Pulmonary Embolism: From the Inari FlowTriever to Pulmonary Endarterectomy

Never confuse varicose veins with cellulitis and simply give a course of antibiotics to send the patient away — that is the wrongest possible thing to do, and it is not a constructed scenario. This happens regularly in real-life GP clinics, and any swollen leg deserves at least a Doppler ultrasound before it is written off as a skin infection.

Out of roughly 25 healthcare facilitators sending referrals, only one or two send a report in a structured format. A recent case arrived with mismatched patient names, ages and even genders across different files for what turned out to be the same patient — a PDF here, a broken image file there, no consolidated record. I would rather give no advice than wrong advice built on poorly collated information.

Absolutely, yes — particularly if the D-dimer is done after the acute phase, in a subacute presentation of a few days. Despite the test's high sensitivity, the result can come back in the low hundreds, nowhere near diagnostic. DVT is an anatomical problem, and for an anatomical problem the answer is to see it directly on ultrasound, not infer it from a blood marker. Vascular ultrasound is learnable within three to four months, and we train nearly all our trainees to do it routinely.

Laser ablation for superficial spider veins or one or two perforators has an excellent prognosis, and works well up to the perforator level. But if the saphenofemoral junction itself is regurgitant, open surgery to ligate the SFJ and clip the draining tributaries is usually the better option rather than relying on endovascular ablation alone.

In a fragile patient, angioplasty is best avoided below the knee — it gives reasonable short-term results but nothing very promising long-term. If intervention is genuinely needed, it is more often approached surgically, favouring a reverse femoro-tibial bypass using the patient's own saphenous vein over a prosthetic graft, and favouring open surgery over an endovascular approach in this territory. Below the knee: use the simpler, older, better-proven option, and know when not to intervene at all.

A central clot occluding the pulmonary artery right at the point where it bifurcates into the right and left pulmonary arteries, named for its resemblance to a horse's saddle.

It engages the clot and locks it into a disc mechanism, then extracts it through a combination of mechanical maceration, breaking the clot into smaller pieces, and suction.

Pulmonary endarterectomy, a surgical procedure performed on cardiopulmonary bypass with the body cooled to 18 to 20 degrees Celsius and roughly 30 to 45 minutes of circulatory arrest to remove the clot from the pulmonary arterial tree.

Lung function, pulmonary artery pressures and right heart function typically improve dramatically within a couple of days after surgery.