Winter 2015 – In Situ Thrombosis of the Pulmonary Arteries: An Emerging New Perspective on Pulmonary Embolism

In Situ Thrombosis of the Pulmonary Arteries: An Emerging New Perspective on Pulmonary Embolism

Author: Virginia Corbett1, Houria Hassouna2, Reda Girgis3

Author Affiliations:

1College of Human Medicine, Michigan State University, East Lansing, MI, USA

2Division of Thrombosis, Department of Internal Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA

3Department of Pulmonary Medicine, College of Human Medicine, Michigan State University, Grand Rapids, MI, USA

[button link=”” type=”big” color=”green” newwindow=”yes”] Full Text Article PDF[/button]

Corresponding Author: Virginia Corbett, corbettv[at]

Key Words: pulmonary embolism; in situ pulmonary artery thrombosis; deep vein thrombosis (DVT); pulmonary circulation; Virchow’s triad

Abstract: The annual incidence of pulmonary embolism(PE) in the United States is reported to be 0.69 per1,000 persons with mortality of up to 30% depending upon the size of the emboli.1 PE and deep venous thrombosis (DVT) are both considered manifestations ofthe same disease of venous thromboembolism. Virchowpostulated that dysfunction of vessel walls, alternationsin blood flow and hypercoagulability of theblood triggered inappropriate thrombus formation.2 DVT most commonly occurs as local clot formation in the deep calf veins. PE arises when clots break off from a peripheral DVT and become lodged within the pulmonary arterial vasculature. PE is routinely diagnosed when filling defects are found in the pulmonary arteries on computed tomography angiogram (CTA). Among the general population of patients presenting to emergency rooms, absence of DVT may occur in up to 57% of those diagnosed with PE.3 A high prevalence of isolated PE may suggest localized thrombus formation in the pulmonary arteries instead of embolization from peripheral clots.

Published on date: January 1, 2015

Senior Editor: Kailyne Van Stavern

Junior Editor: Garrett Roe

DOI: Pending

Citation: Corbett V. Hassouna H. Girgis R. In Situ Thrombosis of the Pulmonary Arteries: An Emerging New Perspective on Pulmonary Embolism . Medical Student Research Journal. 2015;4(Winter):54-8.


