radiological signs of right ventricle strain/pulmonary hypertension (RVS/PH). Univariate and bivariate analyses were performed, with stratification by time intervals according to different pandemic waves in the COVID cohort. A total of 1905 patients (530 in the pre-COVID cohort and 1375 in the COVID cohort), with a mean age of 68.3 years (standard deviation, 16.5) and 981 (51.5%) women were included. No significant differences were observed regarding the incidence of PE between both cohorts. In patients with PE, no significant differences regarding age or sex were found, but a significantly higher frequency of peripheral PE was observed in the COVID cohort (42.0% vs. 6.5%, p < 0.001). Regarding signs of RVS/PH, a lower degree of septal deviation and contrast reflux to the inferior vena cava was observed in the COVID cohort, but no significant differences were observed in the right-to-left ventricular ratio. For the COVID cohort, the distribution of central vs. peripheral PE was similar in patients without laboratory-confirmed COVID-19 infection. Finally, the analysis of signs of RVS/PH stratifying by pandemic waves showed a lower frequency of RVS/PH signs in the 2nd and 3rd pandemic waves. In conclusion, despite a significantly higher number of CTPAs were performed during the pandemic, the incidence of PE was similar to that of the pre-pandemic period. A higher number of peripheral PE and less radiological signs of RVS/PH were observed during the pandemic. These findings could be explained by an increased incidental detection of PE during the pandemic. Our study has some limitations, mainly derived from its retrospective and single-center nature, which should be overcome in future research.


COVID-19; Pulmonary embolism; Emergency department; Pandemic; Cohort study

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Antonio Jesús Láinez-Ramos-Bossini,Beatriz Moraleda Cabrera,Francisco Garrido Sanz,Elvira Ruiz Castellano,Mónica Crespo Balbuena,Francisco Javier Pérez García,Carlos Jiménez Mascuñán,Mario Rivera Izquierdo. Pulmonary embolism at the emergency department during the COVID-19 pandemic. A comparative cohort study from a tertiary level hospital in southern Spain. Signa Vitae. 2022.doi:10.22514/sv.2022.067.


[1] Moore AJE, Wachsmann J, Chamarthy MR, Panjikaran L, Tanabe Y, Rajiah P. Imaging of acute pulmonary embolism: an update. Cardiovascular Diagnosis and Therapy. 2018; 8: 225–243.

[2] Láinez-Ramos-Bossini AJ, Moreno-Suárez S, Pérez-García MC, Gálvez-López R, Sanz FG, Rivera-Izquierdo M. Acute pulmonary embolism: appropriateness of emergency department management according to clinical guidelines. To be published in Radiologia. 2020.[Preprint]

[3] Raskob GE, Angchaisuksiri P, Blanco AN, Büller H, Gallus A, Hunt BJ, et al. Thrombosis: a major contributor to global disease burden. Seminars in Thrombosis and Hemostasis. 2014; 40: 724–735.

[4] Serhal M, Barnes GD. Venous thromboembolism: a clinician update. Vascular Medicine. 2019; 24: 122–131.

[5] Casey K, Iteen A, Nicolini R, Auten J. COVID-19 pneumonia with hemoptysis: acute segmental pulmonary emboli associated with novel coronavirus infection. American Journal of Emergency Medicine. 2020; 38: 1544.e1–1544.e3.

[6] Hanff TC, Mohareb AM, Giri J, Cohen JB, Chirinos JA. Thrombosis in COVID-19. American Journal of Hematology. 2020; 95: 1578–1589.

[7] Roncon L, Zuin M, Barco S, Valerio L, Zuliani G, Zonzin P, et al. Incidence of acute pulmonary embolism in COVID-19 patients: systematic review and meta-analysis. European Journal of Internal Medicine. 2020; 82: 29–37.

[8] Middeldorp S, Coppens M, van Haaps TF, Foppen M, Vlaar AP, Müller MCA, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. Journal of Thrombosis and Haemostasis. 2020; 18: 1995–2002.

[9] Wu T, Zuo Z, Yang D, Luo X, Jiang L, Xia Z, et al. Venous thromboembolic events in patients with COVID-19: a systematic review and meta-analysis. Age and Ageing. 2021; 50: 284–293.

[10] Zhang R, Ni L, Di X, Wang X, Ma B, Niu S, et al. Systematic review and meta-analysis of the prevalence of venous thromboembolic events in novel coronavirus disease-2019 patients. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2021; 9: 289–298. e5.

[11] Malas MB, Naazie IN, Elsayed N, Mathlouthi A, Marmor R, Clary B. Thromboembolism risk of COVID-19 is high and associated with a higher risk of mortality: a systematic review and meta-analysis. EClinicalMedicine. 2020; 29: 100639.

[12] Akhter MS, Hamali HA, Mobarki AA, Rashid H, Oldenburg J, Biswas A. SARS-CoV-2 infection: modulator of pulmonary embolism paradigm. Journal of Clinical Medicine. 2021; 10: 1064.

