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Chen F, Huang JG, Liu X, Zhou W. Left iliac vein involvement is a protective factor against symptomatic pulmonary embolism in lower left extremity deep vein thrombosis. J Vasc Surg Venous Lymphat Disord 2022; 10:1272-1278. [PMID: 35931360 DOI: 10.1016/j.jvsv.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/13/2022] [Accepted: 05/24/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Left iliac vein compression is associated with left iliac vein thrombosis (IVT), potentially limiting the migration of the thrombus from this stenotic segment to the pulmonary arteries. We sought to investigate the differences in clinical characteristics and risk factors of symptomatic pulmonary embolism (SPE) in patients with deep vein thrombosis (DVT) in different limbs and anatomical locations. METHODS A retrospective analysis was conducted of 1476 patients with acute unilateral lower extremity DVT. Differences of clinical characteristics and risk factors between left-sided and right-sided DVT, IVT, and non-IVT, cases with SPE and cases without SPE were compared. Risk factors for SPE were investigated using logistic regression analysis. RESULTS SPE was more common in patients with right-sided DVT than patients with left-sided DVT (13.8% vs 7.0%; P < .001). SPE incidence in left IVT (5.4%) was lower than that in left non-IVT, right IVT, and right non-IVT (12.8%, 10.1%, 16.6%, respectively; P < .001). There was no difference in SPE incidence among patients with left non-IVT, right IVT and right non-IVT (P > .05). In patients with left-sided DVT, male sex was associated with an increased odds of SPE (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.10-2.85; P = .02). IVT, surgery, and immobilization were associated with a decreased odds of SPE (OR, 0.46 [95% CI, 0.28-0.76; P < .01]; OR, 0.55 [95% CI, 0.32-0.95; P = .03]; and OR, 0.53 [95% CI, 0.32-0.86; P = .01]). In patients with right-sided DVT, provoked DVT was associated with a decreased odds of SPE (OR, 0.50; 95% CI, 0.27-0.93; P = .03). CONCLUSIONS Left IVT is associated with a lower SPE incidence than right-sided DVT. Left IVT and may be a relative protective factor against SPE.
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Affiliation(s)
- Feng Chen
- Department of Vascular and Interventional Radiology, the second affiliated Hospital, Nanchang University, Nanchang, China.
| | - Jian Gang Huang
- Department of Gynaecology, Longyan First Hospital, Fujian Medical University, Longyan, China
| | - Xing Liu
- Department of General Surgery, People's Hospital of Nanchang County, Nanchang, China
| | - Wei Zhou
- Department of Vascular and Interventional Radiology, the second affiliated Hospital, Nanchang University, Nanchang, China
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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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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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Mityul M, Kim DJ, Salter A, Yano M. CT IVC venogram: normalized quantitative criteria for patency and thrombosis. Abdom Radiol (NY) 2019; 44:2262-2267. [PMID: 30788557 DOI: 10.1007/s00261-019-01940-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Establish normal attenuation ratios for vein to artery on CT IVC venogram and determine a vascular attenuation ratio diagnostic of thrombus. METHODS This retrospective, HIPAA-compliant study included 56 CT IVC venograms. Images were reviewed for the presence of femoral vein or IVC thrombus. Attenuation ratios for each vein and its corresponding artery were calculated by two observers and averaged in four venous stations (right and left femoral veins, and IVC at the confluence of the iliac veins and at the left renal vein). The reference standard for the absence of thrombus was clinical follow-up and for the presence of thrombus it was thrombectomy or catheter venogram. Receiver operating characteristic (ROC) analysis was performed using ratios from one venous station and threshold for thrombus was determined using the Youden's index. RESULTS 36 of 56 CTs demonstrated no thrombus. 20 CTs demonstrated thrombus, confirmed in eight patients. For CTs with no thrombus, median ratios among the venous stations ranged from 0.89 (IQR 0.83-0.93) to 0.91 (IQR 0.86-0.94). ROC analysis of ratios from a single representative station (left femoral vein, n = 4 confirmed clots) demonstrated an area under the curve (AUC) of 0.994 (p = 0.001) and a threshold of 0.67 for diagnosing thrombus [sensitivity 100% (95% CI 39.76-100%), specificity 97.5% (86.84-99.94%)]. CONCLUSION The normal attenuation ratio of vein to artery in the absence of venous thrombus on a 3-min delay CT IVC venogram is approximately 0.91. A ratio less than 0.67 is highly suggestive of thrombus.
