Computed Tomography Pulmonary Angiography Research Articles

Comparison of Water-Equivalent and Effective Diameter-Based Size-Specific Dose Estimates in Computed Tomography Pulmonary Angiography: Implications for Radiation Dose Optimization

This retrospective study investigates dose estimation in computed tomography pulmonary angiography (CTPA) by analyzing 200 examinations from 96 male and 104 female patients. Two size-specific dose estimation (SSDE) methods were evaluated: one based on effective diameter (SSDEDeff) and the other on water-equivalent diameter (SSDEDw). The effective diameter (Deff) was manually measured using the lateral (LAT) and anteroposterior (AP) dimensions, while the water-equivalent diameter (Dw) was calculated from the region of interest (ROI) using mean Hounsfield Unit (HU) values and cross-sectional area. SSDE calculations were compared to the conventional CT dose metric, CTDIvol, to assess its underestimation relative to SSDEDw. The findings revealed a dose underestimation of up to 18% for CTDIvol compared to SSDEDw, particularly for patients with larger body habitus. SSDEDeff consistently overestimated the dose by 7.73% compared to SSDEDw, as Deff relied only on external dimensions while Dw considered tissue attenuation for a more individualized dose assessment. High correlations were observed between lateral diameter (dLAT) and both Deff (R2 = 0.9175) and Dw (R2 = 0.7578). However, the systematic overestimation by SSDEDeff emphasizes the importance of clearly specifying the metric used for SSDE, as differences can influence reported doses by 5-10%, affecting clinical dose monitoring and adherence to diagnostic reference levels. This study highlights the limitations of CTDIvol and SSDEDeff compared to SSDEDw, especially in regions with heterogeneous tissue. The results support the use of individualized radiation dose assessments to improve radiation safety, particularly in CTPA, which has seen increased application during the COVID-19 pandemic.

Development and validation of a Prediction Model for Chronic Thromboembolic Pulmonary Disease

BackgroundAcute pulmonary embolism (APE) is a critical disease with a high mortality rate, some of the surviving patients may develop chronic thromboembolic pulmonary disease (CTEPD), which affects the patient’s prognosis. However, the research on the early diagnosis of CTEPD is limited. This study aimed to establish a prediction model for earlier identification of CTEPD.MethodsThis prospective study included 464 consecutive patients with APE confirmed between January 2020 and September 2023, at 7 centers from China. After follow-up for at least 3 months, the patients were divided into the CTEPD and non-CTEPD groups based on symptoms and computed tomography pulmonary angiography (CTPA) or pulmonary ventilation perfusion (V/Q) scans showing residual thrombosis. The independent risk factors for CTEPD were identified via univariate and multivariate logistic regression analyses. Next, a nomogram of predictive model was established, and validation was completed via decision curve analysis (DCA) and receiver operating characteristic curve analysis.ResultIn total, 130 (28%) patients presented with CTEPD, 17% (22/130) of CTEPD patients developed chronic thromboembolic pulmonary hypertension (CTEPH). Based on the multivariate analysis, a time interval from symptoms onset to diagnosis (time-to-diagnosis) ≥ 15 days (95% confidence interval [CI]: 3.392–14.972, p < 0.001), recurrent pulmonary embolism (RPE) (95%CI: 1.560–17.300, p = 0.007), right ventricular dysfunction (RVD) (95%CI: 1.042–6.437, p = 0.040), central embolus (95%CI: 1.776–7.383, p < 0.001) and residual pulmonary vascular obstruction (RPVO) > 10% (95%CI: 4.884–21.449, p < 0.001) were identified as the independent predictors of CTEPD. Then, A prediction model with a C-index of 0.895 (95% CI 0.863–0.927) was established for high-risk patients. The nomogram had an excellent predictive performance for earlier identification of CTEPD, with an area under the curve of 0.908 (95%CI: 0.875–0.941) in the training cohort and 0.875 (95%CI: 0.803–0.947) in the validation cohort.ConclusionThe current study established and validated a reliable nomogram for predicting CTEPD, which would assist clinicians identify the high-risk patients for CTEPD earlier.

