European Radiology

, Volume 14, Issue 1, pp 93–98 | Cite as

Value of negative spiral CT angiography in patients with suspected acute PE: analysis of PE occurrence and outcome

  • C. R. KrestanEmail author
  • N. Klein
  • D. Fleischmann
  • A. Kaneider
  • C. Novotny
  • S. Kreuzer
  • C. Riedl
  • E. Minar
  • K. Janata
  • C. J. Herold


The aim of this study was to analyze pulmonary embolism (PE) occurrence and retrospective clinical outcome in patients with clinically suspected acute PE and a negative spiral CT angiography (SCTA) of the pulmonary arteries. Within a 35-month period, 485 consecutive patients with clinical symptoms of acute PE underwent SCTA of the pulmonary arteries. Patients with a negative SCTA and without anticoagulation treatment were followed-up and formed the study group. Patient outcome and recurrence of PE was evaluated retrospectively during a period of 6 months after the initial SCTA, and included a review of computerized patient records, and interviews with physicians and patients. Patients were asked to fill out a questionnaire concerning all relevant questions about their medical history and clinical course during the follow-up period. Special attention was focused on symptoms indicating recurrent PE, as well as later confirmation and therapy of PE. Of the 485 patients, 325 patients (67%) had a negative scan, 134 (27.6%) had radiological signs of PE, and 26 (5.4%) had an indeterminant result. Of 325 patients with a negative scan, 269 (83%) were available for follow-up. The main reasons for loss to follow-up were change of address, name, or phone number, or non-resident patients who left abroad. Of 269 patients available for follow-up, 49 patients (18.2% of 269) received anticoagulant treatment because of prior or recent deep venous thrombosis (32.6%) or a history of PE (34.7%), cardiovascular disease (18.4%), high clinical probability (8.2%), positive ventilation–perfusion scan (4.2%), and elevated D-dimer test (2%). The remaining 220 patients, who did not receive anticoagulant medication, formed the study group. Of this study group, 1 patient died from myocardial infarction 6 weeks after the initial SCTA, and the postmortem examination also detected multiple peripheral emboli in both lungs (p=0.45%; 0.01–2.5, 95% confidence interval). The PE did not occur in any other patient. In patients with suspected PE and negative SCTA without anticoagulant therapy, the risk of recurrent PE in this study was less than 1% and similar to that in patients after a negative pulmonary angiogram. Therefore, we conclude that patients can be managed safely without anticoagulation therapy; however, this approach may not be appropriate for critically ill patients and those with persistent high clinical suspicion of acute PE.


