Diagnosis of Pulmonary Embolism at a Large Teaching Hospital

Schluger, Neil W.; Henschke, Claudia I.; King, Thomas H.; Russo, Roseann; Binkert, Barbara; Rackson, Marlene; Hayt, David B.

doi:10.1097/00005382-199422000-00013

Cited by 80 publications

(37 citation statements)

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“…However, despite excellent sensitivity and specificity, the method has not gained widespread acceptance because it is invasive and clinicians are unwilling to expose patients, who often have unstable cardiovascular conditions, to a potentially risky procedure. This explains the results of a study in a large academic hospital which revealed that 92% of patients with low probability V/Q scans and 70% of patients with intermediate probability scans were not further investigated, either with pulmonary angiography or with any other imaging modality [6]. Nevertheless, as this study showed, a large number of patients were treated on the basis of the best clinical guess method.…”

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confidence: 92%

Spiral computed tomography of pulmonary embolism

Herold¹

2002

European Respiratory Journal

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Spiral computed tomography of pulmonary embolism. C.J. Herold. #ERS Journals Ltd 2002. ABSTRACT: Within the last several years, spiral computed tomography angiography (SCTA) of the pulmonary arteries has emerged as a noninvasive angiographic modality for the evaluation of patients with suspected pulmonary embolism (PE). SCTA is based on continuous computed tomography (CT) data acquisition during patient transport through the rotating X-ray tube and detector system, where scanning is performed in the time period in which the injected contrast material passes through the pulmonary arteries. Single detector spiral CT has a sensitivity of y85-90% and a specificity between 88-95%. Sensitivity and specificity are very likely to increase with the use of multidetector spiral CT scanners that allow scanning of large lung volumes with a scan collimation as narrow as 1 mm.Currently, SCTA is most commonly used as a primary imaging method in patients with suspected PE, and as a second-line method in cases with inconclusive ventilation/ perfusion scintigraphy results. SCTA has proven to be cost-effective, especially in combination with ultrasound of the lower extremities.Limitations of the method include a decreased sensitivity for the detection of small isolated clots in the peripheral pulmonary arterial bed, and a potentially reduced image quality in patients with coexistent cardiopulmonary disorders.Despite these limitations, several studies have now documented that, in patients with suspected pulmonary embolism, it is safe to withhold anticoagulation therapy if a spiral computed tomography exam of the pulmonary arteries is negative and no lower extremity venous thrombosis is present. In the future, multislice computed tomography scanning of the pulmonary arteries with multiplanar reformation and one-stop shopping, i.e. scanning of the pulmonary arteries and the lower extremity veins in a single session, will further enhance the role of computed tomography angiography in the examination of patients with suspected pulmonary embolism. Pulmonary embolism (PE) is often encountered both in the hospital setting and in private clinical practice. Because untreated PE is associated with a greatly increased mortality risk, accurate diagnosis of PE is of critical importance [1,2]. However, because clinical findings, laboratory tests, and signs and symptoms at physical examination are often nonspecific, imaging methods are a significant part of the diagnostic evaluation of patients with suspected PE.Since PE is not an isolated disorder but, rather, a symptom of the entire venous thromboembolism complex, imaging studies of the lower extremities and the pelvis, the most common source of pulmonary emboli, are a fundamental requirement for the diagnostic work-up of patients with suspected PE. Various imaging modalities have been attempted in this evaluation process within the last few decades. For many years, ventilation/perfusion (V/Q) scintigraphy has served as the noninvasive procedure of choice for the assessment of patients with susp...

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confidence: 92%

Spiral computed tomography of pulmonary embolism

Herold¹

2002

European Respiratory Journal

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“…Because of these potential risks there is considerable reluctance by clinicians and radiologists in the performance of pulmonary angiography for PTE. Even in large academic centres in the United States and United Kingdom it has been estimated that only 5 to 15% of patients with indeterminate ventilation-perfusion scintigrams undergo pulmonary angiography (4,5) .…”

Section: Pulmonary Angiographymentioning

confidence: 99%

“…Pulmonary angiography however is an invasive method available in a small number of centers that is performed less and less in the evaluation of these patients (4,5) . The introduction of spiral computed tomography (CT) in the early 1990s has made it possible to image the entire chest in a short period of time and analysis of the pulmonary arteries during the peak of contrast enhancement.…”