Lung parenchymal and cardiac appearances on CTPA impact survival in chronic thromboembolic pulmonary hypertension: results from the ASPIRE Registry

BackgroundChronic thromboembolic pulmonary hypertension (CTEPH) is commonly evaluated using CT pulmonary angiography (CTPA). We evaluated the frequency and impact of parenchymal and cardiac abnormalities on survival in CTEPH.MethodsPatients were identified from the ASPIRE (Assessing-the-Spectrum-of-Pulmonary-Hypertension-Identified-at-a-Referral-Centre) Registry. Kaplan-Meier analysis was used to assess survival.Results290 patients (55% female, mean age 65±14 years) with CTEPH were included. Mosaic perfusion was noted in 83%, lung infarction in 73% and parenchymal lung disease in 28%. The severity of mosaic perfusion and lung infarction correlated with markers of disease severity (p&lt;0.001). Whereas the presence of mosaic perfusion was associated with improved survival in all patients (p=0.03), it did not predict outcome in those undergoing pulmonary endarterectomy (PEA) (p=0.6) and those not undergoing PEA (p=0.22). The presence of lung infarction had no impact on mortality. The presence of co-existing lung disease was associated with a worse survival (p&lt;0.008), in patients not undergoing PEA. Mosaic perfusion was less common in patients with parenchymal lung disease (65%) compared to those without parenchymal lung disease (90%), p&lt;0.001. Increased right: left ventricular ratio and aortic diameter predicted worse outcome (p&lt;0.002).ConclusionLung parenchymal and cardiac changes on CTPA predict outcome in CTEPH. Co-existing parenchymal lung disease is not uncommon and when present may mask the presence of mosaic perfusion. This study highlights the importance of systematically evaluating the lung parenchyma and cardiac changes in patients with CTEPH.

Comparison of ventilation/perfusion scintigraphy and pulmonary CT angiography: Findings in the diagnosis of CTEPH and CTED.

Despite the high sensitivity and specificity of ventilation/perfusion (VQ) scintigraphy in the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic disease (CTED), V/Q scintigraphy cannot distinguish whether the thrombus is acute or chronic. In our study, we aimed to compare pulmonary computed tomography angiography (CTA) findings with V/Q scintigraphy findings in CTEPH and CTED patients and to identify findings that would indicate chronic thrombus. Eighteen patients diagnosed with CTEPH and CTED at our institution were included in the study between January 2020 and January 2024. Computed tomography angiographyfindings were recorded as V/Q findings [location (segmental, subsegmental, lobar), number, appearance (wedge or patchy) of mismatch perfusion defects], and the correlation of these findings was investigated. The average age of 18 patients was 63.3±11.7, 66.7% were female and the majority of the patients were non-smokers, and no significant difference was detected between the CTED and CTEPH groups. Apart from the areas where chronic thrombus was localized on CTA, more widespread mismatch defects were observed by VQ scintigraphy. Most of the mismatch defects were wedge-shaped and there was similarity between groups. The presence of mosaic perfusion was detected in 62.5% of those with mismatch patchy defects (P=0.043). A negative correlation was detected between pulse oxygen saturation and the number of mismatch subsegmentary defects (r: -0.651, P=0.005). Systolic pulmonary artery pressure (sPAP) was found to be positively correlated with the number of mismatch defects (r: 0.523, P=0.026). Ventilation/perfusionscintigraphy is superior in the diagnosis of CTEPH/CTED. The presence of mismatch patch defects on V/Q scintigraphy in patients with clinical, echocardiographic, and CTA findings suggests that the presence of mismatch patch defects on V/Q scintigraphy may be a sign of chronic thrombus and the number of mismatch defects may be correlated with the severity of the disease.

Clinical manifestations and misdiagnosis factors of pulmonary embolism patients seeking treatment in cardiology.

To explore the clinical manifestations and factors leading to misdiagnosis in pulmonary embolism (PE) patients in a cardiology department. We retrospectively analyzed 74 patients diagnosed with PE at our hospital from March 2018 to March 2022, comparing them to 136 patients suspected of PE but excluded by computed tomography pulmonary angiography during the same period. Both groups received the same basic care, including disease counseling, nutritional planning, and monitoring. We compared general information, clinical manifestations, risk factors, and auxiliary examinations to identify correlations between specific manifestations and misdiagnosis factors. The male-to-female ratio in the PE group was approximately 3:4, which was statistically significant compared to the control group (P < .05), though its impact on PE incidence was low. Common symptoms in the PE group included chest tightness, shortness of breath, sweating, and chest pain, with no significant difference from the control group (P > .05). Notable risk factors included deep vein thrombosis (DVT) (43.24%), prolonged bed rest (32.43%), lower limb varicose veins (18.92%), trauma (21.62%), pulmonary infections (62.16%), coronary heart disease (37.84%), respiratory failure (32.43%), and chronic obstructive pulmonary disease (13.51%). DVT was significantly associated with PE (P < .05). Multivariate logistic regression identified DVT (OR = 118.528, 95% CI: 6.959-2018.906, P = .001) and lower limb varicose veins (OR = 212.766, 95% CI: 6.584-6875.950, P = .003) as independent predictive factors for suspected PE. Clinical manifestations strongly correlated with PE included pulmonary rales, cyanosis, tachycardia, hypotension, elevated D-dimer, positive N-terminal pro-brain natriuretic peptide, and sinus tachycardia on echocardiogram. PE in cardiology patients may present with pulmonary rales, hypotension, shortness of breath, and abdominal symptoms, warranting reexamination for PE. Misdiagnosis factors typically involve chest pain, tightness, and shortness of breath. Lower limb varicose veins and DVT are reliable predictors of suspected PE.

