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Arnoldussen CWKP. Imaging of Deep Venous Pathology. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03785-y. [PMID: 38951251 DOI: 10.1007/s00270-024-03785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 06/04/2024] [Indexed: 07/03/2024]
Abstract
Imaging plays an important role in the identification and assessment of clinically suspected venous pathology. The purpose of this article is to review the spectrum of image-based diagnostic tools used in the investigation of suspected deep vein disease, both obstructive (deep vein thrombosis and post-thrombotic vein changes) as well as insufficiency (e.g., compression syndromes and pelvic venous insufficiency). Additionally, specific imaging modalities are used for the treatment and during clinical follow-up. The use of duplex ultrasound, magnetic resonance venography, computed tomography venography and intravascular ultrasound as well as conventional venography will be discussed in this pictorial review.
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Affiliation(s)
- Carsten W K P Arnoldussen
- Interventional and Cardiovascular Radiologist, Department of Diagnostic and Interventional Radiology and Nuclear Medicine, VieCuri Medical Centre, Tegelseweg 210, 5912 BL, Venlo, Limburg, The Netherlands.
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Falster C, Jacobsen N, Coman KE, Højlund M, Gaist TA, Posth S, Møller JE, Brabrand M, Laursen CB. Diagnostic accuracy of focused deep venous, lung, cardiac and multiorgan ultrasound in suspected pulmonary embolism: a systematic review and meta-analysis. Thorax 2021; 77:679-689. [PMID: 34497138 DOI: 10.1136/thoraxjnl-2021-216838] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 08/12/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the diagnostic accuracy of point-of-care ultrasound in suspected pulmonary embolism. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, Embase, CINAHL and Cochrane library were searched on 2 July 2020 with no restrictions on the date of publication. Subject headings or subheadings combined with text words for the concepts of pulmonary embolism, ultrasound and diagnosis were used. ELIGIBILITY CRITERIA AND DATA ANALYSIS Eligible studies reported sensitivity and specificity of deep venous, lung, cardiac or multiorgan ultrasound in patients with suspected pulmonary embolism, using an adequate reference-test. Prospective, cross-sectional and retrospective studies were considered for eligibility. No restrictions were made on language. Studies were excluded if a control group consisted of healthy volunteers or if transesophageal or endobronchial ultrasound was used. Risk of bias was assessed using quality assessment of diagnostic accuracy studies-2. Meta-analysis of sensitivity and specificity was performed by construction of hierarchical summary receiver operator curves. I2 was used to assess the study heterogeneity. MAIN OUTCOME MEASURES The primary outcome was overall sensitivity and specificity of reported ultrasound signs, stratified by organ approach (deep venous, lung, cardiac and multiorgan). Secondary outcomes were stratum-specific sensitivity and specificity within subgroups defined by pretest probability of pulmonary embolism. RESULTS 6378 references were identified, and 70 studies included. The study population comprised 9664 patients with a prevalence of pulmonary embolism of 39.9% (3852/9664). Risk of bias in at least one domain was found in 98.6% (69/70) of included studies. Most frequently, 72.8% (51/70) of studies reported >24 hours between ultrasound examination and reference test or did not disclose time interval at all. Level of heterogeneity ranged from 0% to 100%. Most notable ultrasound signs were bilateral compression of femoral and popliteal veins (22 studies; 4708 patients; sensitivity 43.7% (36.3% to 51.4%); specificity 96.7% (95.4% to 97.6%)), presence of at least one hypoechoic pleural-based lesion (19 studies; 2134 patients; sensitivity 81.4% (73.2% to 87.5%); specificity 87.4% (80.9% to 91.9%)), D-sign (13 studies; 1579 patients; sensitivity 29.7% (24.6% to 35.4%); specificity 96.2% (93.1% to 98.0%)), visible right ventricular thrombus (5 studies; 995 patients; sensitivity 4.7% (2.7% to 8.1%); specificity 100% (99.0% to 100%)) and McConnell's sign (11 studies; 1480 patients; sensitivity 29.1% (20.0% to 40.1%); specificity 98.6% (96.7% to 99.4%)). CONCLUSION Several ultrasound signs exhibit a high specificity for pulmonary embolism, suggesting that implementation of ultrasound in the initial assessment of patients with suspected pulmonary embolism may improve the selection of patients for radiation imaging. PROSPERO REGISTRATION NUMBER CRD42020184313.
