Abstract
This article provides an update of the current trends in the management of acute thromboembolic disease, aimed at emphasizing new options applicable in daily practice. CT is no longer exclusively dedicated to the diagnosis of PE but also participates in the prognostic approach of this disease focusing on the detection of CT features of right ventricular dysfunction. The availability of perfusion CT allows evaluation of the extent of perfusion impairment, thus introducing a more reliable prognostic parameter than the estimation of the clot burden. Radiologists can provide clinicians with relevant information regarding the early risk stratification that is worth describing in daily practice. Optimized management of young patients, pregnant women, and evolution toward chronic pulmonary embolism will also be covered in this chapter.
References
Anderson DR, Kahn SR, Rodgers MA et al (2007) Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism. JAMA 298:2743–2753
Araoz PA, Haramati LB, Mayo JR, Mortani Barbosa EJ Jr, Rybicki FJ, Colletti PM (2012) Panel discussion : pulmonary embolism imaging and outcomes. AJR Am J Roentgenol 198:1313–1319
Bauer RW, Frellesen C, Renker M et al (2011) Dual energy CT pulmonary blood volume assessment in acute pulmonary embolism – correlation with D-dimer level, right heart strain and clinical outcome. Eur Radiol 21:1914–1921
Becattini C, Agnelli G, Germini F, Vedovati MC (2014) Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis. Eur Respir J 43:1678–1690
Bedayat A, Sewatkar R, Cai T et al (2015) Association between confidence level of acute pulmonary embolism diagnosis on CTPA images and clinical outcome. Acad Radiol 22:1555–1561
Blackmon KN, Florin C, Bogoni L, McCain JW, Koonce JD, Bastarrika G, Thilo C, Costello P, Salganicoff M, Schoepf UJ (2013) Computer-aided detection of pulmonary embolism at CT pulmonary angiography: can it improve performance of inexperienced readers? Eur Radiol 21:1214–1223
Bourjeily G, Chalhoub M, Phornphutkul C, Alleyne TC, Woodfield CA, Chen KK (2010) Neonatal thyroid function: effect of a single exposure to iodinated contrast medium in utero. Radiology 256:744–750
Cai XR, Feng YZ, Qiu L et al (2015) Iodine distribution map in dual-energy computed tomography pulmonary artery imaging with rapid kVp switching for the diagnosis analysis and quantitative evaluation of acute pulmonary embolism. Acad Radiol 22:743–751
Chae EJ, Seo JB, Jang MY et al (2010) Dual-energy CT for assessment of the severity of acute pulmonary embolism: pulmonary perfusion defect score compared with CT angiographic obstruction score and right ventricular/left ventricular diameter ratio. AJR Am J Roentgenol 194:604–610
Christner JA, Zavaletta VA, Eusemann CD, Walz-Flannigan AI, McCollough CH (2010) Dose reduction in helical CT: dynamically adjustable z-axis X-ray beam collimation. AJR Am J Roentgenol 194:W49–W55
de Broucker T, Pontana F, Santangelo T, Faivre JB, Tacelli N, Delannoy-Deken V, Duhamel A, Remy J, Remy-Jardin M (2012) Single- and dual-source chest CT protocols: levels of radiation dose in routine clinical practice. Diagn Interv Imaging 93:852–858
Delesalle MA, Pontana F, Duhamel A, Faivre JB, Flohr T, Tacelli N, Remy J, Remy-Jardin M (2013) Spectral optimization of chest CT angiography with reduced iodine load: experience in 80 patients evaluated with dual-source, dual-energy CT. Radiology 267:256–266
Den Exter PL, Van Es J, LJM K et al (2015) Thromboembolic reoslution assessed by CT pulmonary angiography after treatment of acute pulmonary embolism. Thromb Haemost 114:26–34
