CT For Pulmonary Embolism Research Articles

Comparison of the age-adjusted and clinical probability-adjusted D-dimer to exclude pulmonary embolism in the ED

BackgroundDiagnosing pulmonary embolism (PE) in the emergency department (ED) can be challenging because its signs and symptoms are non-specific. ObjectiveWe compared the efficacy and safety of using age-adjusted D-dimer interpretation, clinical probability-adjusted D-dimer interpretation and standard D-dimer approach to exclude PE in ED patients. Design/methodsWe performed a health records review at two emergency departments over a two-year period. We reviewed all cases where patients had a D-dimer ordered to test for PE or underwent CT or VQ scanning for PE. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. We applied the three D-dimer approaches to the low and moderate probability patients. The primary outcome was exclusion of PE with each rule. Secondary objective was to estimate the negative predictive value (NPV) for each rule. Results1163 emergency patients were tested for PE and 1075 patients were eligible for inclusion in our analysis. PE was excluded in 70.4% (95% CI 67.6–73.0%), 80.3% (95% CI 77.9–82.6%) and 68.9%; (95% CI 65.7–71.3%) with the age-adjusted, clinical probability-adjusted and standard D-dimer approach. The NPVs were 99.7% (95% CI 99.0–99.9%), 99.1% (95% CI 98.3–99.5%) and 100% (95% CI 99.4–100.0%) respectively. ConclusionThe clinical probability-adjusted rule appears to exclude PE in a greater proportion of patients, with a very small reduction in the negative predictive value.

The Value of a Disease-Specific Template and an IT-Based Quality Tracking System in Pulmonary Embolism CT Angiography

The Value of a Disease-Specific Template and an IT-Based Quality Tracking System in Pulmonary Embolism CT Angiography

Benchmarking adult CT-dose levels to regional and national references using a dose-tracking software: a multicentre experience

ObjectivesTo benchmark CT-dose data for standard adult CT studies to regional and national reference levels using a dose-tracking system.MethodsData from five CT systems from three hospitals were collected over a 1- to 2.5-year period (2012–2014), using the same type of dose management system. Inclusion criteria were adult patients and standard CT-head, CT-abdomen-pelvis, CT-thorax, CT-lumbar spine, CT-pulmonary embolism, CT-cervical spine and CT-thorax-abdomen studies, with one helical scan. Volumetric CT-dose index (CTDIvol), dose length product (DLP) and scan length from 31,709 scans were analysed statistically.ResultsAfter dose optimisation CTDIvol and DLP values were below the national diagnostic reference levels (DRLs) for all CT studies and for all systems investigated. Mostly no significant differences were found between CTDIvol and DLP levels (p values ≥ 0.01) of CT studies performed on different scanners within the same hospital. Significant dose differences (p values < 0.01) were instead observed among hospitals for comparable CT studies. Dose level range and scan length differences for similar CT studies were revealed.ConclusionsDose-tracking systems help to reduce CT-dose levels below national DRLs. However, dose and protocol data comparison between and within hospitals has the potential to further reduce variability in dose data of standard adult CT studies.Key Points• Retrospective three-centre study on dose levels of standard adult CT procedures.• Dose-tracking systems help hospitals to stay below national dose reference levels.• Dose-tracking systems help to align CT dose levels between scanners within hospitals.• Benchmarking shows CT dose level variability for similar examinations in different hospitals.• Differences in dose level range/scan length for similar CT studies are revealed.

A Simple, Safe Approach to Decrease Use of CT for Pulmonary Embolism

Pulmonary embolism (PE) is one of the most vexing diagnoses in emergency medicine — a disease with protean symptoms that can be suddenly fatal.

ECG-gated pulmonary artery CTA for evaluation of right ventricular function in patients with acute pulmonary embolism.