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Affiliation(s)
- Marina Mityul
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Campus Box 8131, 510 S. Kingshighway Blvd, St Louis, MO, 63110, USA
| | - David J Kim
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Campus Box 8131, 510 S. Kingshighway Blvd, St Louis, MO, 63110, USA
| | - Amber Salter
- Division of Biostatistics, Washington University School of Medicine, Campus Box 8067, 660 Euclid Ave., St Louis, MO, 63110-1093, USA
| | - Motoyo Yano
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Campus Box 8131, 510 S. Kingshighway Blvd, St Louis, MO, 63110, USA.
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Hanley M, Steigner ML, Ahmed O, Azene EM, Bennett SJ, Chandra A, Desjardins B, Gage KL, Ginsburg M, Mauro DM, Oliva IB, Ptak T, Strax R, Verma N, Dill KE. ACR Appropriateness Criteria® Suspected Lower Extremity Deep Vein Thrombosis. J Am Coll Radiol 2018; 15:S413-S417. [DOI: 10.1016/j.jacr.2018.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Tilve-Gómez A, Rodríguez-Fernández P, Trillo-Fandiño L, Plasencia-Martínez JM. Imaging techniques used in the diagnostic workup of acute venous thromboembolic disease. RADIOLOGIA 2016; 59:329-342. [PMID: 27986265 DOI: 10.1016/j.rx.2016.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 09/09/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Early diagnosis is one of the most important factors affecting the prognosis of pulmonary embolism (PE); however, the clinical presentation of PE is often very unspecific and it can simulate other diseases. For these reasons, imaging tests, especially computed tomography angiography (CTA) of the pulmonary arteries, have become the keystone in the diagnostic workup of PE. The wide availability and high diagnostic performance of pulmonary CTA has led to an increase in the number of examinations done and a consequent increase in the population's exposure to radiation and iodinated contrast material. Thus, other techniques such as scintigraphy and venous ultrasonography of the lower limbs, although less accurate, continue to be used in certain circumstances, and optimized protocols have been developed for CTA to reduce the dose of radiation (by decreasing the kilovoltage) and the dose of contrast agents. We describe the technical characteristics and interpretation of the findings for each imaging technique used to diagnose PE and discuss their advantages and limitations; this knowledge will help the best technique to be chosen for each case. Finally, we comment on some data about the increased use of CTA, its clinical repercussions, its "overuse", and doubts about its cost-effectiveness.
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Affiliation(s)
- A Tilve-Gómez
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España.
| | - P Rodríguez-Fernández
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España
| | - L Trillo-Fandiño
- Servicio de Radiodiagnóstico, IISGS, XXIV, Hospital Álvaro Cunqueiro, Vigo (Pontevedra), España
| | - J M Plasencia-Martínez
- Servicio de Radiodiagnóstico, Hospital General Universitario José María Morales Meseguer, Murcia, España
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7
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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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9
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Levin D, Seo JB, Kiely DG, Hatabu H, Gefter W, van Beek EJR, Schiebler ML. Triage for suspected acute Pulmonary Embolism: Think before opening Pandora's Box. Eur J Radiol 2015; 84:1202-11. [PMID: 25864020 DOI: 10.1016/j.ejrad.2015.03.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/26/2015] [Accepted: 03/23/2015] [Indexed: 12/22/2022]
Abstract
This is a review of the current strengths and weaknesses of the various imaging modalities available for the diagnosis of suspected non-massive Pulmonary Embolism (PE). Without careful consideration for the clinical presentation, and the timely application of clinical decision support (CDS) methodology, the current overutilization of imaging resources for this disease will continue. For a patient with a low clinical risk profile and a negative D-dimer there is no reason to consider further workup with imaging; as the negative predictive value in this scenario is the same as imaging. While the current efficacy and effectiveness data support the continued use of Computed Tomographic angiography (CTA) as the imaging golden standard for the diagnosis of PE; this test does have the unintended consequences of radiation exposure, possible overdiagnosis and overuse. There is a persistent lack of appreciation on the part of ordering physicians for the effectiveness of the alternatives to CTA (ventilation-perfusion imaging and contrast enhanced magnetic resonance angiography) in these patients. Careful use of standardized protocols for patient triage and the application of CDS will allow for a better use of imaging resources.
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Affiliation(s)
- David Levin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Joon Beom Seo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, M-15, M-Floor, Royal Hallamshire Hospital, Sheffield, UK
| | - Hiroto Hatabu
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School Boston, MA, USA
| | - Warren Gefter
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Mark L Schiebler
- Department of Radiology, UW-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792-3252, USA.
