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Diagnosing pulmonary embolism: time to rewrite the textbooks

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Abstract

Computed tomography (CT) is rapidly becoming the first line modality for imaging pulmonary embolism (PE). However, limitations for the accurate diagnosis of small peripheral emboli have prevented the unanimous acceptance of CT as the new standard of reference for imaging PE although the actual significance of the detection and treatment of isolated peripheral emboli is uncertain. At the same time the high negative predictive value of CT pulmonary angiography for excluding clinically significant PE has been established in retrospective and prospective studies. The introduction of multidetector-row spiral CT has greatly improved visualization of peripheral pulmonary arteries and detection of small emboli. Previous concerns regarding the accuracy of spiral CT for the accurate diagnosis of peripheral pulmonary emboli should thus be overcome. Multidetector-row spiral CT has become a widely available and cost-effective modality, which has surpassed other imaging modalities for PE diagnosis to a point where over-utilization may become of concern. Our most immediate goal must be to educate our referring colleagues about these important transitions so that the diagnostic algorithm in patients with suspected acute PE is updated to accurately reflect our current diagnostic prowess in medical imaging.

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References

  1. SZ Goldhaber L Visani M De Rosa (1999) ArticleTitleAcute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 353 1386–1389 Occurrence Handle10.1016/S0140-6736(98)07534-5 Occurrence Handle1:STN:280:DyaK1M3ktFOmtQ%3D%3D Occurrence Handle10227218

    Article  CAS  PubMed  Google Scholar 

  2. KL Dunn JP Wolf DM Dorfman P Fitzpatrick JL Baker SZ Goldhaber (2002) ArticleTitleNormal D-dimer levels in emergency department patients suspected of acute pulmonary embolism. J Am Coll Cardiol 40 1475 Occurrence Handle12392839 Occurrence Handle1:CAS:528:DC%2BD38XovVGkur8%3D

    PubMed  CAS  Google Scholar 

  3. JA Kline RD Nelson RE Jackson DM Courtney (2002) ArticleTitleCriteria for the safe use of D-dimer testing in emergency department patients with suspected pulmonary embolism: a multicenter US study. Ann Emerg Med 39 144–152 Occurrence Handle11823768

    PubMed  Google Scholar 

  4. F Turkstra PM Kuijer EJ van Beek DP Brandjes JW ten Cate HR Buller (1997) ArticleTitleDiagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism. Ann Intern Med 126 775–781 Occurrence Handle9148650 Occurrence Handle1:STN:280:DyaK2s3ot12itw%3D%3D

    PubMed  CAS  Google Scholar 

  5. LM Jongbloets AW Lensing MM Koopman HR Buller JW ten Cate (1994) ArticleTitleLimitations of compression ultrasound for the detection of symptomless postoperative deep vein thrombosis. Lancet 343 1142–1144 Occurrence Handle7910237 Occurrence Handle1:STN:280:DyaK2c3jvFSgtg%3D%3D

    PubMed  CAS  Google Scholar 

  6. PS Wells AW Lensing BL Davidson MH Prins J Hirsh (1995) ArticleTitleAccuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery. A meta-analysis. Ann Intern Med 122 47–53 Occurrence Handle1:STN:280:DyaK2M%2Fnslaitw%3D%3D

    CAS  Google Scholar 

  7. MR Mac Gillavry BJ Sanson HR Buller DP Brandjes (2000) ArticleTitleCompression ultrasonography of the leg veins in patients with clinically suspected pulmonary embolism: is a more extensive assessment of compressibility useful? Thromb Haemost 84 973–976 Occurrence Handle11154143 Occurrence Handle1:CAS:528:DC%2BD3MXlvFaltA%3D%3D

    PubMed  CAS  Google Scholar 

  8. JW Gurney (1993) ArticleTitleNo fooling around: direct visualization of pulmonary embolism. radiology 188 618–619 Occurrence Handle1:STN:280:DyaK3szlsV2rtA%3D%3D Occurrence Handle8351321

