Computed Tomography Pulmonary Angiography and Venography: Diagnostic and Prognostic Properties

ABSTRACT

Computed tomography pulmonary angiography (CTPA) is now an established test in the diagnosis of suspected pulmonary embolism (PE). Some may argue that it has become the “one-stop” center for diagnosis and prognosis of acute PE and deep vein thrombosis (DVT). Current literature shows CTPA to be reliable and accurate. Management studies have shown patient outcomes are excellent when CTPA is used in the diagnostic algorithm. The addition of computed tomography venography (CTV) increases the sensitivity, which may be worth the added radiation in certain patient populations. Although measures of right heart function, pulmonary artery pressures, and clot burden via CTPA need to be standardized and further validated prospectively, this test may also play a prominent role in determining short-term outcomes in patients with established acute PE.

Pulmonary embolism - deep vein thrombosis - computed tomography - right heart failure

REFERENCES

• 1 Blachere H, Latrabe V, Montaudon M et al.. Pulmonary embolism revealed on helical CT angiography: comparison with ventilation-perfusion radionuclide lung scanning.  AJR Am J Roentgenol. 2000;  174 1041-1047
• 2 Macdonald W B, Patrikeos A P, Thompson R I, Adler B D, van der Schaaf A A. Diagnosis of pulmonary embolism: ventilation perfusion scintigraphy versus helical computed tomography pulmonary angiography.  Australas Radiol. 2005;  49 32-38
• 3 Mayo J R, Remy-Jardin M, Muller N L et al.. Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy.  Radiology. 1997;  205 447-452
• 4 Perrier A, Howarth N, Didier D et al.. Performance of helical computed tomography in unselected outpatients with suspected pulmonary embolism.  Ann Intern Med. 2001;  135 88-97
• 5 Ruiz Y, Caballero P, Caniego J L et al.. Prospective comparison of helical CT with angiography in pulmonary embolism: global and selective vascular territory analysis: interobserver agreement.  Eur Radiol. 2003;  13 823-829
• 6 Safriel Y, Zinn H. CT pulmonary angiography in the detection of pulmonary emboli: a meta-analysis of sensitivities and specificities.  Clin Imaging. 2002;  26 101-105
• 7 Ost D, Rozenshtein A, Saffran L, Snider A. The negative predictive value of spiral computed tomography for the diagnosis of pulmonary embolism in patients with nondiagnostic ventilation-perfusion scans.  Am J Med. 2001;  110 16-21
• 8 Van Strijen M J, De Monye W, Kieft G J, Pattynama P M, Prins M H, Huisman M V. Accuracy of single-detector spiral CT in the diagnosis of pulmonary embolism: a prospective multicenter cohort study of consecutive patients with abnormal perfusion scintigraphy.  J Thromb Haemost. 2005;  3 17-25
• 9 Ghaye B, Szapiro D, Mastora I et al.. Peripheral pulmonary arteries: how far in the lung does multi-detector row spiral CT allow analysis?.  Radiology. 2001;  219 629-636
• 10 Patel S, Kazerooni E A, Cascade P N. Pulmonary embolism: optimization of small pulmonary artery visualization at multi-detector row CT.  Radiology. 2003;  227 455-460
• 11 Raptopoulos V, Boiselle P M. Multi-detector row spiral CT pulmonary angiography: comparison with single-detector row spiral CT.  Radiology. 2001;  221 606-613
• 12 Quiroz R, Kucher N, Zou K H et al.. Clinical validity of a negative computed tomography scan in patients with suspected pulmonary embolism: a systematic review.  JAMA. 2005;  293 2012-2017
• 13 Roy P M, Colombet I, Durieux P, Chatellier G, Sors H, Meyer G. Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism.  BMJ. 2005;  331 259
• 14 Stein P D, Fowler S E, Goodman L R et al.. Multidetector computed tomography for acute pulmonary embolism.  N Engl J Med. 2006;  354 2317-2327
• 15 Wells P S, Anderson D R, Rodger M et al.. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer.  Thromb Haemost. 2000;  83 416-420