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10
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Sivananthan G, Halin NJ, Estes JM, Alessi-Chinetti JM, Polak JF. Value of complete full-length lower extremity sonography in patients undergoing computed tomographic pulmonary angiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:2137-2143. [PMID: 25425370 DOI: 10.7863/ultra.33.12.2137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the diagnostic yield of complete lower extremity venous sonography for diagnosing deep venous thrombosis (DVT) in patients undergoing computed tomographic (CT) pulmonary angiography for suspected pulmonary embolism (PE). METHODS We retrospectively reviewed all cases of lower extremity venous sonography and CT pulmonary angiography performed within 1 day of each other (n = 147) in a tertiary care center. Indications for the studies performed, angiographic findings, sonographic findings, age, sex, inpatient/outpatient status, lower extremity symptoms, and treatment status were recorded. Prevalence rates and patient characteristics were compared by χ(2) and Fisher exact probability tests where appropriate. Multivariable logistic regression with acute PE as the outcome was performed for age, sex, interval between angiography and sonography, indication for angiography, inpatient/outpatient status, and venous sonographic findings. RESULTS The prevalence of PE (23.8%) was similar to the prevalence of DVT (27.9%). Angiographic findings were not associated with the interval between angiography and sonography or inpatient/outpatient status. Acute DVT was more likely (P = .0009) when angiographic findings were positive (51.4%), but DVT prevalence was still substantial (20.5%) in patients with negative angiographic findings. Lower extremity symptoms were not associated with DVT in cases with negative angiographic findings (P = .48). Eighteen of the 23 patients with acute DVT and negative angiographic findings were treated. CONCLUSIONS There is a high rate of DVT in a population undergoing CT pulmonary angiography for suspected PE even when PE is not diagnosed. Our data apply to a tertiary care institution, suggest a surveillance bias, and favor the utility of venous sonography in this population.
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Affiliation(s)
- Gajan Sivananthan
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA.
| | - Neil J Halin
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - James M Estes
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - Jean M Alessi-Chinetti
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - Joseph F Polak
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
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11
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Pham AD, Névéol A, Lavergne T, Yasunaga D, Clément O, Meyer G, Morello R, Burgun A. Natural language processing of radiology reports for the detection of thromboembolic diseases and clinically relevant incidental findings. BMC Bioinformatics 2014; 15:266. [PMID: 25099227 PMCID: PMC4133634 DOI: 10.1186/1471-2105-15-266] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 07/19/2014] [Indexed: 12/21/2022] Open
Abstract
Background Natural Language Processing (NLP) has been shown effective to analyze the content of radiology reports and identify diagnosis or patient characteristics. We evaluate the combination of NLP and machine learning to detect thromboembolic disease diagnosis and incidental clinically relevant findings from angiography and venography reports written in French. We model thromboembolic diagnosis and incidental findings as a set of concepts, modalities and relations between concepts that can be used as features by a supervised machine learning algorithm. A corpus of 573 radiology reports was de-identified and manually annotated with the support of NLP tools by a physician for relevant concepts, modalities and relations. A machine learning classifier was trained on the dataset interpreted by a physician for diagnosis of deep-vein thrombosis, pulmonary embolism and clinically relevant incidental findings. Decision models accounted for the imbalanced nature of the data and exploited the structure of the reports. Results The best model achieved an F measure of 0.98 for pulmonary embolism identification, 1.00 for deep vein thrombosis, and 0.80 for incidental clinically relevant findings. The use of concepts, modalities and relations improved performances in all cases. Conclusions This study demonstrates the benefits of developing an automated method to identify medical concepts, modality and relations from radiology reports in French. An end-to-end automatic system for annotation and classification which could be applied to other radiology reports databases would be valuable for epidemiological surveillance, performance monitoring, and accreditation in French hospitals.
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Affiliation(s)
- Anne-Dominique Pham
- Department of Biostatistics and Clinical Research, CHU de Caen, Caen F-14000, France.
