Angiography For Acute Pulmonary Embolism Research Articles

Ordinal Scoring of Coronary Artery Calcification by Computed Tomography Pulmonary Angiography in Acute Pulmonary Embolism.

To assess coronary artery calcification (CAC) in patients with acute pulmonary embolism and determine whether this correlates with right ventricular dilation (RVD) and mortality. Computed tomography pulmonary angiography scans of 330 patients were used to perform retrospective assessment of the pulmonary artery computed tomography obstruction index (PACTOI), the right/left ventricle diameter ratio, the diameter of the pulmonary trunk, and the ordinal CAC score. Age (P < 0.001), urea level (P < 0.001), D-dimer level (P = 0.006), diameter of the pulmonary trunk (P < 0.001), and PACTOI (P < 0.001) were significantly higher in the RVD-positive patient group. We found a significant relation between increased CAC score and increased mortality (P = 0.038). Left-sided CAC was detected much more often in RVD-positive patients (P = 0.008). Coronary artery calcification is common in patients with acute pulmonary embolism, especially when those patients are also RVD-positive. A significant relation was found between RVD and left-sided CAC.

Evaluation of the Benefit of Extended Catheter-Directed Thrombolysis with Serial Angiography for Acute Pulmonary Embolism

PurposeTo evaluate whether extended catheter-directed thrombolysis (CDT) with repeat visits to the angiography suite provide added benefit in treatment of acute pulmonary embolism (PE). Materials and MethodsThis was a retrospective review of CDT procedures performed for acute PE in 156 patients (age 56.1 y ± 15.3, 46.2% women) between 2009 and 2019. All patients underwent at least 1 follow-up visit to the angiography suite for evaluation of pulmonary artery pressure (PAP) and thrombus burden (Miller score) before termination (111/156, 71.2%) or continuation of CDT (45/156, 28.8%). ResultsPatients who had CDT extended beyond the first follow-up visit required a higher total dose of tissue plasminogen activator (40.7 mg ± 14.3 vs 22.6 mg ± 9.9, P < .001) to achieve a similar final Miller score (6.4 ± 3.8 vs 7.6 ± 3.9, P = .1) and a similar reduction in systolic PAP (−14.4 mm Hg ± 10.2 vs −12.6 mm Hg ± 11.9, P = .6). The initial Miller scores were similar in both groups (19.7 ± 5.8 vs 19 ± 4, P = .4) but were significantly higher during the first follow-up visit (after 18 hours ± 5.5 vs 20 hours ± 4.8, P = .06) in patients requiring multiple follow-up visits (12.2 ± 5 vs 7.6 ± 3.9, P < .001). Multiple regression analyses identified heart rate > 100 beats/min and systolic PAP > 55 mm Hg as associated with the need for extended CDT. Extended CDT did not result in a higher hemorrhagic complication rate (1/45 vs 6/111, P = .7). ConclusionsPatients presenting with higher heart rates and systolic PAP may benefit from extended CDT to achieve similar reductions in PAP and thrombus burden, without clear added risk of hemorrhage.

Postcontrast Acute Kidney Injury After Computed Tomography Pulmonary Angiography for Acute Pulmonary Embolism.

Despite the widespread use of computed tomography pulmonary angiography with contrast media for the diagnosis of acute pulmonary embolism, high-quality evidence on risk factors for postcontrast acute kidney injury related to its use is lacking. The present study aimed to investigate whether the level of estimated glomerular filtration rate observed in the emergency department (ED) is significantly associated with the occurrence of postcontrast acute kidney injury in patients undergoing computed tomography pulmonary angiography. We performed a retrospective observational study using data automatically collected by a clinical data retrieval system from 1300 patients who underwent computed tomography pulmonary angiography for suspected acute pulmonary embolism in the ED. A total of 632 patients were selected for the study after exclusion. Univariate analyses were performed to identify significant risk factors for postcontrast acute kidney injury (the primary outcome). Multivariate logistic regression analysis was used to confirm the effect of estimated glomerular filtration rate in the ED on the occurrence of postcontrast acute kidney injury after adjustment for confounding variables. The total incidence rate of postcontrast acute kidney injury was 6.49% (41/632 patients). No statistically significant association between estimated glomerular filtration rate and the risk of postcontrast acute kidney injury was observed. Our study findings could serve as useful reference for physicians who are concerned about performing computed tomography pulmonary angiography for fear of renal function deterioration.