    CAS  PubMed  Google Scholar 

  9. PK Woodard (1997) ArticleTitlePulmonary arteries must be seen before they can be assessed. Radiology 204 11–12 Occurrence Handle9205214 Occurrence Handle1:STN:280:DyaK2szkvFaisg%3D%3D

    PubMed  CAS  Google Scholar 

  10. R Hull GE Raskob JS Ginsberg et al. (1994) ArticleTitleA noninvasive strategy for the treatment of patients with suspected pulmonary embolism. Arch Intern Med 154 289–297 Occurrence Handle10.1001/archinte.154.3.289 Occurrence Handle1:STN:280:DyaK2c7isl2isg%3D%3D Occurrence Handle8297195

    Article  CAS  PubMed  Google Scholar 

  11. AB van Rossum AR van Erkel EL van Persijn van Meerten ER Ton SA Rebergen PM Pattynama (1998) ArticleTitleAccuracy of helical CT for acute pulmonary embolism: ROC analysis of observer performance related to clinical experience. Eur Radiol 8 1160–1164 Occurrence Handle9724430 Occurrence Handle1:STN:280:DyaK1czptFOrsw%3D%3D

    PubMed  CAS  Google Scholar 

  12. K Garg CH Welsh AJ Feyerabend et al. (1998) ArticleTitlePulmonary embolism: diagnosis with spiral CT and ventilation-perfusion scanning–correlation with pulmonary angiographic results or clinical outcome. Radiology 208 201–208 Occurrence Handle9646814 Occurrence Handle1:STN:280:DyaK1czhtVOrsA%3D%3D

    PubMed  CAS  Google Scholar 

  13. AB van Rossum PM Pattynama WM Mallens J Hermans HG Heijerman (1998) ArticleTitleCan helical CT replace scintigraphy in the diagnostic process in suspected pulmonary embolism? A retrospective-prospective cohort study focusing on total diagnostic yield. Eur Radiol 8 90–96 Occurrence Handle1:STN:280:DyaK1c7gs1amtg%3D%3D

    CAS  Google Scholar 

  14. H Blachere V Latrabe M Montaudon et al. (2000) ArticleTitlePulmonary embolism revealed on helical CT angiography: comparison with ventilation-perfusion radionuclide lung scanning. AJR Am J Roentgenol 174 1041–1047 Occurrence Handle10749247 Occurrence Handle1:STN:280:DC%2BD3c3htVyjtw%3D%3D

    PubMed  CAS  Google Scholar 

  15. AR van Erkel AB van Rossum JL Bloem J Kievit PNT Pattynama (1996) ArticleTitleSpiral CT angiography for suspected pulmonary embolism: a cost-effectiveness analysis. Radiology 201 29–36 Occurrence Handle8816516 Occurrence Handle1:STN:280:DyaK28vhtlemtw%3D%3D

    PubMed  CAS  Google Scholar 

  16. M Remy-Jardin J Remy L Wattinne F Giraud (1992) ArticleTitleCentral pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breath-hold technique–comparison with pulmonary angiography. Radiology 185 381–387 Occurrence Handle1:STN:280:DyaK3s%2FivFeisQ%3D%3D Occurrence Handle1410342

    CAS  PubMed  Google Scholar 

  17. CL Teigen TP Maus PF II Sheedy et al. (1995) ArticleTitlePulmonary embolism: diagnosis with contrast-enhanced electron beam CT and comparison with pulmonary angiography. Radiology 194 313–319 Occurrence Handle1:STN:280:DyaK2M7isFWqug%3D%3D Occurrence Handle7824704

    CAS  PubMed  Google Scholar 

  18. LR Goodman JJ Curtin MW Mewissen et al. (1995) ArticleTitleDetection of pulmonary embolism in patients with unresolved clinical and scintigraphic diagnosis: helical CT versus angiography. AJR Am J Roentgenol 164 1369–1374 Occurrence Handle7754875 Occurrence Handle1:STN:280:DyaK2M3nsVCqtQ%3D%3D