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Affiliation(s)
- Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark .,Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Niels Jacobsen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Mikkel Højlund
- Department of Public Health, Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Stefan Posth
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark.,Department of Regional Health Research, University of Southern Denmark, Esbjerg, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Impact of CT venography added to CT pulmonary angiography for the detection of deep venous thrombosis and relevant incidental CT findings. Eur J Radiol 2020; 133:109388. [PMID: 33197747 DOI: 10.1016/j.ejrad.2020.109388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/17/2020] [Accepted: 10/26/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess the additional diagnostic value of CT venography (CTV) simultaneously performed with CT pulmonary angiography (CTPA) in the context of thromboembolic disease for the detection of deep venous thrombosis (DVT) and other relevant incidental CT findings. MATERIALS AND METHODS Retrospectively and consecutively, we included all patients referred to our emergency department within the last 24 months for suspected pulmonary embolism (PE) who underwent CTPA combined with CTV. Two radiologists blinded to clinical information and results independently analysed CTV images in the context of DVT of the lower extremities and other, unsuspected abdominal/pelvic findings. These latter were classified as relevant with therapeutic consequences or irrelevant. One radiologist reviewed patient clinical records. Inter-observer agreement for DVT detection was calculated. RESULTS Of 696 patients, 119 had PE (17.1%) and 54 had DVT (7.8%), 16 (2.3%) of them without concomitant PE. Inter-observer agreement between the two readers was substantial (kappa = 0.78). CTV examinations led to diagnosis of relevant incidental abdominal/pelvic findings in 40 (5.7%) patients, including 11 with new malignant tumours, and 8 with progressive metastatic disease. The evaluated clinical and biological risk factors were not significantly associated with the presence of relevant incidental findings. CTV changed therapeutic management in 29 patients (4.3%): 15 had DVTs without PE, and 14 had abdominal/pelvic findings with therapeutic consequences. CONCLUSION CTV simultaneously performed with CTPA offers limited incremental value for detecting DVT. It may reveal other relevant findings leading to therapeutic changes, but the low rate does not justify screening patients with suspected PE.
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Moore AJE, Wachsmann J, Chamarthy MR, Panjikaran L, Tanabe Y, Rajiah P. Imaging of acute pulmonary embolism: an update. Cardiovasc Diagn Ther 2018; 8:225-243. [PMID: 30057872 DOI: 10.21037/cdt.2017.12.01] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Imaging plays an important role in the evaluation and management of acute pulmonary embolism (PE). Computed tomography (CT) pulmonary angiography (CTPA) is the current standard of care and provides accurate diagnosis with rapid turnaround time. CT also provides information on other potential causes of acute chest pain. With dual-energy CT, lung perfusion abnormalities can also be detected and quantified. Chest radiograph has limited utility, occasionally showing findings of PE or infarction, but is useful in evaluating other potential causes of chest pain. Ventilation-perfusion (VQ) scan demonstrates ventilation-perfusion mismatches in these patients, with several classification schemes, typically ranging from normal to high. Magnetic resonance imaging (MRI) also provides accurate diagnosis, but is available in only specialized centers and requires higher levels of expertise. Catheter pulmonary angiography is no longer used for diagnosis and is used only for interventional management. Echocardiography is used for risk stratification of these patients. In this article, we review the role of imaging in the evaluation of acute PE.
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Affiliation(s)
- Alastair J E Moore
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jason Wachsmann
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Murthy R Chamarthy
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Lloyd Panjikaran
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Yuki Tanabe
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Prabhakar Rajiah
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
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Raju S, Byrne J. External jugular vein thrombosis secondary to deep tissue neck massage. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2017; 3:146-148. [PMID: 29349404 PMCID: PMC5764886 DOI: 10.1016/j.jvscit.2017.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/10/2017] [Indexed: 12/28/2022]
Abstract
An 85-year-old man presented with an acute asymptomatic lateral neck mass in the context of deep tissue neck massages during the past year. He was referred to vascular surgery after an ultrasound examination of the neck revealed a thrombus in the external jugular vein. His past medical history and comorbidities were noncontributory. A multidisciplinary team of vascular surgeons and hematologists did not recommend any anticoagulation, given that the patient did not have any risk factors for thrombosis as well as normal D-dimer levels. The patient was maintained on his previous dose of aspirin (81 mg daily).