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Watanabe H, Kanematsu M, Kondo H, Tomimatsu H, Sakurai K, Goshima S, Kawada H, Noda Y, Miyoshi T. Whole-body CT screening: scan delay and contrast injection duration for optimal enhancement of abdominal organs and deep vessels. Clin Imaging 2014; 38:129-35. [PMID: 24387919 DOI: 10.1016/j.clinimag.2013.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/23/2013] [Accepted: 11/25/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess the optimal scan delays and contrast injection durations for contrast-enhanced whole-body computed tomography (CT). MATERIALS AND METHODS One hundred forty-two patients were randomized into three groups: protocol A-scan delay of 65 s after starting contrast injection over 30 s; protocol B-105 and 70 s; and protocol C-145 and 110 s, respectively. Contrast enhancement and diagnostic acceptability were assessed. RESULTS Qualitative assessment was subtle among the three protocols. Homogenous enhancement of deep veins was more assuredly achieved with protocol C. CONCLUSION With protocol C, qualitatively acceptable enhancement can be obtained in whole-body CT.
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Affiliation(s)
- Haruo Watanabe
- Department of Radiology, Gifu Central Hospital, 3-25 Kawabe, 501-1198, Gifu, Japan; Department of Radiology, Gifu University Hospital, Gifu, Japan.
| | - Masayuki Kanematsu
- Department of Radiology, Gifu University Hospital, Gifu, Japan; Radiology Services, Gifu University Hospital, Gifu, Japan
| | - Hiroshi Kondo
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | | | - Kota Sakurai
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Satoshi Goshima
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Hiroshi Kawada
- Department of Radiology, Gifu University Hospital, Gifu, Japan
| | - Yoshifumi Noda
- Department of Radiology, Gifu University Hospital, Gifu, Japan
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Li F, Wang X, Huang W, Ren W, Cheng J, Zhang M, Zhao Y. Risk factors associated with the occurrence of silent pulmonary embolism in patients with deep venous thrombosis of the lower limb. Phlebology 2013; 29:442-6. [PMID: 23761869 DOI: 10.1177/0268355513487331] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of our study is to investigate the prevalence of silent pulmonary embolism in patients with deep venous thrombosis in the lower limbs and to evaluate the associated risk factors. METHODS A total of 322 patients with acute deep venous thrombosis confirmed by CT venography or Doppler ultrasonography were studied. The diagnosis of silent pulmonary embolism was established by computed tomography pulmonary arteriography (CTPA). The association between covariates and the prevalence of silent pulmonary embolism in patients with deep venous thrombosis in lower limbs were assessed using chi-square test and multivariable regression. RESULTS The incidence of silent pulmonary embolism was 33.5% (108 in 322 patients) in all patients with deep venous thrombosis in lower limbs. Chi-square test showed male gender, the right lower limb, proximal location of the thrombus, unprovoked venous thrombosis and coexisting heart diseases were related to a higher incidence of silent pulmonary embolism in patients with deep venous thrombosis in lower limbs. The multivariate regression analysis confirmed that the risk factors associated with silent pulmonary embolism in deep venous thrombosis patients included the right side and proximal location of the thrombus (odds ratio: 2.023, 95% CI: 1.215-3.368; odds ratio: 3.610, 95% CI: 1.772-7.354), unprovoked venous thrombosis (odds ratio: 2.037, 95% CI: 1.188-3.493), coexisting heart diseases (odds ratio: 4.507, 95% CI: 2.667-7.618). CONCLUSION Silent pulmonary embolism occurred frequently in patients with deep venous thrombosis in lower limbs. The right side, the proximal location of the thrombus, unprovoked venous thrombosis and coexisting heart diseases increased the risk for the occurrence of silent pulmonary embolism.
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Affiliation(s)
- Fenghe Li
- Department of Vascular Sugery, 1st Hospital of Chongqing Medical University, Chongqing, China
| | - Xuehu Wang
- Department of Vascular Sugery, 1st Hospital of Chongqing Medical University, Chongqing, China
| | - Wen Huang
- Department of Vascular Sugery, 1st Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Ren
- Department of Vascular Sugery, 1st Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Cheng
- Department of Radialogy, 1st Hospital of Chongqing Medical University, Chongqing, China
| | - Mao Zhang
- Department of Vascular Sugery, 1st Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhao
- Department of Vascular Sugery, 1st Hospital of Chongqing Medical University, Chongqing, China
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Vascular Enhancement and Image Quality of CT Venography: Comparison of Standard and Low Kilovoltage Settings. AJR Am J Roentgenol 2011; 197:838-43. [DOI: 10.2214/ajr.10.5424] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Konstantinides S. A New Method to Diagnose Pulmonary Embolism: David against Goliath(s). Am J Respir Crit Care Med 2011; 184:626-7. [DOI: 10.1164/rccm.201106-1114ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Slater S, Oswal D, Bhartia B. A retrospective study of the value of indirect CT venography: a British perspective. Br J Radiol 2011; 85:917-20. [PMID: 21896661 DOI: 10.1259/bjr/28355108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The aim of this study was to establish the value of indirect CT venography (CTV) in clinical practice within the UK. METHODS 804 combined CT pulmonary angiogram and CTV studies were retrospectively reviewed. CTV was performed 180 s after the injection of contrast using an incremental technique with a 5-mm collimation and a 5-cm interspace between images extending from the iliac crests to the tibial plateaus. RESULTS 12.9% of studies had isolated pulmonary emboli (PE), 3.0% had both a PE and deep vein thrombosis (DVT) and 1.1% had an isolated DVT. The proportion of positive cases diagnosed by CTV alone was 6.6%. CONCLUSION In a UK-based practice, the incidence and the proportion of isolated DVT diagnosed by CTV are lower than expected from published data. An analysis of possible causes for this is made within the paper.