    PubMed  CAS  Google Scholar 

  19. O Cauvain M Remy-Jardin J Remy et al. (1996) ArticleTitleSpiral CT angiography in the diagnosis of central pulmonary embolism: comparison with pulmonary angiography and scintigraphy. Rev Mal Respir 13 141–153 Occurrence Handle8711233 Occurrence Handle1:STN:280:DyaK283nt1SlsQ%3D%3D

    PubMed  CAS  Google Scholar 

  20. JR Mayo M Remy-Jardin NL Muller et al. (1997) ArticleTitlePulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy. Radiology 205 447–452 Occurrence Handle1:STN:280:DyaK1c%2FhvFCnsg%3D%3D Occurrence Handle9356627

    CAS  PubMed  Google Scholar 

  21. SD Qanadli ME Hajjam B Mesurolle et al. (2000) ArticleTitlePulmonary embolism detection: prospective evaluation of dual-section helical CT versus selective pulmonary arteriography in 157 patients. Radiology 217 447–455 Occurrence Handle11058644 Occurrence Handle1:STN:280:DC%2BD3crhtFCjsQ%3D%3D

    PubMed  CAS  Google Scholar 

  22. B Ohnesorge T Flohr C Becker et al. (2000) ArticleTitleCardiac imaging by means of electrocardiographically gated multisection spiral CT: initial experience. Radiology 217 564–571 Occurrence Handle1:STN:280:DC%2BD3crhtFChsg%3D%3D Occurrence Handle11058661

    CAS  PubMed  Google Scholar 

  23. PIOPED-Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. JAMA 1990; 95: 498-502.

    Google Scholar 

  24. RF Oser DA Zuckerman FR Gutierrez JA Brink (1996) ArticleTitleAnatomic distribution of pulmonary emboli at pulmonary angiography: implications for cross sectional imaging. Radiology 199 31–35 Occurrence Handle1:STN:280:DyaK283gtFyktg%3D%3D Occurrence Handle8633168

    CAS  PubMed  Google Scholar 

  25. MR Tetalman PB Hoffer LL Heck A Kunzmann A Gottschalk (1973) ArticleTitlePerfusion lung scan in normal volunteers. Radiology 106 593–594 Occurrence Handle4684802 Occurrence Handle1:STN:280:DyaE3s%2FoslCgsw%3D%3D

    PubMed  CAS  Google Scholar 

  26. R Novelline O Baltarowich C Athanasoulis A Greenfield K McKusick (1978) ArticleTitleThe clinical course of patients with suspected pulmonary embolism and a negative pulmonary angiogram. Radiology 126 561–567 Occurrence Handle628721 Occurrence Handle1:STN:280:DyaE1c7hs1Ghuw%3D%3D

    PubMed  CAS  Google Scholar 

  27. L Patriquin R Khorasani JF Polak (1998) ArticleTitleCorrelation of diagnostic imaging and subsequent autopsy findings in patients with pulmonary embolism. AJR 171 347–349 Occurrence Handle9694449 Occurrence Handle1:STN:280:DyaK1czlslyhsA%3D%3D

    PubMed  CAS  Google Scholar 

  28. K Garg H Sieler CH Welsh RJ Johnston PD Russ (1999) ArticleTitleClinical validity of helical CT being interpreted as negative for pulmonary embolism: implications for patient treatment. AJR Am J Roentgenol 172 1627–1631 Occurrence Handle10350303 Occurrence Handle1:STN:280:DyaK1M3nslyjtA%3D%3D

    PubMed  CAS  Google Scholar 

  29. NN Lomis HC Yoon AG Moran FJ Miller (1999) ArticleTitleClinical outcomes of patients after a negative spiral CT pulmonary arteriogram in the evaluation of acute pulmonary embolism. J Vasc Interv Radiol 10 707–712 Occurrence Handle10.1016/S1051-0443(99)70104-1 Occurrence Handle10392937 Occurrence Handle1:STN:280:DyaK1MzitVWjug%3D%3D