To evaluate right ventricular function in patients with acute pulmonary embolism (APE) using electrocardiogram-gated CTA and to discuss the clinical value of pulmonary artery CTA PATIENTS AND METHODS: Based on death risk evaluation, 86 APE patients were divided into high-risk group (n=46) and non-high-risk group (n=40). The CT pulmonary embolism (PE) index and parameters of right ventricular function were analyzed from the CTPA images and compared between the two groups. Potential correlation between the two was also discussed. CT PE index (median 24.69%) of the high-risk group was obviously higher than that of the non-high-risk group (median 8.58%) (P<.05). Except the diameter of superior vena cava, all other parameters of right ventricular function were significantly different between the two groups (P<.05). CT PE index was correlated with the parameters of right ventricular function. ECG-gated pulmonary artery CTA is suitable for assessing the severity of APE and right ventricular function.

SU‐F‐I‐36: In‐Utero Dose Measurements Within Postmortem Subjects for Estimating Fetal Doses in Pregnant Patients Examined with Pulmonary Embolism, Trauma, and Appendicitis CT

Purpose:The imaging of pregnant patients is medically necessary in certain clinical situations. The purpose of this work was to directly measure uterine doses in a cadaver scanned with CT protocols commonly performed on pregnant patients in order to estimate fetal dose and assess potential risk.Method:One postmortem subject was scanned on a 320‐slice CT scanner with standard pulmonary embolism, trauma, and appendicitis protocols. All protocols were performed with the scan parameters and ranges currently used in clinical practice. Exams were performed both with and without iterative reconstruction to highlight the dose savings potential. Optically stimulated luminescent dosimeters (OSLDs) were inserted into the uterus in order to approximate fetal doses.Results:In the pulmonary embolism CT protocol, the uterus is outside of the primary beam, and the dose to the uterus was under 1 mGy. In the trauma and appendicitis protocols, the uterus is in the primary beam, the fetal dose estimates were 30.5 mGy for the trauma protocol, and 20.6 mGy for the appendicitis protocol. Iterative reconstruction reduced fetal doses by 30%, with uterine doses at 21.3 for the trauma and 14.3 mGy for the appendicitis protocol.Conclusion:Fetal doses were under 1 mGy when exposed to scatter radiation, and under 50 mGy when exposed to primary radiation with the trauma and appendicitis protocols. Consistent with the National Council on Radiation Protection &amp; Measurements (NCRP) and the International Commission on Radiological Protection (ICRP), these doses exhibit a negligible risk to the fetus, with only a small increased risk of cancer. Still, CT scans are not recommended during pregnancy unless the benefits of the exam clearly outweigh the potential risk. Furthermore, when possible, pregnant patients should be examined on CT scanners equipped with iterative reconstruction in order to keep patient doses as low as reasonable achievable.

Usability of the Massachusetts Prescription Drug Monitoring Program in the Emergency Department: A Mixed-methods Study.

Prescription drug monitoring programs (PDMPs) are underutilized, despite evidence showing that they may reduce the epidemic of opioid-related addiction, diversion, and overdose. We evaluated the usability of the Massachusetts (MA) PDMP by emergency medicine providers (EPs), as a system's usability may affect how often it is used. This was a mixed-methods study of 17 EPs. We compared the time and number of clicks required to review one patient's record in the PDMP to three other commonly performed computer-based tasks in the emergency department (ED: ordering a computed tomography [CT] scan, writing a prescription, and searching a medication history service integrated within the electronic medical record [EMR]). We performed semistructured interviews and analyzed participant comments and responses regarding their experience using the MA PDMP. The PDMP task took a longer time to complete (mean = 4.22 minutes) and greater number of mouse clicks to complete (mean = 50.3 clicks) than the three other tasks (CT-pulmonary embolism = 1.42 minutes, 24.8 clicks; prescription = 1.30 minutes, 19.5 clicks; SureScripts = 1.45 minutes, 9.5 clicks). Qualitative analysis yielded four main themes about PDMP usability, three negative and one positive: 1) difficulty accessing the PDMP, 2) cumbersome acquiring patient medication history information within the PDMP, 3) nonintuitive display of patient medication history information within the PDMP, and 4) overall perceived value of the PDMP despite an inefficient interface. The complicated processes of gaining access to, logging in, and using the MA PDMP are barriers to preventing its more frequent use. All states should evaluate the PDMP usability in multiple practice settings including the ED and work to improve provider enrollment, login procedures, patient information input, prescription data display, and ultimately, PDMP data integration into EMRs.