[13] Giannis D, Ziogas IA, Gianni P. Coagulation disorders in coronavirus infected patients: COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past. Journal of Clinical Virology. 2020; 127: 104362.

[14] Gallastegui N, Zhou JY, Drygalski AV, Barnes RFW, Fernandes TM, Morris TA. Pulmonary embolism does not have an unusually high incidence among hospitalized COVID19 patients. Clinical and Applied Thrombosis/Hemostasis. 2021; 27: 107602962199647.

[15] Porfidia A, Valeriani E, Pola R, Porreca E, Rutjes AWS, Di Nisio M. Venous thromboembolism in patients with COVID-19: systematic review and meta-analysis. Thrombosis Research. 2020; 196: 67–74.

[16] Mai V, Tan BK, Mainbourg S, Potus F, Cucherat M, Lega J, et al. Venous thromboembolism in COVID-19 compared to non-COVID-19 cohorts: a systematic review with meta-analysis. Vascular Pharmacology. 2021; 139: 106882.

[17] Tufano A, Rendina D, Abate V, Casoria A, Marra A, Buonanno P, et al. Venous thromboembolism in COVID-19 compared to non-COVID-19 cohorts: a systematic review with meta-analysis. Journal of Clinical Medicine. 2021; 10: 4925.

[18] Sridharan GK, Vegunta R, Rokkam VRP, Meyyur Aravamudan V, Vegunta R, Khan SR, et al. Venous thromboembolism in hospitalized COVID-19 patients. American Journal of Therapeutics. 2020; 27: e599–e610.

[19] Láinez-Ramos-Bossini AJ, Moreno-Suárez S, Pérez-García MDC, Gálvez-López R, Garrido-Sanz F, Rivera-Izquierdo M. Use of clinical probability scores and D-dimer in suspected pulmonary embolism. Results from a Spanish retrospective study. European Journal of Emergency Medicine. 2020; 27: 468–469.

[20] Pontone G, Scafuri S, Mancini ME, Agalbato C, Guglielmo M, Baggiano A, et al. Role of computed tomography in COVID-19. Journal of Cardiovascular Computed Tomography. 2021; 15: 27–36.

[21] Suh YJ, Hong H, Ohana M, Bompard F, Revel M, Valle C, et al. Pulmonary embolism and deep vein thrombosis in COVID-19: a systematic review and meta-analysis. Radiology. 2021; 298: E70–E80.

[22] Kaminetzky M, Moore W, Fansiwala K, Babb JS, Kaminetzky D, Horwitz LI, et al. Pulmonary embolism at CT pulmonary angiography in patients with COVID-19. Radiology: Cardiothoracic Imaging. 2020; 2: e200308.

[23] Alonso Martinez J, Anniccherico Sánchez F, Urbieta Echezarreta M, García I, Álvaro J. Central versus peripheral pulmonary embolism: analysis of the impact on the physiological parameters and long-term survival. North American Journal of Medical Sciences. 2016; 8: 134–142.

[24] Ministerio de Sanidad, Consumo y Bienestar Social - Situación actual Coronavirus. Available at: https://www.sanidad.gob. es/profesionales/saludPublica/ccayes/alertasActual/nCov/situacionActual.htm (Accessed: 18 January 2022).

[25] Láinez Ramos-Bossini AJ, Láinez Millán B, Ruiz Santiago F, Rivera Izquierdo M. Impact of the COVID-19 pandemic on osteoporotic ver-tebral fracture incidence and follow-up at the emergency department. A retrospective study of a tertiary hospital in southern Spain. Signa Vitae. 2022; 18: 15–23.

[26] Tomerak S, Khan S, Almasri M, Hussein R, Abdelati A, Aly A, et al. Systemic inflammation in COVID-19 patients may induce various types of venous and arterial thrombosis: a systematic review. Scandinavian Journal of Immunology. 2021; 94: e13097.

[27] Doyle AJ, Hunt BJ, Sanderson B, Zhang J, Mak SM, Benedetti G, et al. A comparison of thrombosis and hemorrhage rates in patients with severe respiratory failure due to coronavirus disease 2019 and influenza requiring extracorporeal membrane oxygenation. Critical Care Medicine. 2021; 49: e663–e672.

[28] Flaczyk A, Rosovsky RP, Reed CT, Bankhead-Kendall BK, Bittner EA, Chang MG. Comparison of published guidelines for man-agement of coagulopathy and thrombosis in critically ill patients with COVID 19: implications for clinical practice and future investigations. Critical Care. 2020; 24: 559.

[29] Rindi LV, Al Moghazi S, Donno DR, Cataldo MA, Petrosillo N. Predictive scores for the diagnosis of pulmonary embolism in COVID-19: a systematic review. International Journal of Infectious Diseases. 2022; 115: 93–100.

