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de Jong CMM, Kroft LJM, van Mens TE, Huisman MV, Stöger JL, Klok FA. Modern imaging of acute pulmonary embolism. Thromb Res 2024; 238:105-116. [PMID: 38703584 DOI: 10.1016/j.thromres.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 03/16/2024] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
The first-choice imaging test for visualization of thromboemboli in the pulmonary vasculature in patients with suspected acute pulmonary embolism (PE) is multidetector computed tomography pulmonary angiography (CTPA) - a readily available and widely used imaging technique. Through technological advancements over the past years, alternative imaging techniques for the diagnosis of PE have become available, whilst others are still under investigation. In particular, the evolution of artificial intelligence (AI) is expected to enable further innovation in diagnostic management of PE. In this narrative review, current CTPA techniques and the emerging technology photon-counting CT (PCCT), as well as other modern imaging techniques of acute PE are discussed, including CTPA with iodine maps based on subtraction or dual-energy acquisition, single-photon emission CT (SPECT), magnetic resonance angiography (MRA), and magnetic resonance direct thrombus imaging (MRDTI). Furthermore, potential applications of AI are discussed.
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Affiliation(s)
- C M M de Jong
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - L J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - T E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J L Stöger
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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2
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Kirsch J, Wu CC, Bolen MA, Henry TS, Rajiah PS, Brown RKJ, Galizia MS, Lee E, Rajesh F, Raptis CA, Rybicki FJ, Sams CM, Verde F, Villines TC, Wolf SJ, Yu J, Donnelly EF, Abbara S. ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update. J Am Coll Radiol 2022; 19:S488-S501. [PMID: 36436972 DOI: 10.1016/j.jacr.2022.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Carol C Wu
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Travis S Henry
- Panel Chair, Division Chief of Cardiothoracic Imaging, Duke University, Durham, North Carolina; Co-Director, ACR Education Center HRCT Course; Chair
| | | | - Richard K J Brown
- Vice Chair of Clinical Operations, Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Elizabeth Lee
- University of Michigan Health System, Ann Arbor, Michigan; Director M1Radiology Education University of Michigan Medical School; Associated Program Director Diagnostic Radiology Michigan Medicine; Director of Residency Education Cardiothoracic Division Michigan
| | - Fnu Rajesh
- MetroHealth Medical Center, Cleveland, Ohio; Primary care physician
| | | | | | | | - Franco Verde
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Stephen J Wolf
- Denver Health, Denver, Colorado; American College of Emergency Physicians; Director of Service for Emergency Medicine, Denver Health Medical Center, Denver Colorado; Co-Chair, American College of Emergency Physicians Clinical Policies Committee
| | - Jeannie Yu
- Deputy Chief of Medicine, VA Medical Center, University of California-Irvine, Irvine, California; Society for Cardiovascular Magnetic Resonance
| | - Edwin F Donnelly
- Specialty Chair, Ohio State University Wexner Medical Center, Columbus, Ohio; Ohio State University Medical Center: Chief of Thoracic Radiology, Interim Vice Chair of Academic Affairs, Department of Radiology
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
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3
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Kim HY, Kim KH, Kim J, Park JC. Multimodality cardiovascular imaging in pulmonary embolism. Cardiol J 2019; 28:150-160. [PMID: 31478557 DOI: 10.5603/cj.a2019.0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 11/25/2022] Open
Abstract
Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular (CV) morbidity and mortality. To select appropriate therapeutic strategy and/or to minimize the mortality and morbidity, rapid and correct identification of life-threatening APE is very important. Also, right ventricular (RV) failure usually precedes acute hemodynamic compromise or death, and thus the identification of RV failure is another important step in risk stratification or treatment of APE. With advances in diagnosis and treatment, the prognosis of APE has been dramatically improving in most cases, but inadequate therapy or recurrent episodes of pulmonary embolism (PE) may result in negative outcomes or, so called, chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a condition characterized by remaining chronic thromboembolic material in the pulmonary vasculature and subsequent chronic pulmonary hypertension. Various imaging modalities include chest computed tomography pulmonary angiography (CTPA), echocardiography, magnetic resonance imaging, and nuclear imaging and each are used for the assessment of varying status of PE. Assessment of thromboembolic burden by chest CTPA is the first step in the diagnosis of PE. Hemodynamic assessment can be achieved by echocardiography and also by chest CTPA. Nuclear imaging is useful in discriminating CTEPH from APE. Better perspectives on diagnosis, risk stratification and decision making in PE can be provided by combining multimodality CV imaging. Here, the advantages or pitfalls of each imaging modality in diagnosis, risk stratification, or management of PE will be discussed.