• 16 Moores L K, Jackson Jr W L, Shorr A F, Jackson J L. Meta-analysis: outcomes in patients with suspected pulmonary embolism managed with computed tomographic pulmonary angiography.  Ann Intern Med. 2004;  141 866-874
• 17 Perrier A, Roy P M, Sanchez O et al.. Multidetector-row computed tomography in suspected pulmonary embolism.  N Engl J Med. 2005;  352 1760-1768
• 18 Sohne M, Kruip M J, Nijkeuter M et al.. Accuracy of clinical decision rule, D-dimer and spiral computed tomography in patients with malignancy, previous venous thromboembolism, COPD or heart failure and in older patients with suspected pulmonary embolism.  J Thromb Haemost. 2006;  4 1042-1046
• 19 van Belle A, Buller H R, Huisman M V et al.. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography.  JAMA. 2006;  295 172-179
• 20 Perrier A, Bounameaux H. Accuracy or outcome in suspected pulmonary embolism.  N Engl J Med. 2006;  354 2383-2385
• 21 Le Gal G, Righini M, Parent F, van Strijen M, Couturaud F. Diagnosis and management of subsegmental pulmonary embolism.  J Thromb Haemost. 2006;  4 724-731
• 22 Eyer B A, Goodman L R, Washington L. Clinicians' response to radiologists' reports of isolated subsegmental pulmonary embolism or inconclusive interpretation of pulmonary embolism using MDCT.  AJR Am J Roentgenol. 2005;  184 623-628
• 23 Musset D, Parent F, Meyer G et al.. Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study.  Lancet. 2002;  360 1914-1920
• 24 Jones S E, Wittram C. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome.  Radiology. 2005;  237 329-337
• 25 Ciccotosto C, Goodman L R, Washington L, Quiroz F A. Indirect CT venography following CT pulmonary angiography: spectrum of CT findings.  J Thorac Imaging. 2002;  17 18-27
• 26 Garg K, Mao J. Deep venous thrombosis: spectrum of findings and pitfalls in interpretation on CT venography.  AJR Am J Roentgenol. 2001;  177 319-323
• 27 Ghaye B, Szapiro D, Willems V, Dondelinger R F. Pitfalls in CT venography of lower limbs and abdominal veins.  AJR Am J Roentgenol. 2002;  178 1465-1471
• 28 Katz D S, Loud P A, Bruce D et al.. Combined CT venography and pulmonary angiography: a comprehensive review.  Radiographics. 2002;  22(Spec Iss) S3-19 discussion S20-24
• 29 Baldt M M, Zontsich T, Kainberger F, Fleischmann G, Mostbeck G. Spiral CT evaluation of deep venous thrombosis.  Semin Ultrasound CT MR. 1997;  18 369-375
• 30 Baldt M M, Zontsich T, Stumpflen A et al.. Deep venous thrombosis of the lower extremity: efficacy of spiral CT venography compared with conventional venography in diagnosis.  Radiology. 1996;  200 423-428
• 31 Stehling M K, Rosen M P, Weintraub J, Kim D, Raptopoulos V. Spiral CT venography of the lower extremity.  AJR Am J Roentgenol. 1994;  163 451-453
• 32 Coche E E, Hamoir X L, Hammer F D, Hainaut P, Goffette P P. Using dual-detector helical CT angiography to detect deep venous thrombosis in patients with suspicion of pulmonary embolism: diagnostic value and additional findings.  AJR Am J Roentgenol. 2001;  176 1035-1039
• 33 Garg K, Kemp J L, Russ P D, Baron A E. Thromboembolic disease: variability of interobserver agreement in the interpretation of CT venography with CT pulmonary angiography.  AJR Am J Roentgenol. 2001;  176 1043-1047
• 34 Ghaye B, Szapiro D, Willems V, Dondelinger R F. Combined CT venography of the lower limbs and spiral CT angiography of pulmonary arteries in acute pulmonary embolism: preliminary results of a prospective study.  JBR-BTR. 2000;  83 271-278
• 35 Richman P B, Dominguez S, Kasper D et al.. Interobserver agreement for the diagnosis of venous thromboembolism on computed tomography chest angiography and indirect venography of the lower extremities in emergency department patients.  Acad Emerg Med. 2006;  13 295-301