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Affiliation(s)
- Sneha Raju
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - John Byrne
- Division of Vascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Algoritmo para el diagnóstico y el seguimiento de la tromboembolia pulmonar aguda. RADIOLOGIA 2017; 59:75-87. [DOI: 10.1016/j.rx.2016.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 01/24/2023]
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Cox M, Patel M, Li Z, Kamel S, Deshmukh S, Roth C, Needleman L. Detection of unsuspected pelvic DVTs on abdominopelvic CT scans: a potentially life-saving diagnosis. Emerg Radiol 2016; 24:127-131. [DOI: 10.1007/s10140-016-1456-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 10/14/2016] [Indexed: 11/29/2022]
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8
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Pediatric thromboembolism: a national survey in Japan. Int J Hematol 2016; 105:52-58. [DOI: 10.1007/s12185-016-2079-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 10/21/2022]
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2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Radiol 2016; 13:e1-e29. [PMID: 26810814 DOI: 10.1016/j.jacr.2015.07.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/08/2015] [Indexed: 01/02/2023]
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Rybicki FJ, Udelson JE, Peacock WF, Goldhaber SZ, Isselbacher EM, Kazerooni E, Kontos MC, Litt H, Woodard PK. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 2016; 67:853-79. [PMID: 26809772 DOI: 10.1016/j.jacc.2015.09.011] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Interobserver Agreement between On-Call Radiology Resident and General Radiologist Interpretations of CT Pulmonary Angiograms and CT Venograms. PLoS One 2015; 10:e0126116. [PMID: 25938666 PMCID: PMC4418836 DOI: 10.1371/journal.pone.0126116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/29/2015] [Indexed: 11/19/2022] Open
Abstract
Objectives To evaluate the interobserver agreement (IOA) between the initial radiology resident and the final staff radiologist reports of combined computed tomographic pulmonary angiograms (CTPA) and computed tomographic venograms (CTV) performed during on-call hours. Materials and Methods Approval by the institutional review board was obtained. Six-hundred and ninety-six consecutive studies (CTPA or CTPA with CTV) performed during on-call hours and interpreted by 30 residents were identified. Radiology residents’ reports were compared to the final staff reports. Three tests outcomes were considered (positive, P; negative, N; indeterminate, I). Discordant cases were reviews by a chest radiologist. Results CTPAs were reported by staff radiologists as positive for pulmonary embolism (PE) in 18% (126/694), with a kappa of 0.81 (95% CI 0.77-0.86) with 3 outcomes (P, N, I), and a kappa of 0.89 (95% CI 0.85-0.94) with 2 outcomes (P, N). Regarding PE location, good concordance was observed for positive studies, with a kappa of 0.86 (95% CI 0.78 – 0.95). CTVs were reported as positive by staff radiologists in 8.5% (33/388), with a kappa of 0.66 (95% CI 0.55-0.77) with 3 outcomes (P, N, I), and a kappa of 0.89 (95% CI 0.8-1.0) with 2 outcomes (P, N). The IOA between residents and staff radiologists increased with increasing residency year level for CTPAs, but did not for CTVs. Conclusions Very good and good IOA were observed between resident and staff radiologist interpretations for CTPA and CTV, respectively, with tendency towards improved IOA as residency level of training increased for CTPA, but not for CTV.