Computed tomography pulmonary angiography for acute pulmonary embolism: prediction of adverse outcomes and 90-day mortality in a single test.

PurposePulmonary embolism (PE) is a potentially fatal cardiopulmonary disease; therefore, rapid risk stratification is necessary to make decisions of appropriate management strategies. The aim of this study was to assess various computed tomography (CT) findings in order to find new prognostic factors of adverse outcome and mortality.Material and methodsThe study enrolled 104 patients with acute PE. Based on their outcome, patients were categorised into four groups. Comorbidities such as ischaemic heart disease were obtained from their medical records. Patients CT angiography were reviewed for recording variables such as main pulmonary artery diameter and right ventricle (RV)/left ventricle (LV) ratio. Patient deaths up to three months since diagnosis of PE had been registered. Logistic regression analysis was performed to find predictors.ResultsBased on multiple logistic regression, RV/LV ratio, LV diameter, and right-sided pulmonary infarction are predictors of mortality in 30 days. An RV/LV ratio of 1.19 could successfully discriminate patients who died within 30 days and those who did not.ConclusionsRV/LV ratio, LV diameter, right-sided pulmonary infarction, assessed with helical CT, can help predict 30-day mortality.

Pulmonary Artery Obstruction Index and Right Ventricular Dysfunction Signs in Initial and Follow up Pulmonary Computed Tomography Angiography in Acute Pulmonary Embolism.

Acute Pulmonary Embolism (APE) increases the pressure of the pulmonary arterial system with resulting Right Ventricle Dysfunction (RVD). The aim of this study was to evaluate the relationship between Pulmonary Artery Obstruction Index (PAOI) and signs of right heart dysfunction with computed tomography angiography in APE patients. We evaluated 72 consecutive patients (mean age 64.1±16.9 years; 59.7% female) with APE who had initial echocardiography with computed tomography angiography. Among these 72 patients, only 25 (34.7%) patients had follow up computed tomography angiography images and we evaluate right heart dysfunction with PAOI and Right Ventricle (RV) diameter. In 72 patients with APE, PAOI and RVD signs were significantly high. Twenty five of these 72 patients (34.7%) had follow up computed tomography angiography images and among those 25 patients, there was correlation between reduction of PAOI and RV diameter in follow up period. PAOI and RVD signs in initial computed tomography angiography and in follow up computed tomography angiography can be used in the management of Pulmonary Embolism (PE) patients.

State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism.

Pulmonary CT angiography (CTA) is the imaging modality of choice in suspected acute pulmonary embolism (PE). Current pulmonary CTA techniques involve ever lower doses of contrast medium and radiation along with advanced postprocessing applications to enhance image quality, diagnostic accuracy, and provide added value in patient management. The objective of this article is to summarize these current developments and discuss the appropriate use of state-of-the-art pulmonary CTA. Pulmonary CTA is well established as a fast and reliable means of excluding or diagnosing PE. Continued developments in CT system hardware and postprocessing techniques will allow incremental reductions in radiation and contrast material requirements while improving image quality. Advances in risk stratification and prognostication from pulmonary CTA examinations should further refine its clinical value while minimizing the potential harm from overutilization and overdiagnosis.

Diagnostic accuracy of magnetic resonance angiography for acute pulmonary embolism - a systematic review and meta-analysis.