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Affiliation(s)
- S Slater
- Department of Radiology, Leeds Teaching Hospital NHS Trust, Leeds, UK
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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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Reichert M, Henzler T, Krissak R, Apfaltrer P, Huck K, Buesing K, Sueselbeck T, Schoenberg SO, Fink C. Venous thromboembolism: additional diagnostic value and radiation dose of pelvic CT venography in patients with suspected pulmonary embolism. Eur J Radiol 2011; 80:50-3. [PMID: 21497470 DOI: 10.1016/j.ejrad.2010.12.101] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 12/29/2010] [Indexed: 12/01/2022]
Abstract
PURPOSE To assess the additional diagnostic value of indirect CT venography (CTV) of the pelvis and upper thighs performed after pulmonary CT angiography (CTA) for the diagnosis of venous thromboembolism (VTE). MATERIALS AND METHODS In a retrospective analysis, the radiology information system entries between January 2003 and December 2007 were searched for patients who received pulmonary CTA and additional CTV of the pelvis and upper thighs. Of those patients, the radiology reports were reviewed for the diagnosis of pulmonary embolism (PE) and deep venous thrombosis (DVT) in the pelvic veins and veins of the upper thighs. In cases with an isolated pelvic thrombosis at CTV (i.e. which only had a thrombosis in the pelvic veins but not in the veins of the upper thigh) ultrasound reports were reviewed for the presence of DVT of the legs. The estimated radiation dose was calculated for pulmonary CTA and for CTV of the pelvis. RESULTS In the defined period 3670 patients were referred to our institution for exclusion of PE. Of those, 642 patients (353 men, 289 women; mean age, 65±15 years, age range 18-98 years) underwent combined pulmonary CTA and CTV. Among them, PE was found in 227 patients (35.4%). In patients without PE CTV was negative in all cases. In patients with PE, CTV demonstrated pelvic thrombosis in 24 patients (3.7%) and thrombosis of the upper thighs in 43 patients (6.6%). Of those patients 14 (2.1%) had DVT in the pelvis and upper thighs. In 10 patients (1.5%) CTV showed an isolated pelvic thrombosis. Of those patients ultrasound reports were available in 7 patients, which revealed DVT of the leg veins in 5 cases (1%). Thus, the estimated prevalence of isolated pelvic thrombosis detected only by pelvic CTV ranges between 1-5/642 patients (0.1-0.7%). Radiation dose ranges between 4.8 and 9.7 mSv for additional CTV of the pelvis. CONCLUSION CTV of the pelvis performed after pulmonary CTA is of neglectable additional diagnostic value for the detection of VTE, because the additional radiation dose is high and isolated pelvic DVT is very rare. Venous imaging of the legs (preferably by radiation-free ultrasound) is sufficient for the diagnosis of underlying DVT in patients with suspected PE.
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Affiliation(s)
- Miriam Reichert
- Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim - Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany.
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van Langevelde K, Tan M, Srámek A, Huisman MV, de Roos A. Magnetic resonance imaging and computed tomography developments in imaging of venous thromboembolism. J Magn Reson Imaging 2011; 32:1302-12. [PMID: 21105136 DOI: 10.1002/jmri.22379] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Venous thromboembolism (VTE) is a disease that causes high morbidity and mortality in the population. At present the first-line imaging test for a suspected pulmonary embolism (PE) is computed tomography (CT) pulmonary angiography, and ultrasonography is widely used for the diagnosis of deep-vein thrombosis (DVT). Although these modalities are proven to be safe and accurate, unresolved issues remain, such as whether CT scanning in patients with a suspected PE should be extended to the legs. Another issue is the diagnosis of recurrent DVT. Magnetic resonance imaging (MRI) offers a number of advantages in the imaging of VTE. Recent developments of scanning protocols with shorter acquisition times, sometimes complemented by navigator gating or making use of endogenous contrast, offer new perspectives for the use of MRI. This review provides an overview of state of the art MRI techniques for the diagnosis of PE and DVT. Furthermore, the use of new contrast agents such as fibrin labeling to detect thrombi are addressed.