[30] Nopp S, Moik F, Jilma B, Pabinger I, Ay C. Risk of venous thromboembolism in patients with COVID-19: a systematic review and meta-analysis. Research and Practice in Thrombosis and Haemostasis, 2020; 4: 1178–1191.

[31] Lu Y, Pan L, Zhang W, Cheng F, Hu S, Zhang X, et al. A meta-analysis of the incidence of venous thromboembolic events and impact of anticoagulation on mortality in patients with COVID-19. International Journal of Infectious Diseases. 2020; 100: 34–41.

[32] Martínez Chamorro E, Revilla Ostolaza TY, Pérez Núñez M, Borruel Nacenta S, Cruz-Conde Rodríguez-Guerra C, Ibáñez Sanz L. Pulmonary embolisms in patients with COVID-19: a prevalence study in a tertiary hospital. Radiología. 2021; 63: 13–21.

[33] Grillet F, Behr J, Calame P, Aubry S, Delabrousse E. Acute pul-monary embolism associated with COVID-19 pneumonia detected by pulmonary CT angiography. Radiology. 2020; 296: E186–E188.

[34] Jiménez D, García-Sanchez A, Rali P, Muriel A, Bikdeli B, Ruiz-Artacho P, et al. Incidence of VTE and bleeding among hospitalized patients with coronavirus disease 2019: a systematic review and meta-analysis. Chest. 2021; 159: 1182–1196.

[35] Mestre-Gómez B, Lorente-Ramos RM, Rogado J, Franco-Moreno A, Obispo B, Salazar-Chiriboga D, et al. Incidence of pulmonary em-bolism in non-critically ill COVID-19 patients. Predicting factors for a challenging diagnosis. Journal of Thrombosis and Thrombolysis. 2021; 51: 40–46.

[36] Benito N, Filella D, Mateo J, Fortuna AM, Gutierrez-Alliende JE, Hernandez N, et al. Pulmonary thrombosis or embolism in a large cohort of hospitalized patients with Covid-19. Frontiers in Medicine. 2020; 7: 557.

[37] McFadyen JD, Stevens H, Peter K. The emerging threat of (micro) thrombosis in COVID-19 and its therapeutic implications. Circulation Research. 2020; 127: 571–587.

[38] Thachil J, Srivastava A. SARS-2 coronavirus-associated hemostatic lung abnormality in COVID-19: is it pulmonary thrombosis or pulmonary embolism? Seminars in Thrombosis and Hemostasis. 2020; 46: 777–780.

[39] Birocchi S, Manzoni M, Podda GM, Casazza G, Cattaneo M. High rates of pulmonary artery occlusions in COVID-19. A meta-analysis. European Journal of Clinical Investigation. 2021; 51: e13433.

[40] Argulian E, Sud K, Vogel B, Bohra C, Garg VP, Talebi S, et al. Right ventricular dilation in hospitalized patients with COVID-19 infection. JACC: Cardiovascular Imaging. 2020; 13: 2459–2461.

[41] Cao Y, Zhang M, Guo Y, Zhang Y. The overlooked chamber in coronavirus disease 2019. ESC Heart Failure. 2020; 7: 3483–3486.

[42] Mishra AK, Lal A, Sahu KK, George AA, Martin K, Sargent J. An update on pulmonary hypertension in coronavirus disease-19 (COVID-19). Acta Bio Medica: Atenei Parmensis. 2020; 91: e2020155.

[43] van den Heuvel FMA, Vos JL, Koop Y, van Dijk APJ, Duijnhouwer AL, de Mast Q, et al. Cardiac function in relation to myocardial injury in hospitalised patients with COVID-19. Netherlands Heart Journal. 2020; 28: 410–417.

[44] Tilliridou V, Kirkbride R, Dickinson R, Tiernan J, Yong GL, van Beek EJ, et al. Pulmonary embolism severity before and during the COVID-19 pandemic. The British Journal of Radiology. 2021; 94: 20210264.

[45] Collins MA, Pidgeon JW, Fitzgerald R. Computed tomography manifestations of tricuspid regurgitation. The British Journal of Radiology. 1995; 68: 1058–1060.

[46] Bailis N, Lerche M, Meyer HJ, Wienke A, Surov A. Contrast reflux into the inferior vena cava on computer tomographic pulmonary angiography is a predictor of 24-hour and 30-day mortality in patients with acute pulmonary embolism. Acta Radiologica. 2021; 62: 34–41.

[47] Aviram G, Cohen D, Steinvil A, Shmueli H, Keren G, Banai S, et al. Significance of reflux of contrast medium into the inferior vena cava on computerized tomographic pulmonary angiogram. The American Journal of Cardiology. 2012; 109: 432–437.

[48] Aviram G, Rogowski O, Gotler Y, Bendler A, Steinvil A, Goldin Y, et al. Real-time risk stratification of patients with acute pulmonary embolism by grading the reflux of contrast into the inferior vena cava on computerized tomographic pulmonary angiography. Journal of Thrombosis and Haemostasis. 2008; 6: 1488–1493.

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