The aim of this meta-analysis was to evaluate the diagnostic accuracy of magnetic resonance angiography (MRA) for acute pulmonary embolism (PE). A systematic literature search was conducted that included studies from January 2000 to August 2015 using the electronic databases PubMed, Embase and Springer link. The summary receiver operating characteristic (SROC) curve, sensitivity, specificity, positive likelihood ratios (PLR), negative likelihood ratios (NLR), and diagnostic odds ratio (DOR) as well as the 95 % confidence intervals (CIs) were calculated to evaluate the diagnostic accuracy of MRA for acute PE. Meta-disc software version 1.4 was used to analyze the data. Five studies were included in this meta-analysis. The pooled sensitivity (86 %, 95 % CI: 81 % to 90 %) and specificity (99 %, 95 % CI: 98 % to 100 %) demonstrated that MRA diagnosis had limited sensitivity and high specificity in the detection of acute PE. The pooled estimate of PLR (41.64, 95 % CI: 17.97 to 96.48) and NLR (0.17, 95 % CI: 0.11 to 0.27) provided evidence for the low missed diagnosis and misdiagnosis rates of MRA for acute PE. The high diagnostic accuracy of MRA for acute PE was demonstrated by the overall DOR (456.51, 95 % CI: 178.38 - 1168.31) and SROC curves (AUC = 0.9902 ± 0.0061). MRA can be used for the diagnosis of acute PE. However, due to limited sensitivity, MRA cannot be used as a stand-alone test to exclude acute PE.

Computed Tomography Pulmonary Angiography in Acute Pulmonary Embolism

To assess the effect of computer-assisted detection (CAD) on diagnostic accuracy, reader confidence, and reading time when used as a concurrent reader for the detection of acute pulmonary embolism in computed tomography pulmonary angiography. In this institutional review board-approved retrospective study, 6 observers with varying experience evaluated 158 negative and 38 positive consecutive computed tomography pulmonary angiographies (mean patient age 60 y; 115 women) without and with CAD as a concurrent reader. Readers were asked to determine the presence of pulmonary embolism, assess their diagnostic confidence using a 5-point scale, and document their reading time. Results were compared with an independent standard established by 2 readers, and a third chest radiologist was consulted in case of discordant findings. Using logistic regression for repeated measurements, we found a significant increase in readers' sensitivity (P<0.001) without loss of specificity (P=0.855) with the effects being reader dependent (P<0.001). Sensitivities varied from 68% to 100% without CAD and from 76% to 100% with CAD. A 2-way analysis of variance showed a small but significant decrease in reading time (P<0.001), with the duration varying between 24 and 208 seconds without CAD and between 17 and 196 seconds with CAD, and a significant increase in readers' confidence scores using CAD as a concurrent reader (P<0.001). CAD as a concurrent reader has the potential to increase readers' sensitivity and confidence with a decrease in reading time without loss of specificity. The differences between readers, however, require further evaluation of CAD as a concurrent reader in a larger trial before stronger conclusions can be drawn.

Effect of Computerized Clinical Decision Support on the Use and Yield of CT Pulmonary Angiography in the Emergency Department

To determine the effect of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic (CT) pulmonary angiography for acute pulmonary embolism (PE) in the emergency department (ED). Institutional review board approval was obtained for this HIPAA-compliant study, which was performed between October 1, 2003, and September 30, 2009, at a 793-bed quaternary care institution with 60,000 annual ED visits. Use (number of examinations per 1000 ED visits) and yield (percentage of examinations positive for acute PE) of CT pulmonary angiography were compared before and after CDS implementation in August 2007. The authors included all adult patients presenting to the ED and developed and validated a natural language processing tool to identify acute PE diagnoses. Linear trend analysis was used to assess for variation in CT pulmonary angiography use. Logistic regression was used to determine variation in yield after controlling for patient demographic and clinical characteristics. Of 338,230 patients presenting to the ED, 6838 (2.0%) underwent CT pulmonary angiography. Quarterly CT pulmonary angiography use increased 82.1% before CDS implementation, from 14.5 to 26.4 examinations per 1000 patients (P<.0001) between October 10, 2003, and July 31, 2007. After CDS implementation, quarterly use decreased 20.1%, from 26.4 to 21.1 examinations per 1000 patients between August 1, 2007, and September 30, 2009 (P=.0379). Overall, 686 (10.0%) of the CT pulmonary angiographic examinations performed during the 6-year period were positive for PE; subsequent to CDS implementation, yield by quarter increased 69.0%, from 5.8% to 9.8% (P=.0323). Implementation of evidence-based CDS in the ED was associated with a significant decrease in use, and increase in yield, of CT pulmonary angiography for the evaluation of acute PE.