Superficial Dorsal Vein Thrombosis of the Penis and Pulmonary Embolism in a 15-year-old Boy: A Case Report

Introduction: Penile pain in children and adolescents is an uncommon presenting symptom in the emergency department (ED). The differential diagnosis includes trauma, priapism, urethral stone, infection, Mondor disease, Peyronie disease, and thrombosis. Case Report: A 15-year-old male with a high-risk, B-cell acute lymphocytic leukemia and recent pegaspargase administration presented to the ED with new-onset penile pain. After the administration of opioid analgesics, he developed hypoxia prompting an urgent computed tomography pulmonary angiogram that revealed bilateral segmental acute pulmonary embolism (PE). Ultrasound of the penis revealed findings consistent with superficial dorsal vein thrombosis of the penis. Conclusion: To our knowledge, this is the first case report of an adolescent with superficial dorsal vein thrombosis of the penis and a coexisting PE. Doppler ultrasound can provide a prompt assessment of penile induration and differentiate venous thrombosis from other causes.

Radiological assessment of pulmonary vascular changes and gastrointestinal changes in patients with COVID-19 referred to a tertiary health care center in Chennai, India: a prospective cross-sectional study

BACKGROUND: The coronavirus disease pandemic (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has led to significant morbidity and mortality worldwide since its emergence in 2019. Although primarily a respiratory illness, COVID-19 can also affect other organ systems, including the vascular and gastrointestinal systems. COVID-19 is linked to both venous and arterial thrombosis, and numerous studies have indicated a heightened risk of pulmonary embolism. Autopsies have revealed pulmonary vasculature thrombosis and bowel ischemia in patients with COVID-19. AIM: To assess radiological pulmonary vascular changes, specifically pulmonary embolism, and gastrointestinal changes in patients with COVID-19 referred to a tertiary healthcare center in Chennai, India. MATERIALS AND METHODS: Computed tomography pulmonary angiography and contrast-enhanced computed tomography of the abdomen were conducted in 100 patients with COVID-19 who met the selection criteria. A radiologist with 5 years of experience evaluated pulmonary vascular and bowel changes. Subsequently, statistical analysis was performed to determine the significance of the relationship between patients with COVID-19 and the occurrence of pulmonary vascular and bowel changes. RESULTS: In this study, 11 patients exhibited pulmonary thromboembolism, and 7 showed significant bowel changes such as bowel wall thickening, mesenteric ischemia, and omental infarction, indicative of potential gastrointestinal involvement of patients with COVID-19. A positive correlation was found between pulmonary embolism prevalence in patients with COVID-19. Pulmonary embolism was diagnosed at a mean of 11 days from disease onset. Of the 24 patients with severe acute respiratory illness, 7 showed pulmonary embolism, detected by computed tomography pulmonary angiography. In addition, of the 10 patients on mechanical ventilation, pulmonary embolism was found in 7. Among the seven patients with bowel changes, four had pulmonary embolism, as detected by computed tomography pulmonary angiography, indicating a significant association between the two concomitant complications. The observed bowel changes were attributed to intravascular thrombosis. CONCLUSIONS: Based on our findings, pulmonary emboli and bowel changes often occur in patients with COVID-19. Multivariate analyses also revealed a connection between invasive mechanical ventilation and pulmonary embolism. The results indicate that patients with severe COVID-19 may also experience concurrent acute pulmonary embolism. Thus, for these patients, the use of contrast-enhanced computed tomography instead of standard non-contrast computed tomography may aid in treatment decision-making.