• 36 Kelly A M, Patel S, Carlos R C, Cronin P, Kazerooni E A. Multidetector row CT pulmonary angiography and indirect venography for the diagnosis of venous thromboembolic disease in intensive care unit patients.  Acad Radiol. 2006;  13 486-495
• 37 Muller C, Kopka L, Funke M, Funke C, Grabbe E. Diagnosis of lung embolism and underlying venous thrombosis in multi-slice spiral CT.  Rofo. 2001;  173 528-535
• 38 Begemann P G, Bonacker M, Kemper J et al.. Evaluation of the deep venous system in patients with suspected pulmonary embolism with multi-detector CT: a prospective study in comparison to Doppler sonography.  J Comput Assist Tomogr. 2003;  27 399-409
• 39 Cham M D, Yankelevitz D F, Shaham D et al.. Deep venous thrombosis: detection by using indirect CT venography. The Pulmonary Angiography-Indirect CT Venography Cooperative Group.  Radiology. 2000;  216 744-751
• 40 Duwe K M, Shiau M, Budorick N E, Austin J H, Berkmen Y M. Evaluation of the lower extremity veins in patients with suspected pulmonary embolism: a retrospective comparison of helical CT venography and sonography. 2000 ARRS Executive Council. Award I. American Roentgen Ray Society.  AJR Am J Roentgenol. 2000;  175 1525-1531
• 41 Garg K, Kemp J L, Wojcik D et al.. Thromboembolic disease: comparison of combined CT pulmonary angiography and venography with bilateral leg sonography in 70 patients.  AJR Am J Roentgenol. 2000;  175 997-1001
• 42 Katz D S, Loud P A, Klippenstein D L, Shah R A, Grossman Z D. Extra-thoracic findings on the venous phase of combined computed tomographic venography and pulmonary angiography.  Clin Radiol. 2000;  55 177-181
• 43 Lim K E, Hsu Y Y, Hsu W C, Huang C C. Combined computed tomography venography and pulmonary angiography for the diagnosis PE and DVT in the ED.  Am J Emerg Med. 2004;  22 301-306
• 44 Loud P A, Katz D S, Bruce D A, Klippenstein D L, Grossman Z D. Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography.  Radiology. 2001;  219 498-502
• 45 Loud P A, Katz D S, Klippenstein D L, Shah R D, Grossman Z D. Combined CT venography and pulmonary angiography in suspected thromboembolic disease: diagnostic accuracy for deep venous evaluation.  AJR Am J Roentgenol. 2000;  174 61-65
• 46 Peterson D A, Kazerooni E A, Wakefield T W et al.. Computed tomographic venography is specific but not sensitive for diagnosis of acute lower-extremity deep venous thrombosis in patients with suspected pulmonary embolus.  J Vasc Surg. 2001;  34 798-804
• 47 Taffoni M J, Ravenel J G, Ackerman S J. Prospective comparison of indirect CT venography versus venous sonography in ICU patients.  AJR Am J Roentgenol. 2005;  185 457-462
• 48 Au V W, Walsh G, Fon G. Computed tomography pulmonary angiography with pelvic venography in the evaluation of thrombo-embolic disease.  Australas Radiol. 2001;  45 141-145
• 49 Cham M D, Yankelevitz D F, Henschke C I. Thromboembolic disease detection at indirect CT venography versus CT pulmonary angiography.  Radiology. 2005;  234 591-594
• 50 Ghaye B, Nchimi A, Noukoua C T, Dondelinger R F. Does multi-detector row CT pulmonary angiography reduce the incremental value of indirect CT venography compared with single-detector row CT pulmonary angiography?.  Radiology. 2006;  240 256-262
• 51 Johnson J C, Brown M D, McCullough N, Smith S. CT lower extremity venography in suspected pulmonary embolism in the ED.  Emerg Radiol. 2006;  12 160-163
• 52 Revel M P, Petrover D, Hernigou A, Lefort C, Meyer G, Frija G. Diagnosing pulmonary embolism with four-detector row helical CT: prospective evaluation of 216 outpatients and inpatients.  Radiology. 2005;  234 265-273
• 53 Richman P B, Wood J, Kasper D M et al.. Contribution of indirect computed tomography venography to computed tomography angiography of the chest for the diagnosis of thromboembolic disease in two United States emergency departments.  J Thromb Haemost. 2003;  1 652-657