Biomarkers in pulmonary embolism

Sir, The recent paper by Jeebun et al. 1 reports a correlation between plasma D-Dimer levels and thrombus burden on computed tomography pulmonary angiography in acute pulmonary embolism (PE). Their findings do not seem to heighten the current need …

Computed Tomographic Angiography in Acute Pulmonary Embolism

To compare the indices of right ventricular dysfunction (RVD) obtained from axial transverse images with those derived from the reconstructed 4-chamber and short-axis views in patients with acute pulmonary embolism (PE). Eighty-eight patients with acute PE were retrospectively enrolled. For each patient, axial transverse images and reconstructed 4-chamber and short-axis views were reviewed. Measurements of the ratios of right ventricle to left ventricle (RV/LV) diameters and RV/LV areas were then obtained from all series. Values derived from each method were compared and correlated to arterial obstruction index. In the studied cohort, RV/LV diameters and RV/LV areas obtained from axial transverse images and the reconstructed 4-chamber views were not statistically different. In contrast, a statistically significant difference was observed between the values of RV/LV areas derived from both axial transverse and 4-chamber views and those obtained from short-axis views (P < 0.0001). There was a weak to moderate correlation between both RV/LV diameters and RV/LV areas and the computed tomographic obstruction index. However, when the study cohort was divided into 3 subgroups with an arterial obstruction index of less than 15% (n = 26), 15% to 30% (n = 21), and greater than 30% (n = 41), those who had values greater than 30% revealed the highest correlation with the indices of RVD. In patients with acute PE, the indices of RVD derived from axial transverse images and the reconstructed 4-chamber views yield comparative values. Given the simplicity of the former analysis, it should be taken into consideration for risk stratification in acute PE.

CT pulmonary angiography for acute pulmonary embolism: Cost-effectiveness analysis and review of the literature

Pulmonary embolism (PE) continues to be a diagnostic challenge. Clinical assessment tools, D-dimer testing, ventilation perfusion (V/Q) scanning, ultrasound of the lower limbs, computed tomography (CT), and pulmonary angiography are all adequate methods used in the diagnosis of acute PE. With several options available to physicians, variation in regional costs and practices, and conflicting views on imaging modality performance data, there is considerable uncertainty regarding the most cost-effective strategy. Cost-effectiveness analysis is a helpful tool for determining the most effective diagnostic strategy when several viable options exist. Although limited by a number of necessary assumptions, cost-effective analyses offer a feasible solution to a diagnostic process by using an evidence-based approach. Current evidence shows that CT is a cost-effective alternative to V/Q scanning, particularly when sensitivity is sufficiently high. The purpose of this article is to review the cost-effective role of CT in the diagnosis of acute PE.

Emergency angiography in acute pulmonary embolism: role in clinically suspected cases

