American Thoracic Society Documents: An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline—Evaluation of Suspected Pulmonary Embolism in Pregnancy

Leung, Ann N.; Bull, Todd; Jaeschke, Roman; Lockwood, Charles J.; Boiselle, Phillip M.; Hurwitz, Lynne M.; James, Andra H.; McCullough, Laurence B.; Menda, Yusuf; Paidas, Michael J.; Royal, Henry D.; Tapson, Victor F.; Winer-Muram, Helen T.; Chervenak, Frank A.; Cody, Dianna D.; McNitt‐Gray, Michael F.; Stave, Christopher D; Tuttle, Brandi

doi:10.1148/radiol.11114045

Cited by 124 publications

(78 citation statements)

References 65 publications

(78 reference statements)

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“…However, the evidence to recommend either CTPA or nuclear lung perfusion is complex and effects to the mother and fetus should be taken into consideration. As an initial imaging study a chest film is recommended by the American Thoracic Society (58), and compression ultrasonography of the legs may be suggested in case of leg symptoms; if the ultrasound exam is positive for deepvein thrombosis the need for radiographic imaging is eliminated (21). When the chest film is normal a nuclear lung scintigraphy is recommended; however, if the chest film is abnormal or the lung scintigraphy is nondiagnostic, a CTPA is recommended (58).…”

Section: Radiation Exposure In Ctpamentioning

confidence: 99%

“…As an initial imaging study a chest film is recommended by the American Thoracic Society (58), and compression ultrasonography of the legs may be suggested in case of leg symptoms; if the ultrasound exam is positive for deepvein thrombosis the need for radiographic imaging is eliminated (21). When the chest film is normal a nuclear lung scintigraphy is recommended; however, if the chest film is abnormal or the lung scintigraphy is nondiagnostic, a CTPA is recommended (58). CTPA and nuclear perfusion scanning have equivalent clinical negative predictive value (99% for CTPA and 100% for perfusion scanning) and have equivalent image quality in the care of pregnant patients.…”

Section: Radiation Exposure In Ctpamentioning

confidence: 99%

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The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

Doğan

A²,

Geleijins³

et al. 2015

Diagn Interv Radiol

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A cute pulmonary embolism (PE) is the third most common cardiovascular condition, after coronary artery disease and stroke (1). Due to lack of specific sets of symptoms that accurately predict or exclude the diagnosis of acute PE, the diagnosis strongly relies on noninvasive imaging techniques. Diagnostic strategies for evaluating PE have undergone important changes over the past decades (2). Due to rapid technical advances in speed and spatial resolution, the utility of computed tomography (CT) angiography has been recognized in vascular imaging. Particularly, after the development of multidetector row CT in 1998 (3), CT pulmonary angiography (CTPA) has become the imaging method of choice in the diagnosis of acute PE (4). CTPA has advantages over conventional invasive X-ray pulmonary angiography and nuclear ventilation-perfusion (V/Q) imaging. CT is a widely available, fast and noninvasive technique, has the capability to directly visualize emboli, and may provide alternative diagnoses (4).Despite adequate diagnosis and anticoagulant therapy, death rate after a diagnosis of acute PE is still 8%-15% (5, 6). The prognosis of acute PE mainly depends on residual pulmonary circulation and the severity of right ventricular (RV) dysfunction (7). Recent studies have shown that CT permits the assessment of acute right-sided heart failure. Furthermore, CT can predict adverse clinical outcome by using the RV/left ventricular (LV) diameter ratio (8, 9) or RV ejection fraction in patients with PE (10).The aim of this review is to discuss the developments of CT in PE diagnosis, and to analyze the added value of CT in estimating PE severity and prognosis. Furthermore, CT findings of chronic thromboembolic pulmonary arterial hypertension (CTEPH) as a complication of acute PE will be discussed. CT developments in PE diagnosisHistorically, pulmonary angiography and nuclear planar V/Q-imaging were the main imaging methods used for diagnosing PE. Both methods have recognized limitations. Pulmonary angiography has previously been regarded as reference standard, but the method CHEST IMAGING REVIEW ABSTRACT Pulmonary embolism (PE) is a potentially life threatening condition requiring adequate diagnosis and treatment. Computed tomography pulmonary angiography (CTPA) is excellent for including and excluding PE, therefore CT is the first-choice diagnostic imaging technique in patients suspected of having acute PE. Due to its wide availability and low invasiveness, CTPA tends to be overused. Correct implementation of clinical decision rules in diagnostic workup for PE improves adequate use of CT. Also, CT adds prognostic value by evaluating right ventricular (RV) function. CT-assessed RV dysfunction and to lesser extent central emboli location predicts PE-related mortality in normotensive and hypotensive patients, while PE embolic obstruction index has limited prognostic value. Simple RV/left ventricular (LV) diameter ratio measures >1.0 already predict risk for adverse outcome, whereas ratios <1.0 can safely exclude adverse outcome. Con...