• 54 Walsh G, Redmond S. Does addition of CT pelvic venography to CT pulmonary angiography protocols contribute to the diagnosis of thromboembolic disease?.  Clin Radiol. 2002;  57 462-465
• 55 Wicki J, Perneger T V, Junod A F, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score.  Arch Intern Med. 2001;  161 92-97
• 56 Ghanima W, Almaas V, Aballi S et al.. Management of suspected pulmonary embolism (PE) by D-dimer and multi-slice computed tomography in outpatients: an outcome study.  J Thromb Haemost. 2005;  3 1926-1932
• 57 Perez de Llano L A, Veres Racamonde A, Ortiz Piquer M et al.. Safety of withholding anticoagulant therapy in patients who have clinically suspected pulmonary embolism and negative results on helical computed tomography.  Respiration. 2006;  73 514-519
• 58 Rademaker J, Griesshaber V, Hidajat N, Oestmann J W, Felix R. Combined CT pulmonary angiography and venography for diagnosis of pulmonary embolism and deep vein thrombosis: radiation dose.  J Thorac Imaging. 2001;  16 297-299
• 59 Tamariz L J, Eng J, Segal J B et al.. Usefulness of clinical prediction rules for the diagnosis of venous thromboembolism: a systematic review.  Am J Med. 2004;  117 676-684
• 60 Kearon C, Ginsberg J S, Douketis J et al.. An evaluation of D-dimer in the diagnosis of pulmonary embolism: a randomized trial.  Ann Intern Med. 2006;  144 812-821
• 61 Bates S M, Kearon C, Crowther M et al.. A diagnostic strategy involving a quantitative latex D-dimer assay reliably excludes deep venous thrombosis.  Ann Intern Med. 2003;  138 787-794
• 62 Brotman D J, Segal J B, Jani J T, Petty B G, Kickler T S. Limitations of D-dimer testing in unselected inpatients with suspected venous thromboembolism.  Am J Med. 2003;  114 276-282
• 63 Stein P D, Hull R D, Patel K C et al.. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review.  Ann Intern Med. 2004;  140 589-602
• 64 Ten Cate-Hoek A J, Prins M H. Management studies using a combination of D-dimer test result and clinical probability to rule out venous thromboembolism: a systematic review.  J Thromb Haemost. 2005;  3 2465-2470
• 65 The PIOPED Investigators . Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the prospective investigation of pulmonary embolism diagnosis (PIOPED).  JAMA. 1990;  263 2753-2759
• 66 van Beek E J, Brouwerst E M, Song B, Stein P D, Oudkerk M. Clinical validity of a normal pulmonary angiogram in patients with suspected pulmonary embolism: a critical review.  Clin Radiol. 2001;  56 838-842
• 67 Stein P D, Woodard P K, Weg J G et al.. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators.  Radiology. 2007;  242 15-21
• 68 Goldhaber S Z, Haire W D, Feldstein M L et al.. Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion.  Lancet. 1993;  341 507-511
• 69 Goldhaber S Z, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER).  Lancet. 1999;  353 1386-1389
• 70 Grifoni S, Olivotto I, Cecchini P et al.. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction.  Circulation. 2000;  101 2817-2822
• 71 Jerjes-Sanchez C, Ramirez-Rivera A, Arriaga-Nava R et al.. High dose and short-term streptokinase infusion in patients with pulmonary embolism: prospective with seven-year follow-up trial.  J Thromb Thrombolysis. 2001;  12 237-247
• 72 Kasper W, Konstantinides S, Geibel A, Tiede N, Krause T, Just H. Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism.  Heart. 1997;  77 346-349
• 73 Ribeiro A, Lindmarker P, Juhlin-Dannfelt A, Johnsson H, Jorfeldt L. Echocardiography Doppler in pulmonary embolism: right ventricular dysfunction as a predictor of mortality rate.  Am Heart J. 1997;  134 479-487
• 74 Sukhija R, Aronow W S, Lee J et al.. Association of right ventricular dysfunction with in-hospital mortality in patients with acute pulmonary embolism and reduction in mortality in patients with right ventricular dysfunction by pulmonary embolectomy.  Am J Cardiol. 2005;  95 695-696