Massive and submassive pulmonary embolisms (PE) have been diagnosed by clinical suspicion according to the criteria of low, intermediate and high probability subgroups, depending on symptoms (sudden dyspnea, chest pain, syncope), signs (tachycardia, hypotension, elevated central venous pressure), electrocardiogram (right ventricle strain, right bundle branch block, S1Q3), laboratory data (hypoxia, hypocapnia, elevated plasma D-dimer, lactate dehydrogenase, fibrin degradation products) and echocardiography (right ventricular dilatation, paradoxical septal motion, pulmonary hypertension) in a patient with predisposing risk factors and diagnostic confirmation via ventilation perfusion lung scan. The latter was not done for all patients as it is diagnostic in only 30–50% of cases, and the remaining 50–70% nondiagnostic scans may represent a probability for underlying PE of between 4% and 66% depending on clinical circumstances. Because of its invasive nature and technical complexity, pulmonary angiography (PA), the golden diagnostic standard, was not a routine procedure. We hereby report our experience with emergency PA in clinically suspected cases of PE to highlight its merits and the limitations of clinical examination. We studied 18 patients with clinically suspected PE (six male, 12 female; mean age 49.5 years). Predisposing factors included heart disease in two patients, diabetes mellitus in five patients, polytrauma in three patients and autoimmune disease (i.e. Behcet disease) in one patient. Four patients were dehydrated and bedridden. Following clinical evaluation, elctrocardiogram and chest X-ray, all patients were subjected to routine laboratory evaluation, arterial blood gas measurement and specific coagulation profile (fibrin, fibrin degradation products, D-dimer). All patients were then subjected to first-pass radionuclide angiography. PA was done in all patients within a mean period of 2 days (day 0–day 4). Following acute imaging, PA revealed the presence of PE in only eight patients in the form of distal cutoff and/or filling defects, while 10 patients had negative PA for PE. Compared with patients with negative PA, those with positive findings were more frequently hypotensive (50% vs 20%), more hypoxic (100% vs 90%), more congested (100% vs 80%) with more positive echocardiographic data (85% vs 60%). They also exhibited significant scintigraphic evidence of impaired RV ejection fraction than patients with negativeve PA (80% vs 20%).

Helical Computed Tomography for Diagnosing Pulmonary Embolism

Letters19 September 2000Helical Computed Tomography for Diagnosing Pulmonary EmbolismSuman W. Rathbun, MD, Gary E. Raskob, PhD, and Thomas L. Whitsett, MDSuman W. Rathbun, MDUniversity of Oklahoma Health Sciences Center; Oklahoma City, OK 73190 (Rathbun, Raskob, Whitsett)Search for more papers by this author, Gary E. Raskob, PhDUniversity of Oklahoma Health Sciences Center; Oklahoma City, OK 73190 (Rathbun, Raskob, Whitsett)Search for more papers by this author, and Thomas L. Whitsett, MDUniversity of Oklahoma Health Sciences Center; Oklahoma City, OK 73190 (Rathbun, Raskob, Whitsett)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-133-6-200009190-00026 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:We stand by the conclusions of our systematic review: 1) The use of helical CT in the diagnosis of pulmonary embolism has not been adequately evaluated; 2) the safety of withholding anticoagulant treatment in patients with negative results on helical CT is uncertain; and 3) definitive large, prospective studies should be done to evaluate the sensitivity, specificity, and safety of helical CT for diagnosis of suspected pulmonary embolism. These conclusions are appropriate on the basis of the available evidence from studies in patients.The data quoted by Mayo and colleagues are from a study performed in animals (1). ...References2. Baile EM, King GG, Muller NL, D'Yachkova Y, Coche EE, Pare PD, Mayo JR. Spiral computed tomography is comparable to angiography for the diagnosis of pulmonary embolism. Am J Respir Crit Care Med. 2000;161:1010-5. CrossrefMedlineGoogle Scholar2. Stein PD, Athanasoulis C, Alavi A, Greenspan RH, Hales CA, Saltzman HA, et al . Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation. 1992;85:462-8. CrossrefMedlineGoogle Scholar3. Hull RD, Raskob GE, Coates G, Panju AA. Clinical validity of a normal perfusion lung scan in patients with suspected pulmonary embolism. Chest. 1990;97:23-6. CrossrefMedlineGoogle Scholar4. Mullins MD, Becker DM, Hagspiel KD, Philbrick JT. The role of spiral volumetric computed tomography in the diagnosis of pulmonary embolism. Arch Intern Med. 2000;160:293-8. CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: University of Oklahoma Health Sciences Center; Oklahoma City, OK 73190 (Rathbun, Raskob, Whitsett) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoSensitivity and Specificity of Helical Computed Tomography in the Diagnosis of Pulmonary Embolism Suman W. Rathbun , Gary E. Raskob , and Thomas L. Whitsett Helical Computed Tomography for Diagnosing Pulmonary Embolism John R. Mayo , Elisabeth M. Baile , and Peter D. Pare Metrics 19 September 2000Volume 133, Issue 6Page: 484KeywordsAngiographyComputed axial tomographyLungsPatientsProspective studiesPulmonary embolismSafetySpecificitySystematic reviewsVenous thromboembolism ePublished: 19 September 2000 Issue Published: 19 September 2000 Copyright & PermissionsCopyright © 2000 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Complications and validity of pulmonary angiography in acute pulmonary embolism: Stein PD, Athanasoulis C, Alvavi A, et al. Circulation 1992;85:462-8