Impact of a Clinical Decision Support System on Computed Tomographic Pulmonary Angiogram Yield and Utilization in Hospitalized Patients.

To determine whether point-of-order clinical decision support (CDS) based on the Wells Criteria improves CT pulmonary angiogram (CTPA) yield and utilization in hospitalized patients in an enterprise-wide health system and identify yield-related factors. This retrospective IRB-approved cross-sectional study in an urban, multi-institution health system included hospitalized patients undergoing CTPA 12 months before and after CDS implementation (entire cohort). Chi-square test was used to compare PE yield in patients in whom providers overrode vs. followed CDS alerts after CDS implementation. It was also used to compare utilization and yield pre- vs. post-intervention. Univariate and multivariable regression analyses were performed on patient factors and post-CDS Wells scores to evaluate yield-related factors. For 2,429 inpatient CTPAs post-intervention, CTPA yield was significantly higher when CDS recommendations were followed (18.3% [250/1365]) compared to those overridden (14.2% [151/1064] (p<0.01). For 5,372 CTPAs in the entire cohort, there was no difference in PE yield before (448/2,943; 15.2%) vs. after (401/2,429; 16.5%) CDS implementation (p=0.20). However, in 340,146 admissions over the study period, a 7.4% relative decrease in CTPA utilization (17.5 to 16.2 CTPA examinations/1000 admissions before and after CDS, respectively; p=0.003) was observed. When CDS recommendations were followed, the yield of CTPA was significantly higher than when clinicians overrode CDS alerts. In addition, point-of-order CDS to reduce unnecessary CTPA in hospitalized patients resulted in a significant decrease in CTPA utilization post-CDS implementation with a modest though nonsignificant increase in CTPA yield.

Quantitative assessment of pulmonary blood flow redistribution in the classification of group 1 and group 4 pulmonary hypertension.

All patients with pulmonary hypertension (PH), without left heart disease or lung diseases, need further distinguishing between pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to investigate the value of quantitative assessment of pulmonary blood flow redistribution in further classification. Forty-six patients who underwent echocardiography and computed tomography pulmonary angiography at The First Affiliated Hospital of Xi'an Jiaotong University were included in this cross-sectional study, and all patients were categorized into a non-PH group (18 cases), a PAH group (12 cases), and a CTEPH group (16 cases). The diameter of the left ventricle and right ventricle were measured. The volumes of the main, right, and left pulmonary arteries were calculated. The total blood volume (TBV), the blood volume of vessels at the cross-section with an area <5 mm2 (BV5), between 5 and 10 mm2 (BV5-10), and >10 mm2 (BV10), and the blood volume of the pulmonary arteries and veins, were quantitatively assessed. TBV, BV5, BV5-10 and BV10 were all normalized to the volume of the corresponding lung or lobe. The diameter of the right ventricular, and the volumes of the main pulmonary artery, right pulmonary artery, and left pulmonary artery were not significantly different between the PAH and CTEPH group (P>0.05). The BV10 of CTEPH were significantly lower than those of the PAH group for the whole lung (32.69‰±13.53‰ vs. 18.73‰±6.10‰; t=6.234; P=0.004), right lung (29.06‰±15.01‰ vs. 9.99‰±4.26‰; t=10.819; P<0.001), left lung (32.41‰±15.83‰ vs. 18.32‰±6.43‰; t=4.322; P=0.020), right upper lobe (RUL) (22.26‰±12.07‰ vs. 7.90‰±2.92‰; t=8.991; P=0.001), right middle lobe (20.72‰±9.95‰ vs. 7.54‰±5.32‰; t=7.117; P=0.002), right lower lobe (RLL) (31.55‰±18.22‰ vs. 12.40‰±5.99‰; t=8.098; P=0.001), left upper lobe (28.23‰±14.82‰ vs. 14.95‰±5.24‰; t=5.630; P=0.007) and left lower lobe (31.04‰±14.85‰ vs. 20.04‰±8.58‰; t=2.477; P=0.096). The arterial TBV (42.18‰±13.67‰ vs. 27.76‰±7.96‰; t=6.544; P=0.003), arterial BV10 (18.19‰±7.29‰ vs. 9.36‰±3.83‰; t=7.758; P=0.001), venous TBV (35.58‰±16.35‰ vs. 25.01‰±4.79‰; t=3.727; P=0.033), and venous BV10 (14.50‰±7.09‰ vs. 9.36‰±2.76‰; t=3.676; P=0.034) were also significantly lower in the CTEPH group than those of the PAH group. Age [95% confidence interval (CI): 0.011 to 0.082; P=0.013] and BV10 of the RUL (95% CI: -0.102 to -0.004; P=0.034) were the most discriminative parameters, with an area under the curve of 0.950 in distinguishing PAH and CTEPH (P<0.05). Pulmonary vessel volume increased in PAH, particularly in larger-caliber vessels and the pulmonary artery, while it decreased in CTEPH, especially in larger-caliber vessels and the RLL.