    Article  PubMed  CAS  Google Scholar 

  30. LR Goodman RJ Lipchik RS Kuzo Y Liu TL McAuliffe DJ O’Brien (2000) ArticleTitleSubsequent pulmonary embolism: risk after a negative helical CT pulmonary angiogram–prospective comparison with scintigraphy. Radiology 215 535–542 Occurrence Handle1:STN:280:DC%2BD3c3lslSjsQ%3D%3D Occurrence Handle10796937

    CAS  PubMed  Google Scholar 

  31. A Gottsater A Berg J Centergard B Frennby N Nirhov U Nyman (2001) ArticleTitleClinically suspected pulmonary embolism: is it safe to withhold anticoagulation after a negative spiral CT? Eur Radiol 11 65–72 Occurrence Handle10.1007/s003300000539 Occurrence Handle11194920 Occurrence Handle1:STN:280:DC%2BD3M7ptFeqsw%3D%3D

    Article  PubMed  CAS  Google Scholar 

  32. D Ost A Rozenshtein L Saffran A Snider (2001) ArticleTitleThe negative predictive value of spiral computed tomography for the diagnosis of pulmonary embolism in patients with nondiagnostic ventilation-perfusion scans. Am J Med 110 16–21 Occurrence Handle10.1016/S0002-9343(00)00641-0 Occurrence Handle11152860 Occurrence Handle1:STN:280:DC%2BD3M%2FpsVGltQ%3D%3D

    Article  PubMed  CAS  Google Scholar 

  33. I Tillie-Leblond I Mastora F Radenne et al. (2002) ArticleTitleRisk of pulmonary embolism after a negative spiral CT angiogram in patients with pulmonary disease: 1-year clinical follow-up study. Radiology 223 461–467 Occurrence Handle11997553

    PubMed  Google Scholar 

  34. SJ Swensen PF II Sheedy JH Ryu et al. (2002) ArticleTitleOutcomes after withholding anticoagulation from patients with suspected acute pulmonary embolism and negative computed tomographic findings: a cohort study. Mayo Clin Proc 77 130–138 Occurrence Handle11838646 Occurrence Handle10.4065/77.2.130

    Article  PubMed  Google Scholar 

  35. T Nilsson A Olausson H Johnsson U Nyman P Aspelin (2002) ArticleTitleNegative spiral CT in acute pulmonary embolism. Acta Radiol 43 486–491 Occurrence Handle12423459 Occurrence Handle1:STN:280:DC%2BD38nmtlaqug%3D%3D

    PubMed  CAS  Google Scholar 

  36. D Musset F Parent G Meyer et al. (2002) ArticleTitleDiagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet 360 1914–1920 Occurrence Handle10.1016/S0140-6736(02)11914-3 Occurrence Handle12493257

    Article  PubMed  Google Scholar 

  37. MJ van Strijen W de Monye J Schiereck et al. (2003) ArticleTitleSingle-detector helical computed tomography as the primary diagnostic test in suspected pulmonary embolism: a multicenter clinical management study of 510 patients. Ann Intern Med 138 307–314 Occurrence Handle12585828

    PubMed  Google Scholar 

  38. JW Henry B Relyea PD Stein (1995) ArticleTitleContinuing risk of thromboemboli among patients with normal pulmonary angiograms. Chest 107 1375–1378 Occurrence Handle1:STN:280:DyaK2M3mvFGjtQ%3D%3D Occurrence Handle7750334

    CAS  PubMed  Google Scholar 

  39. B Eyer L Goodman L. Washington R. Lipchik (Eds) (2004) Isolated subsegmental pulmonary embolism (PE) or indeterminate PE discovered on helical CT: clinician response and patient outcome. Abstract The Society of Thoracic Radiology Thoracic Imaging Meeting 2004; March 28-April 1, 2004. Rancho Mirage, California.