Stunned Myocardium due to Decompensation from Hypovolemic Shock in a Pregnant Woman with Uterine Atony Following Cesarean Section

Transient post ischemic left ventricular dysfunction has been called stunned myocardium. The stunned myocardium can lead cardiac problems such as arrhythmias, left ventricular dysfunction, and a myocardial infarction. Stunned myocardium is a reversible condition. In this case, a 25 year old female patient with a history of mild intermittent asthma became hypovolemic and got into shock after developing uterine atony following a cesarean section. The patient did not respond to rapid volume replacement therapy. Subsequently, the patient had acute pulmonary edema, hypotension, and tachycardia developed. Echocardiogram was done showing severe left ventricular dysfunction (ejection fraction (EF), 25-35%) with left inferobasal wall hypokinesis and no right ventricular dysfunction or severe tricuspid regurgitation or right ventricular hypertrophy. Chest x-ray showed newly diagnosed cardiomegaly and bilateral pulmonary congestion. Initial troponin I was elevated, however, the level of troponin I remained stable with the same baseline value. Patient was at high risk for pulmonary embolism (PE) based on risk assessment, therefore, anticoagulation was started. Chest CT for pulmonary embolism was performed, and the result was negative. Two days after, repeated echocardiogram showed improved EF was 35%. Patient was discharged with beta –blocker to reduce oxygen demand of myocardium. This case supports hypovolemic shock not responding to volume replacement therapy can cause myocardium damage which is able to be diagnosed with stunned myocardium.

Body CT in unprovoked PE – a worthwhile fishing trip?

Purpose Cancer and pulmonary embolism (PE) have an established causal relationship but there is a paucity of data on the incidence of occult cancer in patients with PE and no other risk factors. The National Institute of Health and Care Excellence (NICE) guidelines recommend further investigation with abdomino-pelvic computed tomography (CT AP) increasing demand on radiology departments. We aimed to determine if this is an appropriate use of resources by ascertaining occult cancer prevalence, type and stage at diagnosis in such cases. Methods and materials Patients with unprovoked PE diagnosed on CTPA and who subsequently had CT AP were identified from the radiology information system (RIS)/picture archiving and communication system (PACS) for the two-year period January 2013 to December 2014. The following were recorded: age, sex, diagnosis of a cancer, and if present the type and stage. Results Of patients with a positive CTPA and subsequent CT AP, 7.4% had occult cancers (ten cancers in 135 patients). The detected cancers were pancreatic, colonic, bladder, prostate, hepatic, pelvic soft tissue sarcoma and haematological. Of these, 70% were locally advanced or metastatic cancers. Age range: 64–92. No specific factors were identified to enable risk stratification of these patients. Conclusion Occult cancers in patients with PE are often advanced with a poor two-year survival rate. However, a small proportion are treatable and investigation in PE patients with no provoking factors should be considered. No risk factors are identified to risk stratify the cancer detection scans.

Effects of Performance Feedback Reports on Adherence to Evidence-Based Guidelines in Use of CT for Evaluation of Pulmonary Embolism in the Emergency Department: A Randomized Trial.

The purpose of this study was to assess whether implementing emergency department (ED) physician performance feedback reports improves adherence to evidence-based guidelines for use of CT for evaluation of pulmonary embolism (PE) beyond that achieved with clinical decision support (CDS) alone. This prospective randomized controlled trial was conducted from January 1, 2012, to December 31, 2013, at an urban level 1 adult trauma center ED. Attending physicians were stratified into quartiles by use of CT for evaluation of PE in 2012 and were randomized to receive quarterly feedback reporting or not, beginning January 2013. Reports consisted of individual and anonymized group data on guideline adherence (using the Wells criteria), use of CT for PE (number of CT examinations for PE per 1000 patients), and yield (percentage of CT examinations for PE with positive findings). We compared guideline adherence (primary outcome) and use and yield (secondary outcomes) of CT for PE between the control and intervention groups in 2013 and with historical imaging data from 2012. Of 109,793 ED patients during the control and intervention periods, 2167 (2.0%) underwent CT for evaluation of PE. In the control group, guideline adherence remained unchanged between 2012 (78.8% [476/604]) and 2013 (77.2% [421/545]) (p = 0.5); in the intervention group, guideline adherence increased 8.8% after feedback report implementation, from 78.3% (426/544) to 85.2% (404/474) (p < 0.05). Use and yield were unchanged in both groups. Implementation of quarterly feedback reporting resulted in a modest but significant increase in adherence to evidence-based guidelines for use of CT for evaluation of PE in ED patients, enhancing the impact of CDS alone. These results suggest potentially synergistic effects of traditional performance improvement tools with CDS to improve guideline adherence.