Safety and Diagnostic Utility Pulmonary Embolism Rule-Out Criteria (PERC) and D-Dimer in Emergency Department.

This study aimed to assess the diagnostic value and safety of using Pulmonary Embolism Rule-Out Criteria (PERC) in an emergency care setting. We conducted a retrospective application of the PERC to the patients suspected of having pulmonary embolism (PE) and who underwent computed tomography pulmonary angiogram (CTPA) Karolinska University Hospital's emergency department (ED) from 2016 to 2017. The patient data, including D-dimer (DD) and ED waiting times were extracted from the Karolinska Venous Thromboembolism cohort (VTE cohort). Among the 295 patients included in the cohort, 34 (11.5%) were diagnosed with PE. Of these 202 (68.5%) patients were PERC-positive, while 93 (31.5%) were PERC-negative. Among the 93 PERC-negative patients, three had PE; resulting in a sensitivity of 91% (95% CI: 0.77-0.97), a specificity of 34% (95% CI: 0.29-0.40), and a false negative rate (FNR) of 8.8%. Combining positive DD and PERC resulted in a sensitivity of 100% (95% CI: 0.86-1.00), a specificity of 23% (95% CI: 0.15-0.34), and no FNR. When patients classified as high risk for PE (determined by clinical gestalt) were excluded, no PEs were missed. The median total ED stay was 450 minutes in patients who underwent CTPA compared to 203 minutes in the reference group ( p < 0.0001). Using the PERC rule along with DD testing in low-risk patients effectively rules out PE in ED without the need for further testing. Properly using PERC may significantly reduce patients' waiting time in the ED.

INCIDENCE OF PULMONARY THROMBOEMBOLISM IN PATIENTS SUBJECTED TO COMPUTERIZED TOMOGRAPHY AND PULMONARY ANGIOGRAPHY AT THE UNIVERSITY CLINICAL HOSPITAL MOSTAR

Introduction: Pulmonary embolism is a serious medical problem with high mortality if not recognized in time. CT pulmonary angiography is a key method for diagnosing pulmonary embolism in patients with nonspecific symptoms such as shortness of breath, chest pain, and elevated D-dimer values. Objective: To determine the incidence of pulmonary embolism in patients undergoing CT pulmonary angiography at the University Clinical Hospital Mostar. Subjects and methods: A retrospective study included 300 patients with suspected pulmonary embolism who underwent CT pulmonary angiography. Technical imaging parameters included a low-dose protocol with intravenous iodine contrast. The results were analyzed by descriptive statistics, with an assessment of the frequency of pulmonary embolism, thrombus localization and incidental findings. Results: Pulmonary embolism was diagnosed in 27% of patients, with the most frequent involvement of the lobar arteries (43%). Massive emboli were recorded in 33% of cases. The average age of the respondents was 64 years, with an almost equal gender distribution. Elevated D-dimers were not sufficient to confirm the diagnosis in most patients. Incidental findings included pleural effusions, pneumonia, and tumors. Conclusion: CT pulmonary angiography is necessary for accurate diagnosis of pulmonary embolism, especially in patients with nonspecific symptoms. The results highlight the need to combine clinical and imaging methods, as well as adapt diagnostic protocols to reduce radiation exposure and optimize treatment outcomes. In the local context, these guidelines can improve diagnosis and treatment.