Complications and validity of pulmonary angiography in acute pulmonary embolism: Stein PD, Athanasoulis C, Alvavi A, et al. Circulation 1992;85:462-8

Complications and validity of pulmonary angiography in acute pulmonary embolism: Stein PD, Athanosoulis C, Alavi A, Greenspan RH, Hales CA, Saltzman HA, Vriem CD, Terrin ML, Weg JG. Circulation. 1992;85:462-8

Complications and validity of pulmonary angiography in acute pulmonary embolism: Stein PD, Athanosoulis C, Alavi A, Greenspan RH, Hales CA, Saltzman HA, Vriem CD, Terrin ML, Weg JG. Circulation. 1992;85:462-8

Complications and validity of pulmonary angiography in acute pulmonary embolism.

The Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) addressed the value of ventilation/perfusion scans in acute pulmonary embolism (PE). The present study evaluates the risks and diagnostic validity of pulmonary angiography in 1,111 patients who underwent angiography in PIOPED: Complications were death in five (0.5%), major nonfatal complications in nine (1%), and less significant or minor in 60 (5%). More fatal or major nonfatal complications occurred in patients from the medical intensive care unit than elsewhere: five of 122 (4%) versus nine of 989 (1%) (p less than 0.02). Pulmonary artery pressure, volume of contrast material, and presence of PE did not significantly affect the frequency of complications. Renal dysfunction, either major (requiring dialysis) or less severe, occurred in 13 of 1,111 (1%). Patients who developed renal dysfunction after angiography were older than those who did not have renal dysfunction: 74 +/- 13 years versus 57 +/- 17 years (p less than 0.001). Angiograms were nondiagnostic in 35 of 1,111 (3%), and studies were incomplete in 12 of 1,111 (1%), usually because of a complication. Surveillance after negative angiograms showed PE in four of 675 (0.6%). Angiograms, interpreted on the basis of consensus readings, resulted in an unchallenged diagnosis in 96%. The risks of pulmonary angiography were sufficiently low to justify it as a diagnostic tool in the appropriate clinical setting. Clinical judgment is probably the most important consideration in the assessment of risk.

Pulmonary angiography in acute pulmonary embolism: Indications, techniques, and results in 367 patients

Pulmonary angiography is the most specific test available for the diagnosis of acute pulmonary embolism. This technique can safely be performed in critically ill patients. In 367 consecutive studies our incidence of complications has been 4 per cent, and there has been only one death. Hemodynamic studies done as part of the procedure permit evaluation of the severity and the pathophysiology of acute pulmonary embolism. The two diagnostic angiographic findings of pulmonary embolism are intraluminal filling defects and cutoff arteries. Oligemia and asymmetry of blood flow are frequently seen in pulmonary embolism, but are not specific. These latter two abnormalities may occur in chronic lung disease or congestive heart failure without pulmonary embolism. Using these diagnostic criteria in 247 patients studied because of a clinical diagnosis of acute pulmonary embolism, a definitive diagnosis (either definite pulmonary embolism or negative) was established by angiography in 74 per cent. In 9 per cent the diagnosis was probable pulmonary embolism, and in 17 per cent the findings were equivocal for pulmonary embolism. Application of these diagnostic criteria results in minimal false posiive angiographic diagnoses. False negative diagnoses may occur if embolism is limited to peripheral branches of the pulmonary vasculature that are not visualized by current angiographic techniques. The incidence of symptomatic pulmonary embolism limited to these small arteries is uncertain. The primary limitation of this technique is, that in patients with underlying heart disease or chronic lung disease, the results of angiography may be equivocal. The application of new techniques of magnification angiography and/or selective cineangiography offer promise in enhancing the recognition of embolism in this group of patients.