Study of clinical, radiological and echocardiographic features and correlation of Qanadli CT index with RV dysfunction and outcomes in pulmonary embolism

BackgroundThere are no Indian studies correlating the CT pulmonary embolism index (Qanadli) with right ventricular function and outcome. In the present study we aimed to study the clinical manifestations of patients presenting with acute pulmonary thromboembolism and correlate the radiographic features with echocardiographic features and outcome. MethodsThirty five patients presenting with symptomatic acute pulmonary thromboembolism in between 2011 and 2013 were studied for clinical, radiological and echocardiographic features and outcome (in-hospital & 1 month follow up). ResultsThe mean duration of presentation after onset of symptoms was 5.7 ± 3.7 days. Right ventricular dysfunction was observed in 11 (31.4%) patients. Out of 35 patients in whom CT pulmonary angiogram performed, 14 patients had Qanadli PE index >60% of whom 11 (78.6%) patients had right ventricular dysfunction. None had right ventricular dysfunction when PE index was <60% (p < 0.001). There was significant correlation between pulmonary vascular obstruction index and right ventricular dysfunction (p < 0.0001). Nine (25.7%) patients were thrombolysed with Streptokinase. Total mortality including in-hospital and 1 month follow up was 11.4% (4 patients). The mortality in patients with PE index >60% was 21.4% and was nil with <60% (p = 0.02). The mortality in patients with right ventricular dysfunction was 27.2% and was nil without right ventricular dysfunction (p = 0.0075). ConclusionA PE index which was shown to be a strong independent predictor of right ventricular dysfunction in PE, correlating linearly with different variables associated with higher morbidity and mortality, enabling accurate risk stratification and selection of patients for more aggressive treatment.

Abstract 3844: Venous thromboembolism in patients with pancreatic cancer

Abstract Background: Venous thromboembolism (VTE) is a critical complication of malignant disease. Pancreatic cancer is one of the cancers most commonly associated VTE. In general, the VTE incidence rate of Asians is lower than that of Caucasians. In 2007, a Korean study reported that only four cases of VTE (5.3%) occurred in Seventy five patients with advanced pancreatic adenocarcinoma. We evaluated VTE incidence in pancreatic cancer and characteristics of pancreatic cancer patients with VTE. Method: We retrospectively reviewed the medical records of patients with histopathologically proven pancreatic cancer from January 2006 to December 2012 at Soonchunhyang university hospital. We detected VTE through CT (chest CT, pulmonary embolism CT) and low extremity ultrasoundgraphy. Results Five hundred and fourteen patients with pancreatic adenocarcinoma were enrolled. (M: F, 300:214, localized: locally advanced: metastatic=31:230:253, mean age: 66.7 years). Ninety six of 514 patients (18.6%, symptomatic: aymptomatic=38:58, PE: DVT: PE+DVT: visceral thrombosis=20:19:19:38) were diagnosed as VTE. At the time of DVT diagnosis, cancer status of 50 patients cancer was progression, and that of 15 was stable. Thirty one patients were diagnosed with the pancreatic cancer and VTE, at the same time. They all had metastatic lesions. Fifty VTE patients were treated with antithrombotic therapy. Ninety three of 96 patients died, and three of them have probability that cause of death was VTE. The others died of pancreatic cancer progression. From pancreatic cancer diagnosis to VTE diagnosis, the period is 1.7month. (95%CI 1.1-2.3 month). Median overall survival (OS) was not significantly different between pancreatic cancer with VTE or without VTE. OS was significantly longer VTE patients after pancreatic cancer diagnosis than VTE patients with pancreatic cancer at the same time (10.73m vs. 1.7, p=0.00). Conclusion The incidence of VTE (18.6%) in Soonchunhyang university hospital with pancreatic cancer was not lower than that in western groups. Citation Format: Seug Yun Yoon, Namsu Lee, Sook-Ja Kim, Hee-Jeong Cheong, Kyoung Ha Kim, Jong-Ho Won, Hee Sook Park. Venous thromboembolism in patients with pancreatic cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3844. doi:10.1158/1538-7445.AM2014-3844