Development of a predictive nomogram for early identification of pulmonary embolism in hospitalized patients: a retrospective cohort study

BackgroundHospitalized patients often present with complex clinical conditions, but there is a lack of effective tools to assess their risk of pulmonary embolism (PE). Therefore, our study aimed to develop a nomogram model for better predicting PE in hospitalized populations.MethodsData from hospitalized patients (aged ≥ 15 years) who underwent computed tomography pulmonary angiography (CTPA) to confirm PE and non-PE were collected from December 2013 to April 2023. Univariate and multivariate stepwise logistic regression analyses were conducted to identify independent predictors of PE, followed by the construction of a predictive nomogram and internal validation. The efficiency and clinical utility of the nomogram model were assessed using receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and clinical impact curve (CIC).ResultsThe study included 313 PE and 339 non-PE hospitalized patients. Male gender, dyspnea or shortness of breath, interstitial lung disease, lower limb deep vein thrombosis, elevated fibrin degradation product (FDP), pulmonary arterial hypertension, and tricuspid regurgitation were identified as independent risk factors. The AUC of the predictive nomogram model was 0.956 (95% CI: 0.939–0.974), demonstrating superior performance compared with the simplified Wells score of 0.698 (95% CI: 0.654–0.741) and the modified Geneva score of 0.758 (95% CI: 0.717–0.799).ConclusionOur study demonstrated that challenges remain in the accuracy of the Wells score and revised Geneva score in assessing PE in hospitalized patients. Fortunately, the nomogram we developed has shown a favorable ability to discriminate PE cases, providing high reference value for clinical practice. However, given that this was a single-center study, we plan to expand efforts to collect data from additional centers to further validate our model.

Failure rate of the pulmonary embolism rule-out criteria rule for adults 35 years or younger: Findings from the RIETE Registry.

The use of a computed tomography pulmonary angiogram to diagnose pulmonary embolism (PE) has increased, leading not only to higher PE diagnoses but also to overdiagnosis and unnecessary radiation exposure, even in young patients despite a lower PE incidence. The aim of this study was to assess the failure rate of the pulmonary embolism rule-out criteria 35 (PERC-35) rule developed to reduce unnecessary testing in individuals aged ≤35 years among patients included in the Registro Informatizado de la Enfermedad TromboEmbolica Venosa (RIETE) Registry. This retrospective cohort study used data from the RIETE Registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the missed PE rate using PERC-35 criteria. Secondary outcomes included the comparison of demographic and clinical characteristics, PE localization, treatment strategies, and outcomes between PERC-negative (PERC-35N) versus PERC-positive (PERC-35P) patients. Of 58,918 adult patients with acute PE, the PERC-35 rule demonstrated a low missed PE rate of 0.35% (n = 204), with an upper 95% confidence interval [CI] of 0.40%. The missed rate was 7.0% (95% CI 6.0%-7.9%) in the 18- to 35-year subgroup. Compared to PERC-35P patients, PERC-35N patients were younger (mean age 28.4 years), with a lower body mass index, and included a higher proportion of pregnant/postpartum women. PERC-35N patients had a significantly lower rate of chronic diseases and presented less frequently with dyspnea or syncope but more often with chest pain. They showed lower rates of positive D-dimer and troponin levels. PERC-35N patients experienced fewer major bleeding episodes, similar recurrence rates of PE/deep vein thrombosis, and no deaths during anticoagulation. The PERC-35 rule demonstrated a low failure rate to exclude PE in patients aged 18-35 years and could reduce imaging and radiation exposure in young patients with a low PE pretest probability if confirmed prospectively.

The 3-level Wells score combined with D-dimer can accurately diagnose acute pulmonary embolism in hospitalized patients with acute exacerbation of COPD: A multicentre cohort study

BackgroundIdentification of acute pulmonary embolism (APE) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is challenging. Wells score and Revised Geneva score have been developed to diagnose APE. We aim to investigate the predictive accuracy of two clinical scoring systems combined with D-dimer for APE in patients with AECOPD. MethodsA multicentre cross-sectional study was conducted in 13 China hospitals. A total of 731 patients were enrolled. Computed tomography pulmonary angiography (CTPA) was performed within 48 hours of admission. The performance of the clinical scoring systems was compared by calculating the area under the receiver operating characteristic curves (AUROC), sensitivities, and specificities. Results731 patients were included with an average age of 68.9 years, with a male proportion of 585 (80.0 %). 112 (15.3 %) were diagnosed with APE. The optimal D-dimer cut-off value for identifying APE in AECOPD was 690.12 ng/mL. Analysis for assessing the clinical probability of APE using the 3-level Wells and Revised Geneva scores showed the AUC were 0.74 and 0.60, sensitivity were 61.61 % and 77.68 %, and specificity were 85.46 % and 38.29 %, respectively. Analysis using the 3-level Wells and Revised Geneva scores combined with a D-dimer cut-off value of 690.12 ng/mL showed the AUC were 0.909 and 0.869, sensitivity were 73.21 % and 91.96 %, specificity were 92.08 %and 72.70 %. The performance of the 3-level Wells score with D-dimer was significantly better than the performance of the 3-level Revised Geneva score with D-dimer (P = 0.01). ConclusionsThe 3-level Wells score combined with a D-dimer cut-off value of 690.12 ng/mL performed better than other clinical scoring algorithms for assessing clinical probability of APE in patients with AECOPD.