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Affiliation(s)
- Hyung Yoon Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kye Hun Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Jahae Kim
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Korea, Republic Of
| | - Jong Chun Park
- Chonnam National University Hospital, Gwangju, Republic of Korea
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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: 124] [Impact Index Per Article: 20.7] [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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5
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Kirsch J, Brown RKJ, Henry TS, Javidan-Nejad C, Jokerst C, Julsrud PR, Kanne JP, Kramer CM, Leipsic JA, Panchal KK, Ravenel JG, Shah AB, Mohammed TL, Woodard PK, Abbara S. ACR Appropriateness Criteria ® Acute Chest Pain-Suspected Pulmonary Embolism. J Am Coll Radiol 2018; 14:S2-S12. [PMID: 28473076 DOI: 10.1016/j.jacr.2017.02.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 01/08/2023]
Abstract
Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. Lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Jacobo Kirsch
- Principal Author, Cleveland Clinic, Weston, Florida.
| | | | - Travis S Henry
- University of California San Francisco, San Francisco, California
| | - Cylen Javidan-Nejad
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | | | | | - Jeffrey P Kanne
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Christopher M Kramer
- University of Virginia Health System, Charlottesville, Virginia; American College of Cardiology
| | | | | | - James G Ravenel
- Medical University of South Carolina, Charleston, South Carolina
| | - Amar B Shah
- Westchester Medical Center, Valhalla, New York
| | - Tan-Lucien Mohammed
- Specialty Chair, University of Florida College of Medicine, Gainesville, Florida
| | - Pamela K Woodard
- Specialty Chair, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Suhny Abbara
- Panel Chair, UT Southwestern Medical Center, Dallas, Texas
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6
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Abstract
Deep vein thrombosis and pulmonary embolism, collectively referred to as venous thromboembolism, constitute a major global burden of disease. The diagnostic work-up of suspected deep vein thrombosis or pulmonary embolism includes the sequential application of a clinical decision rule and D-dimer testing. Imaging and anticoagulation can be safely withheld in patients who are unlikely to have venous thromboembolism and have a normal D-dimer. All other patients should undergo ultrasonography in case of suspected deep vein thrombosis and CT in case of suspected pulmonary embolism. Direct oral anticoagulants are first-line treatment options for venous thromboembolism because they are associated with a lower risk of bleeding than vitamin K antagonists and are easier to use. Use of thrombolysis should be limited to pulmonary embolism associated with haemodynamic instability. Anticoagulant treatment should be continued for at least 3 months to prevent early recurrences. When venous thromboembolism is unprovoked or secondary to persistent risk factors, extended treatment beyond this period should be considered when the risk of recurrence outweighs the risk of major bleeding.