  1. Office of the Surgeon General (US); National Heart, Lung, and Blood Institute (US). The surgeon general’s call to action to prevent deep vein thrombosis and pulmonary embolism. 2008. Available from: [cited 15 February 2014].
  2. Kyrle PA, Eichinger S. Deep vein thrombosis. Lancet 2005; 365(9465): 1163_74. doi: 10.1016/S0140-6736(05)71880-8
  3. Sohns C, Amarteifio E, Sossalla S, Heuser M, Obenauer S. 64-Multidetector-row spiral CT in pulmonary embolism with emphasis on incidental findings. Clin Imaging 2008; 32(5): 335_41. doi: 10.1016/j.clinimag.2008.01.028
  4. Van belle A, Bu¨ ller HR, Huisman MV, Huisman PM, Kaasjager K, Kamphuisen PW, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA 2006; 295(2): 172_9. doi: 10.1001/jama.295.2.172
  5. Kumar NG, Clark A, Roztocil E, Caliste X, Gillespie DL,Cullen JP. Fibrinolytic activity of endothelial cells from different venous beds. J Surg Res 2015; 194(1): 297_303. doi: 10.1016/j.jss.2014.09.028
  6. Rosenhek R, Korschineck I, Gharehbaghi-schnell E, Jakowitsch J, Bonderman D, Huber K, et al. Fibrinolytic balance of the arterial wall: pulmonary artery displays increased fibrinolytic potential compared with aorta. Lab Invest 2003; 83(6): 871_6. doi: 10.1097/01.LAB.0000073127.46392.9D
  7. Ryan US. Metabolic activity of pulmonary endothelium: modulations of structure and function. Annu Rev Physiol 1986; 48(1): 263_77. doi: 10.1146/
  8. Goodman LR. Small pulmonary emboli: what do we know? Radiology 2005; 234(3): 654_8. doi: 10.1148/radiol.2343041326
  9. Ryan US. Structural bases for metabolic activity. Annu Rev Physiol 1982; 44(1): 223_39. doi: 10.1146/
  10. Key NS, Bach RR. Tissue factor as a therapeutic target. Thromb Haemost 2001; 85(3): 375_6. doi: 10.1517/14728222.6.2.159
  11. Martinelli I. Unusual forms of venous thrombosis and thrombophilia. Pathophysiol Haemost Thromb 2002; 32(5_6): 343_5. doi: 10.1159/000073595
  12. Agarwal PP, Wolfsohn AL, Matzinger FR, Seely JM, Peterson RA, Dennie C. In situ central pulmonary artery thrombosis in primary pulmonary hypertension. Acta Radiol 2005; 46(7): 696_700. doi: 10.1080/02841850500215501
  13. Russo A, De luca M, Vigna C, De Rito V, Pacilli M, Lombardo A, et al. Central pulmonary artery lesions in chronic obstructive pulmonary disease: a transesophagealechocardiography study. Circulation 1999; 100(17): 1808_15. doi: 10.1161/01.CIR.100.17.1808
  14. Wechsler RJ, Salazar AM, Gessner AJ, Spirn PW, Shah RM, Steiner RM. CT of in situ vascular stump thrombosis after pulmonary resection for cancer. AJR Am J Roentgenol 2001; 176(6): 1423_5. doi: 10.2214/ajr.176.6.1761423
  15. Lundy JB, Oh JS, Chung KK, Ritter JL, Gibb I, Nordmann GR, et al. Frequency and relevance of acute peritraumatic pulmonary thrombus diagnosed by computed tomographic imaging in combat casualties. J Trauma Acute Care Surg 2013; 75(2 Suppl 2): S215_20. doi: 10.1097/TA.0b013e318299da66
  16. Knudson MM, Gomez D, Haas B, Cohen MJ, Nathens AB. Three thousand seven hundred thirty-eight posttraumatic pulmonary emboli: a new look at an old disease. Ann Surg 2011; 254(4): 625_32. doi: 10.1097/SLA.0b013e3182300209
  17. Schulz C, Engelmann B, Massberg S. Crossroads of coagulation and innate immunity: the case of deep vein thrombosis. J Thromb Haemost 2013; 11 (Suppl 1): 233_41. doi: 10.1111/jth.12261
  18. Drake TA, Morrissey JH, Edgington TS. Selective cellular expression of tissue factor in human tissues. Implications for disorders of hemostasis and thrombosis. Am J Pathol 1989; 134(5): 1087_97.
  19. Polgar J, Matuskova J, Wagner DD. The P-selectin, tissue factor, coagulation triad. J Thromb Haemost 2005; 3(8): 1590_6. doi: 10.1111/j.1538-7836.2005.01373.x
  20. Sevestre MA, Quashie´ C, Genty C, Rolland C, Que´re´ I, Bosson JL, et al. Clinical presentation and mortality in pulmonary embolism: the Optimev study. J Mal Vasc 2010; 35(4): 242_9. doi: 10.1016/j.jmv.2010.05.004
  21. Van langevelde K, Flinterman LE, Van hylckama vlieg A, Rosendaal FR, Cannegieter SC. Broadening the factor V Leiden paradox: pulmonary embolism and deep-vein thrombosis as 2 sides of the spectrum. Blood 2012; 120(5):933_46. doi: 10.1182/blood-2012-02-407551
  22. De boer JD, Majoor CJ, Van’t veer C, Bel EH, Van der poll T. Asthma and coagulation. Blood 2012; 119(14): 3236_44. doi: 10.1182/blood-2011-11-391532
  23. Chung WS, Lin CL, Ho FM, Li RY, Sung FC, Kao CH, et al. Asthma increases pulmonary thromboembolism risk: a nationwide population cohort study. Eur Respir J 2014; 43(3):801_7. doi: 10.1183/09031936.00043313
  24. Majoor CJ, Kamphuisen PW, Zwinderman AH, Ten Brinke A, Amelink M, Rijssenbeek-Nouwens L, et al. Risk of deep vein thrombosis and pulmonary embolism in asthma. Eur Respir J 2013; 42(3): 655_61. doi: 10.1183/09031936.00150312
  25. Bertoletti L, Quenet S, Laporte S, Sahuquillo JC, Conget F, Pedrajas JM, et al. Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease: data from the RIETE registry. Respir Res 2013; 14: 75. doi: 10.1186/1465-9921-14-75
  26. Rizkallah J, Man SF, Sin DD. Prevalence of pulmonary embolism in acute exacerbations of COPD: a systematic review and metaanalysis. Chest 2009; 135(3): 786_93. doi:10.1378/chest.08-1516
  27. Konstantinides SV. Asthma and pulmonary embolism: bringing airways and vessels closer together. Eur Respir J 2014; 43(3): 694_6. doi: 10.1183/09031936.00009414
  28. Velmahos GC, Spaniolas K, Tabbara M, Abujudeh HH, de Moya M, Gervasini A, et al. Pulmonary embolism and deep venous thrombosis in trauma: are they related? Arch Surg 2009; 144(10): 928_32. doi:10.1001/archsurg.2009.97
  29. Van langevelde K, Sra´mek A, Vincken PW, Van rooden JK, Rosendaal FR, Cannegieter SC. Finding the origin of pulmonary emboli with a total-body magnetic resonance direct thrombus imaging technique. Haematologica 2013; 98(2):309_15. doi: 10.3324/haematol.2012.069195
  30. Kearon C, Akl EA. Duration of anticoagulant therapy for deep vein thrombosis and pulmonary embolism. Blood 2014; 123(12): 1794_1801. doi: 10.1182/blood-2013-12-512681
  31. PREPIC Study Group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave) randomized study. Circulation 2005; 112(3): 416_22. doi: 10.1161/CIRCULATIONAHA.104.512834
  32. Korkmaz A, Ozlu T, Ozsu S, Kazaz Z, Bulbul Y. Long-term outcomes in acute pulmonary thromboembolism: the incidence of chronic thromboembolic pulmonary hypertension and associated risk factors. Clin Appl Thromb Hemost 2012;18(3): 281_8. doi: 10.1177/1076029611431956