PIOPEDII. Multidetector computed tomography for acute pulmonary embolism

Duke University, Durham, North Carolina, United States
New England Journal of Medicine (Impact Factor: 55.87). 07/2006; 354(22):2317-27. DOI: 10.1056/NEJMoa052367
Source: PubMed


The accuracy of multidetector computed tomographic angiography (CTA) for the diagnosis of acute pulmonary embolism has not been determined conclusively.
The Prospective Investigation of Pulmonary Embolism Diagnosis II trial was a prospective, multicenter investigation of the accuracy of multidetector CTA alone and combined with venous-phase imaging (CTA-CTV) for the diagnosis of acute pulmonary embolism. We used a composite reference test to confirm or rule out the diagnosis of pulmonary embolism.
Among 824 patients with a reference diagnosis and a completed CT study, CTA was inconclusive in 51 because of poor image quality. Excluding such inconclusive studies, the sensitivity of CTA was 83 percent and the specificity was 96 percent. Positive predictive values were 96 percent with a concordantly high or low probability on clinical assessment, 92 percent with an intermediate probability on clinical assessment, and nondiagnostic if clinical probability was discordant. CTA-CTV was inconclusive in 87 of 824 patients because the image quality of either CTA or CTV was poor. The sensitivity of CTA-CTV for pulmonary embolism was 90 percent, and specificity was 95 percent. CTA-CTV was also nondiagnostic with a discordant clinical probability.
In patients with suspected pulmonary embolism, multidetector CTA-CTV has a higher diagnostic sensitivity than does CTA alone, with similar specificity. The predictive value of either CTA or CTA-CTV is high with a concordant clinical assessment, but additional testing is necessary when the clinical probability is inconsistent with the imaging results.

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    • "The number of emboli and their locations are expected to correlate with prognosis. Computed tomography angiography allows an accurate visualisation of emboli up to the subsegmental portions of the pulmonary arteries [29]. Many different CTA scores integrate the number of occluded vessels and the degree of obstruction (complete versus incomplete) with conflicting results concerning their association with death. "
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    ABSTRACT: Pulmonary embolism (PE) induces an acute increase in the right ventricle afterload that can lead to right-ventricular dysfunction (RVD) and eventually to circulatory collapse. Hemodynamic status and presence of RVD are important determinants of adverse outcomes in acute PE. Technologic progress allows computed tomography angiography (CTA) to give more information than accurate diagnosis of PE. It may also provide an insight into hemodynamics and right-ventricular function. Proximal localization of emboli, reflux of contrast medium to the hepatic veins, and right-to-left short-axis ventricular diameter ratio seem to be the most relevantCTApredictors of 30-daymortality.These elements require little postprocessing time, an advantage in the emergency room. We herein review the prognostic value of RVD and other CTA mortality predictors for patients with acute PE.
    Full-text · Article · Jun 2014 · BioMed Research International
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    • "While the mortality rate of PE is approximately 30% in noncured patients, the rate reduces to 2–8% with treatment [4] [5]. The symptoms and findings such as shortness of breath, chest pain, syncope, hyperventilation, and unexplained tachycardia are not specific to PE and may develop as well in case of pneumonia, acute exacerbation of COPD, malignity, pleural effusion, or cardiac diseases [6]. That is why the most significant phase of PE diagnosis is clinically suspected. "
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    ABSTRACT: Introduction: The purpose of this study is to analyze the frequency of other diagnoses and findings in patients that were diagnosed with or not diagnosed with PE following the CTPA in the ED and to analyze the relationship between diagnosis and D-dimer. INSTRUMENT AND METHOD: This study involves all patients that presented to the ED that underwent CTPA with the prediagnosis of PE. The items considered in this study were their reason for presenting to the ED and pretest clinical risks for PE, D-dimer, and CTPA results. Findings: Of the 696 cases, the most common cause was shortness of breath (59.3%). The CTPA showed that 145 (20.83%) patients were suffering from PE. Among the remaining cases, 464 (66.66%) patients had pathological findings other than PE and 87 (12.5%) patients were reported as normal. The most common pathological results other than PE found in CTPA were atelectasis in 244 (39.9%) and ground glass in 165 (23.7%), as well as nonpulmonary results in 70 (10.05%) patients. The differences in D-dimer results of patients diagnosed with PE, patients diagnosed with another pathology, and patients with normal CTPA results were statistically significant (P < 0.001). Conclusion: CTPA scanning, performed on the basis of assessment scoring, helps in discovering other fatal pathologies in addition to PE.
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    • "CT-PA scans were considered as positive according to the following criteria: failure of contrast material to fill the entire lumen because of a central filling defect (the artery may be enlarged, as compared with similar arteries); a partial filling defect surrounded by contrast material on a cross-sectional image; contrast material between the central filling defect and the artery wall on an in-plane, longitudinal image; and a peripheral intraluminal filling defect that forms an acute angle with the artery wall [13,14]. A CT Venogram (CTV) was routinely performed in those patients that had a positive CT-PA. "
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    ABSTRACT: This study aims to determine the incidence of pulmonary embolism (PE) in trauma and orthopedic patients within a regional tertiary referral center and its association with the pattern of injury, type of treatment, co-morbidities, thromboprophylaxis and mortality. All patients admitted to our institution between January 2010 and December 2011, for acute trauma or elective orthopedic procedures, were eligible to participate in this study. Our cohort was formed by identifying all patients with clinical features of PE who underwent Computed Tomography-Pulmonary Angiogram (CT-PA) to confirm or exclude the clinical suspicion of PE, within six months after the injury or the surgical procedure.Case notes and electronic databases were reviewed retrospectively to identify each patient's venous thromboembolism (VTE) risk factors, type of treatment, thromboprophylaxis and mortality. Out of 18,151 patients admitted during the study period only 85 (0.47%) patients developed PE (positive CT-PA) (24 underwent elective surgery and 61 sustained acute trauma). Of these, only 76% of the patients received thromboprophylaxis. Hypertension, obesity and cardiovascular disease were the most commonly identifiable risk factors. In 39% of the cases, PE was diagnosed during the in-hospital stay. The median time of PE diagnosis, from the date of injury or the surgical intervention was 23 days (range 1 to 312). The overall mortality rate was 0.07% (13/18,151), but for those who developed PE it was 15.29% (13/85). Concomitant deep venous thrombosis (DVT) was identified in 33.3% of patients. The presence of two or more co-morbidities was significantly associated with the incidence of mortality (unadjusted odds ratio (OR) = 3.52, 95% confidence interval (CI) (1.34, 18.99), P = 0.034). Although there was also a similar clinical effect size for polytrauma injury on mortality (unadjusted OR = 1.90 (0.38, 9.54), P = 0.218), evidence was not statistically significant for this factor. The incidence of VTE was comparable to previously reported rates, whereas the mortality rate was lower. Our local protocols that comply with the National Institute for Health and Clinical Excellence (NICE) guidelines in the UK appear to be effective in preventing VTE and reducing mortality in trauma and orthopedic patients.
    Full-text · Article · Mar 2014 · BMC Medicine
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