Section: Introductionmentioning

confidence: 99%

Diagnóstico por imagem do tromboembolismo pulmonar agudo

Silva¹,

Müller²

2004

J. bras. pneumol.

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The diagnosis of acute pulmonary thromboembolism is based on clinical probability, use of D-dimer (when available) and imaging. The main imaging modalities used in the diagnosis are ventilation-perfusion (V/Q), pulmonary angiography, and computed tomography (CT). In the last decade several studies have demonstrated that spiral CT has a high sensitivity and specificity in the diagnosis of acute pulmonary thromboembolism. The evaluation of the pulmonary arteries has further improved with the recent introduction of multidetector spiral CT scanners. Several groups of investigators have suggested that contrast enhanced spiral should replace scintigraphy in the assessment of patients whose symptoms are suggestive of acute PE. This article discusses the role of the various imaging modalities in the diagnosis of acute pulmonary thromboembolism with emphasis on spiral CT.

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“…There is an assumption that, because urgent anticoagulation is mandatory in major pulmonary embolus (PE), minor episodes in otherwise fit people must not be missed and require similar urgent treatment. In a teaching hospital clinicians commonly make dubious management decisions on the basis of inadequate imaging information 1 . In any case, most patients with suspected VTE are not initially seen by a well informed specialist but are referred to middlegrade physicians by colleagues in emergency, general surgical, orthopaedic and obstetric departments who are often unaware of the literature.…”

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confidence: 99%

“…It is estimated that there are 3,500-7,000 deaths per year from alcoholic hepatitis and/or cirrhosis in the UK 1,2 . The incidence of cirrhosis in alcoholics at autopsy is about10%.…”

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confidence: 99%

A practical approach to the diagnosis of venothromboembolism

Corris

2001

Clinical Medicine

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A negative D-dimer result in a patient presenting with signs and symptoms in keeping with venous thromboembolism but with a low clinical probability is sufficient to exclude the diagnosis Ventilation perfusion isotope scanning, although widely available, should only be used in patients with suspected pulmonary embolism who have a normal chest radiograph or no previous chronic cardiopulmonary disease Studies suggest good sensitivity and specificity of spiral computerised tomography (CT) in the diagnosis of central or segmental pulmonary emboli All hospitals receiving acute medical emergencies should devise their own algorithm for diagnosis of venothromboembolism that reflects local expertise and availability of investigations Key Pointsare no absolute contraindications, although particular care should be exercised in patients with known sensitivity to contrast media and in those with severe pulmonary hypertension, renal impairment or following acute MI. The femoral vein approach is commonly used, but some prefer the internal jugular or subclavian approach because of the reduced risk of disturbing thrombi and the ability to maintain venous access for pressure monitoring and the administration of thrombolytic drugs where indicated. Good liaison between the radiologist and intensive care unit is recommended. Pigtail catheters of sufficient size (7F) to enable high-flow injections of non-ionic contrast media should be used. Volume and flow will depend on facilities available. Superselective injections may be necessary. A main PA injection may be sufficient when prior echocardiography suggests the possibility of a large centrally placed clot. Where prior V/Q scan is non-diagnostic, angiography can be confined to the more abnormal side 65 .Minor complications have been reported in 2% and major or fatal complications in 0.5-1.3% of investigations 66 using these techniques, mainly in patients already severely ill. The introduction of low osmolar non-ionic contrast media has led to a reduction in complications, a recent report finding only one major (non-fatal) complication in every 300 patients 67 .There may be difficulties in interpretation of PA results, even by experienced radiologists. The PIOPED study found 19% interobserver disagreement, varying from 2% for central to 34% for subsegmental abnormalities 68 , and 11% within-observer discrepancy. A recent study with consensus review in patients with non-diagnostic lung scans led to a change in initial diagnosis in 20%. There was better agreement when digital subtraction was used, but this is not widely available. RecommendationsThe algorithm shown in Fig 1 outlines one approach to the investigation of a patient presenting with suspected VTE. ConclusionsThe investigation of suspected VTE will continue to be refined by further evidence from prospective studies using D-dimers and spiral CT. Moreover, newer modalities such as magnetic resonance imaging (MRI) are beginning to demonstrate diagnostic value, particularly in North America. However, at present, routine use of M...

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Diagnosis of Pulmonary Embolism at a Large Teaching Hospital

Cited by 80 publications

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Spiral computed tomography of pulmonary embolism

Spiral computed tomography of pulmonary embolism

Diagnóstico por imagem do tromboembolismo pulmonar agudo

A practical approach to the diagnosis of venothromboembolism

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