• 75 Giannitsis E, Katus H A. Risk stratification in patients with confirmed pulmonary embolism: what to do when echocardiography is not available.  Crit Care Med. 2006;  34 2857-2858
• 76 Kline J A, Hernandez-Nino J, Rose G A, Norton H J, Camargo Jr C A. Surrogate markers for adverse outcomes in normotensive patients with pulmonary embolism.  Crit Care Med. 2006;  34 2773-2780
• 77 Kucher N, Goldhaber S Z. Risk stratification of acute pulmonary embolism.  Semin Thromb Hemost. 2006;  32 838-847
• 78 Ghaye B, Ghuysen A, Bruyere P J, D'Orio V, Dondelinger R F. Can CT pulmonary angiography allow assessment of severity and prognosis in patients presenting with pulmonary embolism? What the radiologist needs to know.  Radiographics. 2006;  26 23-39 discussion 39-40
• 79 Qanadli S D, El Hajjam M, Vieillard-Baron A et al.. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography.  AJR Am J Roentgenol. 2001;  176 1415-1420
• 80 Mastora I, Remy-Jardin M, Masson P et al.. Severity of acute pulmonary embolism: evaluation of a new spiral CT angiographic score in correlation with echocardiographic data.  Eur Radiol. 2003;  13 29-35
• 81 Wu A S, Pezzullo J A, Cronan J J, Hou D D, Mayo-Smith W W. CT pulmonary angiography: quantification of pulmonary embolus as a predictor of patient outcome-initial experience.  Radiology. 2004;  230 831-835
• 82 Ghuysen A, Ghaye B, Willems V et al.. Computed tomographic pulmonary angiography and prognostic significance in patients with acute pulmonary embolism.  Thorax. 2005;  60 956-961
• 83 Quiroz R, Kucher N, Schoepf U J et al.. Right ventricular enlargement on chest computed tomography: prognostic role in acute pulmonary embolism.  Circulation. 2004;  109 2401-2404
• 84 Schoepf U J, Kucher N, Kipfmueller F, Quiroz R, Costello P, Goldhaber S Z. Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism.  Circulation. 2004;  110 3276-3280
• 85 Collomb D, Paramelle P J, Calaque O et al.. Severity assessment of acute pulmonary embolism: evaluation using helical CT.  Eur Radiol. 2003;  13 1508-1514
• 86 He H, Stein M W, Zalta B, Haramati L B. Computed tomography evaluation of right heart dysfunction in patients with acute pulmonary embolism.  J Comput Assist Tomogr. 2006;  30 262-266
• 87 Coche E, Vlassenbroek A, Roelants V et al.. Evaluation of biventricular ejection fraction with ECG-gated 16-slice CT: preliminary findings in acute pulmonary embolism in comparison with radionuclide ventriculography.  Eur Radiol. 2005;  15 1432-1440
• 88 Dogan H, Kroft L J, Huisman M V, van der Geest R J, de Roos A. Right ventricular function in patients with acute pulmonary embolism: analysis with electrocardiography-synchronized multi-detector row CT.  Radiology. 2007;  242 78-84
• 89 ten Wolde M, Sohne M, Quak E, Mac Gillavry M R, Buller H R. Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism.  Arch Intern Med. 2004;  164 1685-1689
• 90 Araoz P A, Gotway M B, Harrington J R, Harmsen W S, Mandrekar J N. Pulmonary embolism: prognostic CT findings.  Radiology. 2007;  242 889-897
• 91 Araoz P A, Gotway M B, Trowbridge R L et al.. Helical CT pulmonary angiography predictors of in-hospital morbidity and mortality in patients with acute pulmonary embolism.  J Thorac Imaging. 2003;  18 207-216
• 92 Contractor S, Maldjian P D, Sharma V K, Gor D M. Role of helical CT in detecting right ventricular dysfunction secondary to acute pulmonary embolism.  J Comput Assist Tomogr. 2002;  26 587-591
• 93 Reid J H, Murchison J T. Acute right ventricular dilatation: a new helical CT sign of massive pulmonary embolism.  Clin Radiol. 1998;  53 694-698
• 94 van der Meer R W, Pattynama P M, van Strijen M J et al.. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism.  Radiology. 2005;  235 798-803