Dewailly M, Remy-jardin M, Duhamel A et al (2010) Computer-aided detection of acute pulmonary embolism with 64-slice multidetector row computed tomography: impact of the scanning conditions and overall image quality in the detection of peripheral clots. J Comput Assist Tomogr 34:23–30
Dunne RM, Ip IK, Abbett S et al (2015) Effect of evidence-based clinical decision support on the use and yield of CT pulmonary angiographic imaging in hospitalized patients. Radiology 276:167–174
Eyer BA, Goodman LR, Washington L (2005) Clinicians’ response to radiologists’ reports of isolated subsegmental pulmonary embolism or inconclusive interpretation of pulmonary embolism using MDCT. AJR Am J Roentgenol 184:623–628
Fedullo PF, Auger WR, Kerr KM et al (2001) Chronic thromboembolic pulmonary hypertension. N Engl J Med 345:1465–1472
Furlan A, Patil A, Park B et al (2011) Accuracy and reproducibility of blood clot burden quantification with pulmonary CT angiography. AJR Am J Roentgenol 196:516–523
Gorgos A, Remy-Jardin M, Duhamel A, Faivre JB, Tacelli N, Delannoy V, Remy J (2009) Evaluation of peripheral pulmonary arteries at 80 kV and 140 kV: dual-energy computed tomography assessment in 51 patients. J Comput Assist Tomogr 33:981–986
Green DB, Raptis CA, Garin IAH, Bhalla S (2015) Negative computed tomography for acute pulmonary embolism: important differential diagnosis considerations for acute dyspnea. Radiol Clin North Am 53:789–799
Guerin L, Coutiraud F, Parent F et al (2014) Prevalence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Thromb Haemost 112:598–605
Hariharan P, Dudzinski DM, Rosovosky R et al (2016) Relation among clot burden, right-sided heart strain and adverse events after acute pulmonary embolism. Am J Cardiol 118:1568–1573
Hennelly KE, Baskin MN, Monuteuax MC et al (2016) Detection of pulmonary embolism in high-risk children. J Pediatr 178:214–218
Jimenez D, Billello KL, Murin S (2013) Point/Counterpoint editorials. Should systemic lytic therapy be used for submassive pulmonary embolism? Yes. Chest 143:296–299
Kamel EM, Schmidt S, Doenz F, Adler-Etechami G, Schnyder P, Quanadli SD (2008) Computed tomographic angiography in acute pulmonary embolism: do we need multiplanar reconstructions to evaluate the right ventricular dysfunction? J Comput Assist Tomogr 32:438–443
Kaul D, Grupp U, Kahn J, Ghadjar P, Wiener E, Hamm B, Streitparth F (2014) Reducing radiation dose in the diagnosis of pulmonary embolism using adaptive statistical iterative reconstruction and lower tube potential in computed tomography. Eur Radiol 24:2685–2692
Kim MJ, Jung HO, Jung JI, Kim KJ, Jeon DS, Youn HJ (2014) CT-derived atrial and ventricular septal signs for risk stratification of patients with acute pulmonary embolism: clinical associations of CT-derived signs for prediction of short-term mortality. Int J Cardiovasc Imaging 30:25–32
Kligerman SJ, Lahiji K, Galvin JR et al (2014) Missed pulmonary emboli on CT angiography/ assessment with pulmonary embolism – computer-aided detection. AJR Am J Roentgenol 202:65–73
Kubo T, Lin PJP, Stiller W, Takahashi M, Kauczor HU, Ohno Y, Hatabu H (2008) Radiation dose reduction in chest CT: a review. AJR Am J Roentgenol 190:335–343
Kumamaru KK, Hunsaker AR, Bedayat A, Soga S, Signorelli J, Adams K, Wake N, Lu MT, Rybicki FJ (2012) Subjective assessment of right ventricle enlargement from computed tomography pulmonary angiography images. Int J Cardiovasc Imaging 28:965–973
Kumamaru KK, Saboo SS, Aghayev A et al (2016) CT pulmonary angiography-based scoring system to predict the prognosis of acute pulmonary embolism. J Cardiovasc Comput Tomogr 10(6):473–479
Lankeit M, Konstantinides S (2012) Is it time for home treatment of pulmonary embolism? Eur Respir J 40:742–749