Pulmonary embolism Helical computed tomography Clinical effectiveness 


  1. 1.
    Goldhaber SZ, Visani L, Rosa M de (1999) Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 353:1386–1389PubMedGoogle Scholar
  2. 2.
    Hampson NB, Culver BH (1997) Clinical aspects of pulmonary embolism. Semin Ultrasound CT MR 18:314–322PubMedGoogle Scholar
  3. 3.
    Cross JJ, Kemp PM, Walsh CG, Flower CD, Dixon AK (1998) A randomized trial of spiral CT and ventilation perfusion scintigraphy for the diagnosis of pulmonary embolism. Clin Radiol 53:177–182PubMedGoogle Scholar
  4. 4.
    Kim KI, Muller NL, Mayo JR (1999) Clinically suspected pulmonary embolism: utility of spiral CT. Radiology 210:693–697PubMedGoogle Scholar
  5. 5.
    van Rossum AB, Pattynama PM, Mallens WM, Hermans J, Heijerman HG (1998) Can helical CT replace scintigraphy in the diagnostic process in suspected pulmonary embolism? A retrolective–prolective cohort study focusing on total diagnostic yield. Eur Radiol 8:90–96PubMedGoogle Scholar
  6. 6.
    Holbert JM, Costello P, Federle MP (1999) Role of spiral computed tomography in the diagnosis of pulmonary embolism in the emergency department. Ann Emerg Med 33:520–528PubMedGoogle Scholar
  7. 7.
    Diffin DC, Leyendecker JR, Johnson SP, Zucker RJ, Grebe PJ (1998) Effect of anatomic distribution of pulmonary emboli on interobserver agreement in the interpretation of pulmonary angiography. AJR 171:1085–1089Google Scholar
  8. 8.
    de Monye W, van Strijen MJ, Huisman MV, Kieft GJ, Pattynama PM (2000) Suspected pulmonary embolism: prevalence and anatomic distribution in 487 consecutive patients. Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism (ANTELOPE) Group. Radiology 215:184–188PubMedGoogle Scholar
  9. 9.
    Stein PD, Henry JW, Gottschalk A (1999) Reassessment of pulmonary angiography for the diagnosis of pulmonary embolism: relation of interpreter agreement to the order of the involved pulmonary arterial branch. Radiology 210:689–691PubMedGoogle Scholar
  10. 10.
    Henry JW, Relyea B, Stein PD (1995) Continuing risk of thromboemboli among patients with normal pulmonary angiograms. Chest 107:1375–1378PubMedGoogle Scholar
  11. 11.
    Rajendran JG, Jacobson AF (1999) Review of 6 month mortality following low-probability lung scans. Arch Intern Med 159:349–352CrossRefPubMedGoogle Scholar
  12. 12.
    Ferretti GR, Bosson JL, Buffaz PD et al. (1997) Acute pulmonary embolism: role of helical CT in 164 patients with intermediate probability at ventilation–perfusion scintigraphy and normal results at duplex US of the legs. Radiology 205:453–458PubMedGoogle Scholar
  13. 13.
    Goodman LR, Lipchik RJ, Kuzo RS, Liu Y, McAuliffe TL, O'Brien DJ (2000) Subsequent pulmonary embolism: risk after a negative helical CT pulmonary angiogram—prospective comparison with scintigraphy. Radiology 215:535–542Google Scholar
  14. 14.
    Remy-Jardin M, Remy J, Artaud D, Fribourg M, Beregi JP (1998) Spiral CT of pulmonary embolism: diagnostic approach, interpretive pitfalls and current indications. Eur Radiol 8:1376–1390PubMedGoogle Scholar
  15. 15.
    Kipper MS, Moser KM, Kortman KE, Ashburn WL (1982) Longterm follow-up of patients with suspected pulmonary embolism and a normal lung scan: perfusion scans in embolic suspects. Chest 82:411–415PubMedGoogle Scholar
  16. 16.
    Henry JW, Stein PD, Gottschalk A, Raskob GE (1996) Pulmonary embolism among patients with a nearly normal ventilation/perfusion lung scan. Chest 110:395–398PubMedGoogle Scholar
  17. 17.
    Garg K, Sieler H, Welsh CH, Johnston RJ, Russ PD (1999) Clinical validity of helical CT being interpreted as negative for pulmonary embolism: implications for patient treatment. AJR 172:1627–1631Google Scholar
  18. 18.
    van Beek EJ, Kuyer PM, Schenk BE, Brandjes DP, ten Cate JW, Buller HR (1995) A normal perfusion lung scan in patients with clinically suspected pulmonary embolism: frequency and clinical validity. Chest 108:170–173PubMedGoogle Scholar
  19. 19.
    Forauer AR, McLean GK, Wallace LP (1998) Clinical follow-up of patients after a negative digital subtraction pulmonary arteriogram in the evaluation of pulmonary embolism. J Vasc Interv Radiol 9:903–908PubMedGoogle Scholar
  20. 20.
    Gottsater A, Berg A, Centergard J, Frennby B, Nirhov N, Nyman U (2001) Clinically suspected pulmonary embolism: Is it safe to withhold anticoagulation after a negative spiral CT? Eur Radiol 11:65–72PubMedGoogle Scholar
  21. 21.
    van Strijen MJ, de Monye W, Kieft GJ, Prins MH, Huisman MV, Pattynama PM (2003) Single-detector helical computed tomography as the primary diagnostic test in suspected pulmonary embolism: a multicenter clinical management study of 510 patients. Ann Intern Med 138:307–314PubMedGoogle Scholar
  22. 22.
    Swensen JS, Sheedy PF, Ryu JH, Pickett DD, Schleck CD, Ilstrup DM, Heit JA (2002) Outcomes after withholding anticoagulation from patients with suspected acute pulmonary embolism and negative computed tomographic findings: a cohort study. Mayo Clin Proc 77:130–138PubMedGoogle Scholar
  23. 23.
    Loud PA, Katz DS, Bruce DA, Klippenstein DL, Grossman ZD (2001) Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography. Radiology 219:498–502PubMedGoogle Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • C. R. Krestan
    • 1
    Email author
  • N. Klein
    • 1
  • D. Fleischmann
    • 1
  • A. Kaneider
    • 1
  • C. Novotny
    • 4
  • S. Kreuzer
    • 1
  • C. Riedl
    • 1
  • E. Minar
    • 2
  • K. Janata
    • 3
  • C. J. Herold
    • 1
  1. 1.Department of RadiologyUniversity Hospital of Vienna-AKHViennaAustria
  2. 2.Division of Angiology, Department of Internal MedicineUniversity Hospital of Vienna-AKHViennaAustria
  3. 3.Department of Emergency MedicineUniversity Hospital of Vienna-AKHViennaAustria
  4. 4.Department of Nuclear MedicineUniversity Hospital of Vienna-AKHViennaAustria

Personalised recommendations