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Affiliation(s)
- Marcello Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, Gabriele D'Annunzio University, Chieti, Italy; Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands.
| | - Nick van Es
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
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Use of clinical prediction rules and D-dimer tests in the diagnostic management of pregnant patients with suspected acute pulmonary embolism. Blood Rev 2016; 31:31-36. [PMID: 27720446 DOI: 10.1016/j.blre.2016.09.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/16/2016] [Accepted: 09/26/2016] [Indexed: 12/18/2022]
Abstract
Because pregnant women have an increased risk of venous thromboembolism (VTE) and at the same time normal pregnancy is associated with symptoms, mimicking those present in the setting of acute pulmonary embolism (PE), the latter diagnosis is frequently suspected in this patient category. Since imaging tests expose both mother and foetus to ionizing radiation, the ability to rule out PE based on non-radiological diagnostic tests is of paramount importance. However, clinical decision rules have only been scarcely evaluated in the pregnant population with suspected PE, while D-dimer levels lose diagnostic accuracy due to a physiological increase during normal pregnancy. Consequently, clinical guidelines provide contradicting and weak recommendations on this subject and the optimal diagnostic strategy remains highly debated. With this systematic review, we aimed to summarize current evidence on the safety and efficacy of clinical decision rules and biomarkers used in the diagnostic management of suspected acute PE in pregnant patients.
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Osman AM, Abdeldayem EH, Osman NM. MR pulmonary angiography: Can it be used as an alternative for CT angiography in diagnosis of major pulmonary thrombosis? THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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9
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Abstract
Abstract
Because the clinical diagnosis of deep-vein thrombosis and pulmonary embolism is nonspecific, integrated diagnostic approaches for patients with suspected venous thromboembolism have been developed over the years, involving both non-invasive bedside tools (clinical decision rules and D-dimer blood tests) for patients with low pretest probability and diagnostic techniques (compression ultrasound for deep-vein thrombosis and computed tomography pulmonary angiography for pulmonary embolism) for those with a high pretest probability. This combination has led to standardized diagnostic algorithms with proven safety for excluding venous thrombotic disease. At the same time, it has become apparent that, as a result of the natural history of venous thrombosis, there are special patient populations in which the current standard diagnostic algorithms are not sufficient. In this review, we present 3 evidence-based patient cases to underline recent developments in the imaging diagnosis of venous thromboembolism.
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10
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Huisman MV, Klok FA. Current challenges in diagnostic imaging of venous thromboembolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2015; 2015:202-209. [PMID: 26637722 DOI: 10.1182/asheducation-2015.1.202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Because the clinical diagnosis of deep-vein thrombosis and pulmonary embolism is nonspecific, integrated diagnostic approaches for patients with suspected venous thromboembolism have been developed over the years, involving both non-invasive bedside tools (clinical decision rules and D-dimer blood tests) for patients with low pretest probability and diagnostic techniques (compression ultrasound for deep-vein thrombosis and computed tomography pulmonary angiography for pulmonary embolism) for those with a high pretest probability. This combination has led to standardized diagnostic algorithms with proven safety for excluding venous thrombotic disease. At the same time, it has become apparent that, as a result of the natural history of venous thrombosis, there are special patient populations in which the current standard diagnostic algorithms are not sufficient. In this review, we present 3 evidence-based patient cases to underline recent developments in the imaging diagnosis of venous thromboembolism.
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Affiliation(s)
- Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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12
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Huisman MV, Klok FA. Diagnostic management of acute deep vein thrombosis and pulmonary embolism. J Thromb Haemost 2013; 11:412-22. [PMID: 23294863 DOI: 10.1111/jth.12124] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute deep vein thrombosis (DVT) and pulmonary embolism (PE) represent two expressions of a similar clinical pathological process, often referred to as venous thromboembolism (VTE). It has long been recognized that, as clinical signs and symptoms of PE and DVT are not specific for the diagnosis, objective diagnosis in both patients presenting with leg symptoms and those with chest symptoms is mandatory. Since the last review on this subject in this journal in 2009, several large trials have been performed that shed new light on all aspects of the diagnostic management of suspected VTE, especially in the field of simplified clinical decision rules, age-dependent D-dimer cut-offs and magnetic resonance imaging. A literature search covering the period 2007-2012 was performed using the Medline/PubMed database to identify all relevant papers regarding the diagnostic management of acute PE and DVT. Established concepts and the latest evidence on this subject will be the main focus of this review.
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Affiliation(s)
- M V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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