OP0055 Utility and Associated Risk of Pulmonary Embolism CT Scans in the Michigan Lupus Cohort

BackgroundExcessive amounts of ionizing radiation from CT scanning can increase cancer risk. Lupus patients are frequently evaluated for chest pain and may have multiple pulmonary embolism CT (PE CT) scans...

SU‐E‐I‐98: Dose Comparison for Pulmonary Embolism CT Studies: Single Energy Vs. Dual Energy

Purpose:The purpose of this study was to assess and compare the size specific dose estimate (SSDE), dose length product (DLP) and noise relationship for pulmonary embolism studies evaluated by single source dual energy computed tomography (DECT) against conventional CT (CCT) studies in a busy cancer center and to determine the dose savings provided by DECT.Methods:An IRB‐approved retrospective study was performed to determine the CTDIvol and DLP from a subset of patients scanned with both DECT and CCT over the past five years. We were able to identify 30 breast cancer patients (6 male, 24 female, age range 24 to 81) who had both DECT and CCT studies performed. DECT scans were performed with a GE HD 750 scanner (140/80 kVp, 480 mAs and 40 mm) and CCT scans were performed with a GE Lightspeed 16 slice scanner (120 kVp, 352 mAs, 20 mm). Image noise was measured by placing an ROI and recording the standard deviation of the mean HU along the descending aorta.Results:The average DECT patient size specific dose estimate was to be 14.2 ± 1.7 mGy as compared to 22.4 ± 2.7 mGy from CCT PE studies, which is a 37% reduction in the SSDE. The average DECT DLP was 721.8 ± 84.6 mGy‐cm as compared to 981.8 ± 106.1 mGy‐cm for CCT, which is a 26% decrease. Compared to CCT the image noise was found to decrease by 19% when using DECT for PE studies.Conclusion:DECT SSDE and DLP measurements indicate dose savings and image noise reduction when compared to CCT. In an environment that heavily debates CT patient doses, this study confirms the effectiveness of DECT in PE imaging.

Venous Thromboembolism (VTE) In Patients With Pancreatic Cancer

Background Venous thromboembolism (VTE) is a critical complication of malignant disease. Pancreatic cancer is one of the cancers most commonly associated VTE. In general, the VTE incidence rate of Asians is lower than that of Caucasians. In 2007, a Korean study reported that only four cases of VTE (5.3%) occurred in Seventy five patients with advanced pancreatic adenocarcinoma. We evaluated VTE incidence in pancreatic cancer and characteristics of pancreatic cancer patients with VTE. (We found out that VTE incidence rate among Asians was not lower, and the event of VTE was poor prognosis.) Method We retrospectively reviewed the medical records of patients with histopathologically proven pancreatic cancer from January 2006 to December 2012 at Soonchunhyang university hospital. We detected VTE through CT (chest CT, pulmonary embolism CT) and low extremity ultrasoundgraphy. Results Five hundred and fourteen patients with pancreatic adenocarcinoma were enrolled. (M: F, 300:214, localized: locally advanced: metastatic=31:230:253, mean age: 66.7 years). Ninety six of 514 patients (18.6%, symptomatic: aymptomatic=38:58, PE: DVT: PE+DVT: visceral thrombosis=20:19:19:38) were diagnosed as VTE. At the time of DVT diagnosis, cancer status of 50 patients cancer was progression, and that of 15 was stable. Thirty one patients were diagnosed with the pancreatic cancer and VTE, at the same time. They all had metastatic lesions. Fifty VTE patients were treated with antithrombotic therapy. Ninety three of 96 patients died, and three of them have probability that cause of death was VTE. The others died of pancreatic cancer progression. From pancreatic cancer diagnosis to VTE diagnosis, the period is 1.7month. (95%CI 1.1-2.3 month). Median overall survival (OS) was not significantly different between pancreatic cancer with VTE or without VTE. OS was significantly longer VTE patients after pancreatic cancer diagnosis than VTE patients with pancreatic cancer at the same time (10.73m vs. 1.7, p=0.00). Conclusion The incidence of VTE (18.6%) in Soonchunhyang university hospital with pancreatic cancer was not lower than that in western groups. Disclosures: No relevant conflicts of interest to declare.

