[Reflections on the management of suspected recent pulmonary embolism]

Pulmonary Embolism (EP) remains a major challenge for the physician, despite increasingly sophisticated investigations and efficient therapeutic programs. Many reasons explain persistent difficulties: the disorder crosses all specialties. A wide variety of clinical presentations has to be considered according to the size of the thrombus, the coexisting conditions ("predisposing factors") and the prior cardio pulmonary status. Major investigations include perfusion and ventilation lung scans, pulmonary angiography, invasive and non invasive investigations of the deep venous system. But obvious practical limitations exist; selection of the most suitable test includes severity of the present patient condition and risk of an early recurrence of EP; risk of the contemplated therapeutic procedure if the diagnosis of EP is confirmed; skillfulness required for the selected investigation. Angiography is mandatory if a substantial hemorrhagic risk exists, if massive EP is suspected, and if at risk treatment procedures are contemplated. In the other cases, and in the absence of significant pulmonary pathology, a lung perfusion scan is the advisable procedure; the diagnosis is excluded if the scan is normal. Previous or current significant pulmonary pathology requires angiography. However, proof of coexisting deep venous thrombosis is an alternative way to enhance the diagnosis in case of poor clinical conditions or other practical considerations.