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Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e351S-e418S. [PMID: 22315267 DOI: 10.1378/chest.11-2299] [Citation(s) in RCA: 404] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Objective testing for DVT is crucial because clinical assessment alone is unreliable and the consequences of misdiagnosis are serious. This guideline focuses on the identification of optimal strategies for the diagnosis of DVT in ambulatory adults. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that clinical assessment of pretest probability of DVT, rather than performing the same tests in all patients, should guide the diagnostic process for a first lower extremity DVT (Grade 2B). In patients with a low pretest probability of first lower extremity DVT, we recommend initial testing with D-dimer or ultrasound (US) of the proximal veins over no diagnostic testing (Grade 1B), venography (Grade 1B), or whole-leg US (Grade 2B). In patients with moderate pretest probability, we recommend initial testing with a highly sensitive D-dimer, proximal compression US, or whole-leg US rather than no testing (Grade 1B) or venography (Grade 1B). In patients with a high pretest probability, we recommend proximal compression or whole-leg US over no testing (Grade 1B) or venography (Grade 1B). CONCLUSIONS Favored strategies for diagnosis of first DVT combine use of pretest probability assessment, D-dimer, and US. There is lower-quality evidence available to guide diagnosis of recurrent DVT, upper extremity DVT, and DVT during pregnancy.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
| | - Roman Jaeschke
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Murray, UT
| | - Steven Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew D Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Clive Kearon
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Holger J Schunemann
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Stephen G Pauker
- Department of Medicine, Tufts New England Medical Center, Boston, MA
| | | | - Gordon H Guyatt
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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Incremental value of CT venography combined with pulmonary CT angiography for the detection of thromboembolic disease: systematic review and meta-analysis. AJR Am J Roentgenol 2011; 196:1065-72. [PMID: 21512072 DOI: 10.2214/ajr.10.4745] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The objective of our study was to assess the incremental role of CT venography (CTV) combined with pulmonary CT angiography (CTA) in detecting venous thromboembolic disease with a systematic review and meta-analysis of the literature. MATERIALS AND METHODS MEDLINE, Embase, and Web of Science were searched for relevant original articles published from January 1, 1995, to December 31, 2009. A random-effects model was used to obtain the incremental value of CTV in detecting thromboembolic disease. RESULTS Twenty-four studies, which included 17,373 patients, met our inclusion criteria. A meta-analysis showed that CTV increased detection rates of venous thromboembolic disease by identifying an additional 3% of cases (95% CI, 2-4%) of isolated deep venous thrombosis (DVT). A subgroup analysis of a high-risk group did not show any difference in the detection of isolated DVT. CONCLUSION The addition of CTV results in the increased detection of thromboembolic disease. CTV combined with pulmonary CTA has a promising role as a quick and efficient test for venous thromboembolism.
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Correlation between the site of pulmonary embolism and the extent of deep vein thrombosis: evaluation by computed tomography pulmonary angiography and computed tomography venography. Jpn J Radiol 2011; 29:171-6. [DOI: 10.1007/s11604-010-0533-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Accepted: 10/13/2010] [Indexed: 10/18/2022]
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Abstract
In this article, we discuss the approach for diagnosing deep vein thrombosis (DVT) in different patient populations. Clinical features and probability assessment guide further diagnostic tests. D-dimer testing is used as screening test; however, duplex ultrasound remains the primary confirmatory test. Computed tomography and magnetic resonance imaging are used only in select patient populations, such as when ultrasound results are equivocal, in patients suspected of central venous DVT, or as a part of combined protocol for diagnosis of pulmonary embolism. Contrast phlebography and plethysmography do not have much of a role during routine diagnosis of DVT.
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Affiliation(s)
- Bhanusupriya Somarouthu
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Computerized tomographic pulmonary angiography versus ventilation perfusion lung scanning for the diagnosis of pulmonary embolism. Curr Opin Pulm Med 2009; 15:425-9. [PMID: 19465853 DOI: 10.1097/mcp.0b013e32832d6b98] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to focus on recent research that has addressed the relative merits of computed tomographic pulmonary angiography (CTPA) and ventilation perfusion (V/Q) scanning for the diagnosis of pulmonary embolism. RECENT FINDINGS Computed tomographic pulmonary angiography is the most sensitive test for the diagnosis of pulmonary embolism and its use has been associated with a rising incidence of the condition. Diagnostic algorithms using either CTPA or V/Q scanning have proven to be comparably safe to exclude the diagnosis of pulmonary embolism. Negative multidetector CTPA study results essentially ruled out the diagnosis of pulmonary embolism without the need to routinely exclude the presence of deep vein thrombosis. Use of multidetector CTPA was associated with significant radiation exposure that potentially increases risk of secondary malignancies. This is particularly a concern for young women given the risk of breast cancer. Single photon emission tomography (SPECT) V/Q and modified diagnostic criteria for V/Q scan interpretation increased their diagnostic accuracy compared with V/Q scanning and offer nuclear medicine modalities that are alternatives to CTPA in at least some patients with suspected pulmonary embolism at a fraction of the risk of radiation exposure. Excluding low risk patients for pulmonary embolism as defined by clinical scoring systems and D-dimer testing would enhance the yield of diagnostic testing. SUMMARY Computed tomographic pulmonary angiography is the most reliable test for diagnosis of pulmonary embolism. However, diagnostic algorithms using V/Q scanning are safe and may be preferred in some patient populations.