Effects of inlet boundary conditions on blood flow and thrombosis modelling in patients with chronic thromboembolic pulmonary hypertension

To investigate the impact of patient-specific boundary conditions (BC) on blood flow and thrombosis modelling for patients with chronic thromboembolic pulmonary hypertension (CTEPH), three types of BCs were utilized to construct CTEPH models based on computed tomography pulmonary angiography images. First BC type is the patient-specific velocity profiles at the main pulmonary artery using phase contrast MRI (PC-MRI). The other two simplified types are the pulsatile BC and steady BC, which are obtained by spatially and temporally averaging the PC-MRI BC. Hemodynamic features including helical density, time-averaged wall shear stress (TAWSS) and oscillatory shear index (OSI), and thrombosis were compared for the three types BCs. The results indicated that, compared to the MRI BC, steady BC overestimated helical density and TAWSS in the pulmonary arteries by approximately 63.1% and 60%, respectively. The impact of simplified pulsatile BC on TAWSS and OSI in most regions of the pulmonary arteries was negligible with differences within 5%. Regarding thrombosis, the area predicted under pulsatile BC was approximately 80% smaller than that under PC-MRI BC. In conclusion, compared to PC-MRI BC, steady inlet BC tend to overestimate hemodynamic parameters, while pulsatile inlet BC yield similar wall shear stress based on parameters in most regions of the pulmonary artery. Patient-specific PC-MRI inlet BC should be used for accurate predictions of helical flow pattern and thrombus formation.

The Global Reading Room: A Discrepancy Between Artificial Intelligence and the Radiologist for Pulmonary Embolus on CT Pulmonary Angiography.

The Global Reading Room: A Discrepancy Between Artificial Intelligence and the Radiologist for Pulmonary Embolus on CT Pulmonary Angiography.

Relationship between Deep Vein Thrombosis and Serial Chest CT Severity Scores in COVID-19 Patients

Aim: We aimed to evaluate risk factors for deep vein thrombosis (DVT) in lower extremities veins in COVID-19 patients and the relationship between DVT with chest CT severity scores (CT-SS). To our knowledge, our study is the first to investigate the relationship between the occurrence of DVT and serial chest CT-SS in COVID-19 patients. Methods: We conducted a retrospective analysis of 131 COVID-19 patients (≥18 years) admitted to our hospital. Two radiologists examined chest CT scans and calculated CT-SS using a visual scoring system. Color Doppler ultrasounds of lower extremity veins were performed for DVT. CT Pulmonary Angiographies (CTPA) were performed on patients clinically suspected of pulmonary embolism (PE). Results: A total of 131 patients were included in our study. 71/131 (54.2%) of the patients were male. 18/131 (13.7%) patients were treated in ICU and 18 (13.7%) patients died. 21/131 patients had DVT (16%) in their lower extremities. Chest CTA was performed in 44/131 (33.6%) patients and PE was detected in 10/44 patients (22.7%). PE was considerably more common in patients with DVT (p = 0.009). The occurrence of DVT was significantly associated with high first chest CT-SS (p=0.002). However, there was no association between the DVT and second and third CT-SS. Significant associations were found between the development of DVT with elevated serum D-Dimer, CRP and fibrinogen levels (p

CT pulmonary angiography in the inpatients: A 5-year retrospective view at the end of COVID-19 public health emergency.