SU‐E‐I‐35: Using Six‐Sigma Methodology for Practice Quality Improvement Projects

Purpose: To illustrate the utility of Six‐Sigma tools for Practice Quality Improvement Projects Methods: Practice Quality Improvement (PQI) Projects are required as a component of Maintenance of Certification (MOC). The methodology of Define, Measure, Analyze, Improve, and Control (DMAIC) is particularly well suited for PQI. An example of the DMAIC approach is presented using the CT pulmonary embolism protocol. Within DMAIC the Define phase consists of stating the problem and the processes involved in the task. During Measure phase the baseline performance of the process is established. Analyze phase involves looking at the data collected and proposing methods to enhance the process. The Improve phase comprises the changes that are made to the process. Control phase consists of follow‐up to insure that improvements are robust and remain in place over time. For the CT pulmonary embolism example:Define: For dose reduction purposes kV is switched from 120 to 100 resulting in higher mA values than desired by the Radiologist. Manual mA is utilized instead of mA modulation techniques.Measure: Baseline CTDIvol values across patient sizes for pulmonary embolism.Analyze: What modulation algorithm will Result in similar doses? Improve: Pilot studies with adjusted mA modulation parameters. Control: Establish a database to continually monitor doses from pulmonary embolism protocol. Results: Baseline measurements demonstrate four dose levels 2.1 mGy, 3.9 mGy, 4.9 mGy, and 10.9 mGy, depending on patient size measured laterally on a localizer radiograph. After a size‐based protocol chart is implemented dose values are variable ranging from 1.02 mGy to 12.19 mGy. Conclusion: The DMAIC approach can successfully be implemented during Practice Quality Improvement Projects.

Comparison of Discrepancy Rates in Resident and Faculty Interpretations of On-Call PE CT and V/Q Scans: Is One Study More Reliable During Off Hours?

There has been no comparison of concordance rates for residents' and faculty members' interpretations of pulmonary embolism (PE) CT and ventilation/perfusion (V/Q) studies. If significantly different rates of agreement are demonstrable, this could influence which test is ordered during off hours. The purpose of this study was to evaluate how the performance of residents compared with that of faculty members in interpreting these two modalities. Interobserver agreement between preliminary resident reports and final attending radiologist interpretations was calculated retrospectively for PE CT studies (n = 1,179) and V/Q scans (n = 331) interpreted by on-call residents from April 2007 to October 2008. Discordant cases were reviewed for clinical significance and outcomes at 3 months. Interobserver variability was also evaluated relative to residents' training levels and faculty members' years of experience. Interobserver agreement between faculty members and residents was substantial, at 95% for PE CT (κ = 0.77) and 77.9% for V/Q scans (κ = 0.67). Although changes in interpretation were significantly more common with V/Q scans (22.1% vs 5%; χ(2) < .0001), the rates of clinically significant discrepancy did not differ significantly between the modalities (2.1% for V/Q vs 1.2% for PE CT; χ(2)P = .20). The overall discrepancy rate and the rate of clinically significant discrepancy did not correlate with residents' training levels or faculty members' years of experience. Concordance rates for residents' interpretations of V/Q scans and PE CT studies were high, and discrepancies resulting in changes in patient management were rare for both modalities. Residents' preliminary interpretations of both modalities are reliable and safe for making initial patient management decisions.