    Google Scholar 

  40. M Remy-Jardin I Tillie-Leblond D Szapiro et al. (2002) ArticleTitleCT angiography of pulmonary embolism in patients with underlying respiratory disease: impact of multislice CT on image quality and negative predictive value. Eur Radiol 12 1971–1978 Occurrence Handle12136315

    PubMed  Google Scholar 

  41. M Remy-Jardin J Remy D Artaud F Deschildre A Duhamel (1997) ArticleTitlePeripheral pulmonary arteries: optimization of the spiral CT acquisition protocol. Radiology 204 157–163 Occurrence Handle9205239 Occurrence Handle1:STN:280:DyaK2szkvFagtw%3D%3D

    PubMed  CAS  Google Scholar 

  42. UJ Schoepf T Helmberger N Holzknecht et al. (2000) ArticleTitleSegmental and subsegmental pulmonary arteries: evaluation with electron-beam versus spiral CT. Radiology 214 433–439 Occurrence Handle10671591 Occurrence Handle1:STN:280:DC%2BD3c7jvVKmuw%3D%3D

    PubMed  CAS  Google Scholar 

  43. B Ghaye D Szapiro I Mastora et al. (2001) ArticleTitlePeripheral pulmonary arteries: how far in the lung does multi-detector row spiral CT allow analysis? Radiology 219 629–636 Occurrence Handle11376246 Occurrence Handle1:STN:280:DC%2BD3M3ps1yksQ%3D%3D

    PubMed  CAS  Google Scholar 

  44. U Schoepf N Holzknecht TK Helmberger et al. (2002) ArticleTitleSubsegmental pulmonary emboli: improved detection with thin-collimation multidetector-row spiral CT. Radiology 222 483–490 Occurrence Handle11818617

    PubMed  Google Scholar 

  45. S Patel EA Kazerooni PN Cascade (2003) ArticleTitlePulmonary embolism: optimization of small pulmonary artery visualization at multi-detector row CT. Radiology 227 455–460 Occurrence Handle12732699

    PubMed  Google Scholar 

  46. D Diffin JR Leyendecker SP Johnson RJ Zucker PJ Grebe (1998) ArticleTitleEffect of anatomic distribution of pulmonary emboli on interobserver agreement in the interpretation of pulmonary angiography. AJR Am J Roentgenol 171 1085–1089 Occurrence Handle9763002 Occurrence Handle1:STN:280:DyaK1cvjtl2ltA%3D%3D

    PubMed  CAS  Google Scholar 

  47. PD Stein JW Henry A Gottschalk (1999) ArticleTitleReassessment of pulmonary angiography for the diagnosis of pulmonary embolism: relation of interpreter agreement to the order of the involved pulmonary arterial branch. Radiology 210 689–691 Occurrence Handle10207468 Occurrence Handle1:STN:280:DyaK1M3itlyktw%3D%3D

    PubMed  CAS  Google Scholar 

  48. A Gottschalk PD Stein LR Goodman HD Sostman (2002) ArticleTitleOverview of prospective investigation of pulmonary embolism diagnosis II. Semin Nucl Med 32 173–182 Occurrence Handle12105798

    PubMed  Google Scholar 

  49. T Flohr K Stierstorfer H Bruder J Simon S Schaller (2002) ArticleTitleNew technical developments in multislice CT–Part 1: Approaching isotropic resolution with sub-millimeter 16-slice scanning. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 174 839–845 Occurrence Handle10.1055/s-2002-32692 Occurrence Handle1:STN:280:DC%2BD38zlslKqug%3D%3D Occurrence Handle12101473

    Article  CAS  PubMed  Google Scholar 

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  1. Department of Radiology, Medical University of South Carolina, 29425, Charleston, USA

    U. Joseph Schoepf

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Schoepf, U.J. Diagnosing pulmonary embolism: time to rewrite the textbooks. Int J Cardiovasc Imaging 21, 155–163 (2005). https://doi.org/10.1007/s10554-004-5345-7

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