To retrospectively evaluate the trends in utilization and results of computed tomography pulmonary angiography (CTPA study) for detection of acute pulmonary embolism (PE) in the hospital inpatients during different phases of COVID-19 public health emergency. We conducted an Institutional Review Board (IRB)-approved retrospective review of CTPA studies for our hospital inpatients in the years from 2019 to 2023, ranging from the prepandemic year (2019) to the year coinciding with the end of public health declarations (2023). Collected characteristics included patient age, patient sex, and result of the study. The utilization of CTPA studies for inpatients was higher in 2020 to 2023, compared to 2019 (3.8% in 2023 compared to 2.4% in 2019, P < .001). The increase in utilization was also statistically significant in each group, when stratified by age and sex (OR = 1.46 for female, OR = 1.71 for male, OR = 1.93 for elderly, and OR = 1.29 for non-elderly inpatients in 2023, compared to 2019). The positivity rate of acute PE in the inpatients was overall higher in 2021, 2022, and 2023, compared to 2019 (for example, 18.5% in 2023 compared to 14.3% in 2019, P = .01). When stratified by age and sex, only the non-elderly patients continued to have a significantly higher rate of acute PE in 2023, compared to 2019 (OR = 1.39). While studies spanning longer time frames and involving multiple institutions are needed to understand and generalize this conclusion, we conclude that the utilization and positivity rates of CTPA studies in inpatients remains high at the end of the COVID-19 pandemic public health emergency.

Diagnostic value of systematic compression ultrasonography for the detection of unrecognized venous thromboembolism in patients admitted to an internal medicine ward for dyspnea.

The diagnosis of venous thromboembolism (VTE) is complex, and many cases of pulmonary embolism (PE) and deep vein thrombosis (DVT) go undetected despite validated diagnostic algorithms. This study evaluated the diagnostic performance of compression ultrasound (CUS) when systematically performed in patients admitted to an internal medicine department for dyspnea and/or respiratory failure. We conducted a prospective observational cohort study of consecutive adult hospitalized patients admitted for dyspnea and/or respiratory failure with at least one of the following: tachycardia (> 100bpm), tachypnea (> 20/min), chest pain, cough, syncope, or hemoptysis. Patients with a previous diagnosis of VTE or who underwent computed tomography pulmonary angiography (CTPA) or CUS during evaluation in the emergency department were excluded. The study included 263 patients (50.2% women, average age 84years). CUS was positive in 31 patients (11.8%); Bilateral DVT was diagnosed in two patients and unilateral DVT in 29 patients. Of these, 10 underwent CT scan, with PE confirmed in 9 cases. Using the Wells score for DVT (cut-off ≥ 2), only 8 patients (25.8%) were at high risk. The accuracy of the Wells score in identifying PE was suboptimal, as 5 of 9 patients (55.5%) with confirmed PE were in the low-risk group (three-level interpretation) and 8 (89.9%) were in the "EP unlikely" group (two-level interpretation). The systematic use of CUS as a point-of-care tool can improve the diagnostic accuracy for VTE in patients admitted to internal medicine departments with dyspnea/respiratory failure.

Type of D-dimer assay determines the diagnostic yield of Computed Tomography in patients suspected for pulmonary embolism

ImportancePulmonary embolism (PE) is a life-threatening condition with high morbidity and mortality. The diagnosis of PE is challenging due to nonspecific symptoms, making reliable diagnostic tools essential. This study addresses the clinical impact of inter-assay variability in D-dimer measurements on the utilization and diagnostic yield of computed tomography pulmonary angiography (CTPA). ObjectiveTo investigate the effect of different D-dimer assays on the decision to perform CTPA and the subsequent diagnostic yield in patients with suspected PE. DesignThis retrospective cohort study analyzed data from three teaching hospitals in the Netherlands, covering the years 2018, 2019, 2022, and 2023. SettingMulticenter study involving three teaching hospitals in the south-west region of the Netherlands. ParticipantsThe study included data from 40,096 clinically requested D-dimer results and 11,372 CTPA records of patients with suspected PE. The D-dimer assays used were the Roche Tinaquant and Siemens Innovance. ResultsThe study found significant differences in CTPA utilization and diagnostic yield based on the D-dimer assay used. Hospitals using the Roche Tinaquant assay ordered 21% fewer CTPAs and had an 7% higher positivity rate compared to those using the Siemens Innovance assay. Conclusion and relevanceThe findings highlight the necessity for assay-specific cut-off values or, ideally, the standardization of the D-dimer assay to optimize the accuracy and efficiency of PE diagnosis. This study demonstrates that the choice of D-dimer assay significantly influences the clinical management of suspected PE, affecting both the number of CTPAs performed and the positivity rate of these scans. Implementing assay-specific cut-off values or standardization of the D-dimer assay could reduce unnecessary CTPA scans, minimize patient exposure to radiation, and lower healthcare costs. These results advocate for enhanced collaboration between clinicians and laboratory specialists to accurately interpret D-dimer results within the context of the specific assay used. Future research should validate these findings in prospective studies and explore standardized protocols that account for inter-assay variability.