Lee EY, Tse SKS, Zurakowski D, Johnson VM, Lee NJ, Tracy DA, Boiselle PM (2012a) Children suspected of having pulmonary embolism: multidetector CT pulmonary angiography – thromboembolic risk factors and implications for appropriate use. Radiology 262:242–251
Lee EY, Neuman MI, Lee NJ, Johnson VM, Zurakowski D, Tracy DA, Boiselle PM (2012b) Pulmonary embolism detected by pulmonary MDCT angiography in older children and young adults: risk factor assessment. AJR Am J Roentgenol 198:1431–1437
Leung AN, Bull TM, Jaeschke R et al (2011) An official American Thoracic Society/Society of Thoracic radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. Am J Respir Crit Care Med 184:1200–1208
Lu MT, Demehri S, Cai T, Parast L, Hunsaker AR, Goldhaber SZ, Rybicki FJ (2012) Axial and reformatted four-chamber right ventricle-to-left ventricle diameter ratios on pulmonary CT angiography as predictors of death after acute pulmonary embolism. AJR Am J Roentgenol 198:1353–1360
Lu GM, Luo S, Meinel FG, McQuiston AD, Zhou CS et al (2014) High-pitch computed tomography pulmonary angiography with iterative reconstruction at 80 kVp and 20 mL contrast agent volume. Eur Radiol 24:3260–3268
Mamlouk MD, vanSonnenberg E, Gosalia R et al (2010) Pulmonary embolism at CT angiography: implications for appropriateness, cost and radiation exposure in 2003 patients. Radiology 256:625–632
Mastora I, Remy-Jardin M, Masson P, Galland E, Delannoy V, Bauchart JJ, Remy J (2003) Severity of acute pulmonary embolism: evaluation of a new spiral CT angiographic score in correlation with echocardiographic data. Eur Radiol 13:29–35
Matsuoka S, Hunsaker AR, Gill RR et al (2009) Vascular enhancement and image quality of MDCT pulmonary angiography in 400 cases: comparison of standard and low kilovoltage settings. AJR Am J Roentgenol 192:1651–1656
McLaughlin PD, Liang T, Homiedan M, Louis LJ, O’Connel TW, Krzymyk K, Nicolaou S, Mayo MR (2015) High pitch, low voltage dual source CT pulmonary angiography: assessment of image quality and diagnostic acceptability with hybrid iterative reconstruction. Emerg Radiol 22:117–123
Niemann T, Simon H, Faivre JB, Yasunaga K, Bendaoud S, Simeone A, Remy J, Duhamel A, Flohr T, Remy-Jardin M (2013) Clinical evaluation of automatic tube voltage selection in chest CT angiography. Eur Radiol 23:2643–2651
Pengo V, Lensing AW, Prins MH et al (2004) Incidence of thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 350:2257–2264
Piazza G, Goldhaber SZ (2010) Management of submassive pulmonary embolism. Circulation 122:1124–1129
Pontana F, Chalayer C, Faivre JB, Murphy C, Remy-Jardin M, Remy J (2012) Pseudo-embolic perfusion defects in COPD: evaluation with dual-energy CT angiography (DECT) in 170 patients. Abstract B 0272, European Congress of Radiology, SS504 – CTTA - Dual energy and dose reduction
Pontana F, Pagniez J, Duhamel A et al (2013) Reduced-dose low-voltage chest CT angiography with sinogram-affirmed iterative reconstruction versus standard-dose filtered back projection. Radiology 267:609–618
Quanadli SD, EI Hajjam M, Vieillard-Baron A, Joseph T, Mesurolle B, Oliva VL, Barré O, Bruckert F, Dubourg O, Lacombe P (2001) New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol 176:1415–1420
Raja AS, Ip IK, Prevedello LM et al (2012) Effect of computerized clinical decision support on the use and yield of CT pulmonary angiography in the emergency department. Radiology 262:468–474
Reid JH, Murchison JT (1998) Acute right ventricular dilatation: a new helical CT sign of massive pulmonary embolism. Clin Radiol 53:694–698
Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, Sostman HD (2007) Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 245:315–329
Ridge CA, Mhuircheartaigh JN, Dodd JD, Skehan SJ (2011) Pulmonary CT angiography protocol adapted to the hemodynamic effects of pregnancy. AJR Am J Roentgenol 197:1058–1063
Ritchie G, McGurk S, Mc Creath C, Graham C, Murchison JT (2007) Prospective evaluation of unsuspected pulmonary embolism on contrast multidetector CT (MDCT) scanning. Thorax 62:536–540
Schueller-Weidekamm C, Schaefer-Prokop CM, Weber M, Herold CJ, Prokop M (2006) CT angiography of pulmonary arteries to detect pulmonary embolism: improvement of vascular enhancement with low kilovoltage settings. Radiology 241:899–907
Sigal-Cinqualbre AB, Hennequin R, Abada HT, Chen X, Paul JF (2004) Low-kilovoltage multi-detector row chest CT in adults: feasibility and effect on image quality and iodine dose. Radiology 231:169–174
Sodickson A, Weiss M (2012) Effect of patient size on radiation dose reduction and image quality in low-kVp CT pulmonary angiography performed with reduced IV contrast dose. Emerg Radiol 19:437–445
Stein PD, Goodman LR, Hull RD et al (2012) Diagnosis and management of isolated subsegmental pulmonary embolism: review and assessment of the options. Clin Appl Thromb Hemost 18:20–26
Szucs-Farkas Z, Kurmann L, Strautz T, Patak MA, Vock P, Schindera ST (2008) Patient exposure and image quality of low-dose pulmonary computed tomography angiography: comparison of 100- and 80-kVp protocols. Invest Radiol 43:871–876
Szucs-Farkas Z, Schibler F, Cullmann J et al (2011) Diagnostic accuracy of pulmonary CT angiography at low tube voltage: intraindividual comparison of a normal-dose protocol at 120 kVp and a low-dose protocol at 80 kVp using reduced amount of contrast medium in a simulation study. AJR Am J Roentgenol 197:W852–W859
Thieme SF, Ashoori N, Bamberg F et al (2012) Severity assessment of pulmonary embolism using dual energy CT – correlation of a perfusion defect score with clinical and morphological parameters of blood oxygenation and right ventricular failure. Eur Radiol 22:269–278
Todd JL, Tapson VF (2009) Thrombolytic therapy for acute pulmonary embolism: a critical appraisal. Chest 135:1321–1329
Torbicki A, Perrier A, Konstantinides SV et al (2008) Guidelines on the diagnosis and management of acute pulmonary embolism: the task force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Heart J 29:2276–2315
Wittenberg R, Berger FH, Peters JF et al (2012) Acute pulmonary embolism: effect of a computer-assisted detection prototype on diagnosis – an observer study. Radiology 262:305–313
Woo JKH, Chiu RYW, Thakur Y, Mayo JR (2012) Risk-benefit analysis of pulmonary CT angiography in patients with suspected pulmonary embolus. AJR Am J Roentgenol 198:1332–1339
Yuan R, Shuman WP, Earls JP, Hague CJ, Mumtaz HA, Scott-Moncrieff A, Ellis JD, Mayo JR, Leipsic JA (2012) Reduced iodine load at CT pulmonary angiography with dual-energy monochromatic imaging: comparison with standard CT pulmonary angiography – a prospective randomized trial. Radiology 262:290–297
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2017 Springer International Publishing AG
About this chapter
Cite this chapter
Hutt, A., Felloni, P., Remy, J., Remy-Jardin, M. (2017). CT of Pulmonary Embolism: Imaging Update. In: Nikolaou, K., Bamberg, F., Laghi, A., Rubin, G.D. (eds) Multislice CT. Medical Radiology(). Springer, Cham. https://doi.org/10.1007/174_2017_19
Download citation
DOI: https://doi.org/10.1007/174_2017_19
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-42585-6
Online ISBN: 978-3-319-42586-3
eBook Packages: MedicineMedicine (R0)