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Stein PD, Matta F, Yaekoub AY, Kazerooni EA, Cahill JE, Goodman LR, Sostman HD, Hales CA, Denier JE, Weg JG, Ghumman D, Chan KM, Woodard PK, Kwun Y. CT Venous Phase Venography With 64-Detector CT Angiography in the Diagnosis of Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2009; 16:422-9. [DOI: 10.1177/1076029609335502] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The value of computed tomographic (CT) venography in combination with CT pulmonary angiography has been questioned because of the potential dangers of radiation. Accordingly, we retrospectively evaluated the diagnostic yield of 64-detector CT angiography with CT venography. Among patients who routinely underwent CT venography with CT angiography, the CT angiogram showed acute pulmonary embolism (PE) in 206 of 1903 patients (10.8%). A positive CT venogram in a patient with a negative CT angiogram was shown in 25 of 1903 patients (1.3%). Either the CT angiogram or the CT venogram showed venous thromboembolism in 231 of 1903 patients (12.1%). The proportion of patients with venous thromboembolism diagnosed only by a CT venogram was 25 of 231 (10.8%). In conclusion, the proportion of patients with venous thromboembolism diagnosed only by a CT venogram is sufficiently high to merit consideration of its use especially in those at high risk for DVT.
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Affiliation(s)
- Paul D. Stein
- Department of Medicine, Wayne State University, Detroit, Michigan, , Department of Research, St Joseph Mercy Oakland Hospital, Pontiac, Michigan
| | - Fadi Matta
- Department of Research, St Joseph Mercy Oakland Hospital, Pontiac, Michigan
| | - Abdo Y. Yaekoub
- Department of Research, St Joseph Mercy Oakland Hospital, Pontiac, Michigan
| | - Ella A. Kazerooni
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Jennifer Ellis Cahill
- Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | | | - H. Dirk Sostman
- Weill Cornell Medical College and Methodist Hospital, Houston, Texas
| | - Charles A. Hales
- Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - James E. Denier
- Department of Research, St Joseph Mercy Oakland Hospital, Pontiac, Michigan
| | - John G. Weg
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Dilraj Ghumman
- Department of Research, St Joseph Mercy Oakland Hospital, Pontiac, Michigan
| | - Kevin M. Chan
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | | | - Yoojin Kwun
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
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64-MDCT pulmonary angiography and CT venography in the diagnosis of thromboembolic disease. AJR Am J Roentgenol 2009; 192:654-61. [PMID: 19234261 DOI: 10.2214/ajr.07.3939] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The purpose of our study was to investigate whether CT venography (CTV) performed after CT pulmonary angiography (CTPA) using 64-MDCT provides additional findings in the diagnosis of thromboembolic disease. MATERIALS AND METHODS Three hundred six consecutive patients in whom pulmonary embolism (PE) was clinically suspected were included in the study. The study group was classified according to the diagnostic quality of the CTPA examinations, the presence or absence of PE and deep venous thrombosis (DVT), and the most proximal localization that the embolus could lodge in the pulmonary artery. RESULTS The diagnostic quality of CTPA was insufficient in 5.9%, acceptable in 8.2%, and excellent in 85.9% of the patients. The diagnostic quality of CTV was insufficient in 11.4%, acceptable in 47.4%, and excellent in 41.2%. The percentages of nondiagnostic examinations for CTPA and CTV were 5.2% and 10.8%, respectively. Acute PE and acute DVT were observed in 25.2% and 18.0%, respectively. The percentage of subsegmental emboli among patients with acute PE was 15.6%. The percentage of patients with thromboembolic disease was 29.1%. Of patients who were diagnosed as having thromboembolic disease, 13.5% (12 of 89 patients) had DVT only. Of all patients, 3.9% (12 of 306) had only isolated DVT. The number of patients with subsegmental PE who had DVT was two (0.7% all patients). CONCLUSION As in MDCT scanning with a smaller number of slices, the combination of CTV with CTPA in 64-MDCT results in a small but definitive increase in the percentage of patients with a diagnosis of thromboembolic disease.
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Goodman LR, Sostman HD, Stein PD, Woodard PK. CT venography: a necessary adjunct to CT pulmonary angiography or a waste of time, money, and radiation? Radiology 2009; 250:327-30. [PMID: 19188309 DOI: 10.1148/radiol.2502081075] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Lawrence R Goodman
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI 53226-3596, USA.
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Great saphenous vein thrombosis causing acute pulmonary embolism suggested by combined CT venography and pulmonary angiography. Emerg Radiol 2008; 15:263-5. [DOI: 10.1007/s10140-007-0680-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2007] [Accepted: 10/15/2007] [Indexed: 10/22/2022]
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