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Affiliation(s)
- Kirsten van Langevelde
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
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20
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Hunsaker AR, Lu MT, Goldhaber SZ, Rybicki FJ. Imaging in acute pulmonary embolism with special clinical scenarios. Circ Cardiovasc Imaging 2010; 3:491-500. [PMID: 20647583 DOI: 10.1161/circimaging.109.855981] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andetta R Hunsaker
- Applied Imaging Science Laboratory, the Thoracic Imaging Section, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Abstract
Pulmonary embolism (PE) is a frequently occurring, acute, and potentially fatal condition. Numerous risk factors for PE, both inherited and acquired, have been identified. Adequate diagnosis is mandatory to prevent PE-related morbidity and mortality on the one hand, and unnecessary treatment on the other. Only around 1 in 5 individuals with suspected PE will have the diagnosis confirmed, therefore, the diagnostic work-up for PE should comprise safe, efficient, and noninvasive methods. The first step in the approach to diagnosis of patients with suspected PE is to determine the clinical probability and to perform a D-dimer test. PE can be excluded in patients with a 'low', 'intermediate' or 'unlikely' clinical probability and a normal D-dimer test. Additional imaging is required for those with a 'high' or 'likely' clinical probability or a positive D-dimer test. CT pulmonary angiography or ventilation-perfusion scintigraphy, followed by additional testing is the next step when test results are nondiagnostic. Although various diagnostic strategies have been introduced and validated, selected patients may require a tailored approach.
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Affiliation(s)
- Renée A Douma
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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22
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Frequency of Use of Imaging Tests in the Diagnosis of Pulmonary Embolism: Effects of Physician Specialty, Patient Characteristics, and Region. AJR Am J Roentgenol 2010; 194:1018-26. [DOI: 10.2214/ajr.09.3215] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, Berrington de González A, Miglioretti DL. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. ARCHIVES OF INTERNAL MEDICINE 2009; 169:2078-86. [PMID: 20008690 PMCID: PMC4635397 DOI: 10.1001/archinternmed.2009.427] [Citation(s) in RCA: 1650] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Use of computed tomography (CT) for diagnostic evaluation has increased dramatically over the past 2 decades. Even though CT is associated with substantially higher radiation exposure than conventional radiography, typical doses are not known. We sought to estimate the radiation dose associated with common CT studies in clinical practice and quantify the potential cancer risk associated with these examinations. METHODS We conducted a retrospective cross-sectional study describing radiation dose associated with the 11 most common types of diagnostic CT studies performed on 1119 consecutive adult patients at 4 San Francisco Bay Area institutions in California between January 1 and May 30, 2008. We estimated lifetime attributable risks of cancer by study type from these measured doses. RESULTS Radiation doses varied significantly between the different types of CT studies. The overall median effective doses ranged from 2 millisieverts (mSv) for a routine head CT scan to 31 mSv for a multiphase abdomen and pelvis CT scan. Within each type of CT study, effective dose varied significantly within and across institutions, with a mean 13-fold variation between the highest and lowest dose for each study type. The estimated number of CT scans that will lead to the development of a cancer varied widely depending on the specific type of CT examination and the patient's age and sex. An estimated 1 in 270 women who underwent CT coronary angiography at age 40 years will develop cancer from that CT scan (1 in 600 men), compared with an estimated 1 in 8100 women who had a routine head CT scan at the same age (1 in 11 080 men). For 20-year-old patients, the risks were approximately doubled, and for 60-year-old patients, they were approximately 50% lower. CONCLUSION Radiation doses from commonly performed diagnostic CT examinations are higher and more variable than generally quoted, highlighting the need for greater standardization across institutions.
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Burnside PR, Green E, Kline JA. Indirect computed tomography venography: a report of vascular opacification. Emerg Radiol 2009; 17:195-201. [DOI: 10.1007/s10140-009-0831-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 08/12/2009] [Indexed: 10/20/2022]
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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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Affiliation(s)
- Stavros Konstantinides
- Department of Cardiology and Pulmonology, Georg August University of Göttingen, Göttingen, Germany.
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