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Section: Radiation Exposure In Ctpamentioning

confidence: 99%

Section: Radiation Exposure In Ctpamentioning

confidence: 99%

The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

Doğan

A²,

Geleijins³

et al. 2015

Diagn Interv Radiol

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“…To provide guidance for clinicians, the American Thoracic Society recently published evidence-based guidelines and recommendations for the management of pregnant patients suspected of having PE (3). In the document, chest radiography is recommended as the first radiation-associated imaging procedure.…”

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confidence: 99%

Perfusion Scintigraphy Versus 256-Slice CT Angiography in Pregnant Patients Suspected of Pulmonary Embolism: Comparison of Radiation Risks

et al. 2014

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One aim of the current study was to determine normalized dose data for maternal radiosensitive organs and embryo/fetus from 256-slice CT pulmonary angiography (CTPA) performed on pregnant patients suspected of having pulmonary embolism. A second aim was to provide reliable maternal and fetal doses and associated radiation cancer risk estimates from 256-slice CTPA and lung perfusion scintigraphy (LPS) for comparison. Methods: Mathematic anthropomorphic phantoms were generated to simulate the average woman at early pregnancy and at the third, sixth, and ninth months of gestation. In each phantom, 0-3 additional 1.5-cm-thick fat tissue layers were added to derive 4 phantoms representing pregnant women with different body sizes. Monte Carlo methods were used to simulate low-dose 256-slice CTPA exposures on each of the 16 generated phantoms. Normalized organ and embryo/fetal dose data were derived for exposures at 80, 100, and 120 kV. Maternal effective dose and embryo/fetal dose from 256-slice CTPA and associated lifetime attributable risks of radiation cancer were determined for different body sizes and gestational stages and compared with corresponding data from LPS. Results: For an average-sized pregnant patient at the first trimester, the 256-slice CTPA exposure resulted in a maternal effective dose of 1 mSv and an embryo/fetal dose of 0.05 mGy. However, maternal effective dose considerably increased with body size, whereas embryo/fetal dose increased with both body size and gestational stage. Compared with LPS, low-dose CTPA to an averagesized pregnant patient resulted in a 30% higher maternal effective dose but a 3.4-6 times lower embryo/fetal dose. Nevertheless, LPS was associated with less aggregated radiation risk for an average-sized pregnant patient, with the difference from CTPA being increased further for larger patients. Conclusion: Compared with CTPA performed with a modern wide-area CT scanner, LPS remains comparatively more dose-efficient.

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“…These doses were the effective doses determined from a literature search and reported effective doses at our institution. 6,15,17 Respondents knew that the radiation dose from a V/Q scan is less than that from a CTPA. Only 3 of 26 (11%) respondents were aware that, at the present time, there are no generally accepted limits for cumulative lifetime radiation dose that a patient can safely receive from diagnostic imaging.…”

Section: Physician Surveymentioning

confidence: 99%

Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice

Ahn

Edmonds

McLeod

et al. 2014

CJEM

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Objective: To assess the current level of knowledge and practice patterns of emergency physicians regarding radiation exposure from diagnostic imaging modalities for investigating acute pulmonary embolism (PE). Methods: An online survey was sent to adult emergency physicians working at two academic tertiary care adult emergency departments (EDs) to determine imaging choices for investigating PE in various patient populations and to assess their current knowledge of radiation doses and risks. A retrospective chart review was performed for all adult patients who underwent computed tomographic pulmonary angiography (CTPA) and/or ventilation-perfusion (V/Q) scanning in the same EDs. Results: The survey response rate was 72.1% (31 of 43 physicians). For patients , 30 years old, 83.9% of physicians chose V/Q scanning as their test of choice, regardless of gender. Although only a third of respondents knew the estimated radiation dose of a V/Q scan (37.5%) and a CTPA (32%), the majority were aware that V/Q scans involved less ionizing radiation than CTPAs. In the retrospective review, 663 charts were reviewed, including 201 CTPAs and 462 V/Q scans. V/Q scanning was the preferred modality in female patients (75.9% v. CTPA 24.1% [OR 2.1; 95% CI 1.5-2.9]) and in patients , 30 years old (87.9% v. CTPA 12.1% [OR 4.8; ]).Conclusions: Although surveyed physicians possessed limited knowledge of radiation doses of CTPA and V/Q scans, they preferentially used the lower radiation V/Q scans in younger patients, particularly females, in both the survey vignettes and in clinical practice. This may reflect efforts to reduce radiation exposures at our institution. RÉ SUMÉObjectif: L'é tude visait à é valuer le degré de connaissances des urgentologues et leur pratique en ce qui concerne l'exposition au rayonnement é mis par les diffé rents types d'imagerie diagnostique, dans le contexte de l'embolie pulmonaire (EP) aiguë . Mé thodes: Un questionnaire d'enquê te en ligne a é té envoyé à des urgentologues travaillant dans deux services d'urgence (SU) universitaires, de soins tertiaires, pour adultes, visant à dé terminer le type choisi d'imagerie pour confirmer la pré sence d'une EP dans diffé rents groupes de patients, et à é valuer leur degré de connaissances sur les doses de rayonnement et leurs risques. Nous avons procé dé à un examen ré trospectif des dossiers mé dicaux de tous les adultes ayant subi une angiographie pulmonaire par tomodensitomé trie (APTDM) et/ou une scintigraphie de ventilation et de perfusion (VA/Q) dans ces mê mes SU. Ré sultats: Le taux de ré ponse a atteint 72.1% (31 mé decins sur 43). Chez les patients de moins de 30 ans, 83.9% des mé decins ont choisi la scintigraphie de VA/Q comme examen de premiè re intention, indé pendamment du sexe. Un tiers seulement des ré pondants connaissait la dose estimé e de rayonnement de la scintigraphie de VA/Q (37.5%) et de l'APTDM (32%), mais la majorité savait que la scintigraphie de VA/Q é mettait moins de rayonnement ionisant que l'APTDM. ]).Conclusions: Les mé dec...

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American Thoracic Society Documents: An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline—Evaluation of Suspected Pulmonary Embolism in Pregnancy

Abstract: The recommendations presented in this guideline are based upon the currently available evidence; availability of new clinical research data and development and dissemination of new technologies will necessitate a revision and update.

Cited by 124 publications

References 65 publications

The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism

Perfusion Scintigraphy Versus 256-Slice CT Angiography in Pregnant Patients Suspected of Pulmonary Embolism: Comparison of Radiation Risks

Familiarity with radiation exposure dose from diagnostic imaging for acute pulmonary embolism and current patterns of practice

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