Nieskuteczność heparyn drobnocząsteczkowych w pierwotnej profilaktyce przeciwzakrzepowej u chorego z wrodzonym niedoborem antytrombiny (AT)

A 39 year old man with normal, stable blood pressure was admitted to the Cardio-Pulmonary Intensive Care Unit due to diagnosed spiral CT pulmonary embolism (PE) and deep venous thrombosis (DVT). In 1999, a hereditary antithrombin (AT) deficiency was confirmed in the presented case. In 2006, because of a knee injury, the patient was provided with a plaster cast and primary antithrombotic prophylaxis with low molecular weight heparin (LMWH) (80 mg of enoxaparin) was administered subcutaneously once a day (patient's weight was 80 kg). Despite prophylaxis PE and DVT occurred after 6 weeks of treatment. The patient was successfully treated with unfractioned heparin, repeated infusions of AT concentrate and oral anticoagulants (OA). Transient pulmonary hypertension documented by echocardiography and hemoptysis complicated course of PE. Secondary prophylaxis with OA, and INR maintenance between 2-3, was successfully continued.

Time-Resolved MR Angiography: A Primary Screening Examination of Patients with Suspected Pulmonary Embolism and Contraindications to Administration of Iodinated Contrast Material

The purpose of this study was to evaluate the efficiency and reproducibility of a single-breath-hold time-resolved 3D MR angiographic technique in the diagnosis of pulmonary embolism. Twenty-seven consecutively registered patients with clinically suspected pulmonary embolism and contraindication to administration of iodinated contrast agents underwent imaging by time-resolved 3D MR angiography at 1.5 T. Bolus timing was not required. Two reviewers independently analyzed MR angiograms for overall image quality and evidence of pulmonary embolism. Additional imaging techniques, including pulmonary embolism CT angiography, ventilation-perfusion (V/Q) lung scanning, venous duplex sonography for deep venous thrombosis, and echocardiography for right ventricular strain, and 30-day and 3-month clinical follow-up were used to confirm the MR angiographic findings. Image quality was sufficient for diagnosis in the cases of 98% of lobar, 92-93% of segmental, and 94-95% of all vessel parts from the main pulmonary artery though the segmental branches with excellent interobserver agreement. Findings on MR angiography were concordant with the anatomic distribution of abnormalities for all pulmonary embolism CT angiographic examinations (n = 2) and four of seven V/Q lung scans. Screening with time-resolved 3D MR angiography allowed confident exclusion or inclusion of pulmonary embolism in 96% of patients. Time-resolved 3D MR angiography provides high temporal resolution (nine phases, one phase per 3.3 seconds) and consistently yields arterial phase only images. As found with clinical follow-up, confident diagnosis of pulmonary embolism from the main pulmonary artery through the segmental branches can be incorporated into a clinical service as a screening examination of patients with contraindications to the use of iodinated contrast material.

Computed tomography pulmonary embolism index for the assessment of survival in patients with pulmonary embolism

This study was an analysis of the correlation between pulmonary embolism (PE) and patient survival. Among 694 consecutive patients referred to our institution with clinical suspicion of acute PE who underwent CT pulmonary angiography, 188 patients comprised the study group: 87 women (46.3%, median age: 60.7; age range: 19-88 years) and 101 men (53.7%, median age: 66.9; age range: 21-97 years). PE was assessed by two radiologist who were blinded to the results from the follow-up. A PE index was derived for each set of images on the basis of the embolus size and location. Results were analyzed using logistic regression, and correlation with risk factors and patient outcome (survival or death) was calculated. We observed no significant correlation between the CTPE index and patient outcome (p = 0.703). The test of logistic regression with the sum of heart and liver disease or presence of cancer was significantly (p< 0.05) correlated with PE and overall patient outcome. Interobserver agreement showed a significant correlation rate for the assessment of the PE index (0.993; p< 0.001). In our study the CT PE index did not translate into patient outcome. Prospective larger scale studies are needed to confirm the predictive value of the index and refine the index criteria.