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Imaging for Pulmonary Embolism, Known Clot

Variant: 1   Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
MRA chest with IV contrast Usually Appropriate O
CTA pulmonary arteries with IV contrast Usually Appropriate ☢☢☢
V/Q scan lung Usually Appropriate ☢☢☢
V/Q scan with SPECT or SPECT/CT lung Usually Appropriate ☢☢☢
US echocardiography transthoracic resting May Be Appropriate O
MRA chest without and with IV contrast May Be Appropriate O
MRA chest without IV contrast May Be Appropriate O
US echocardiography transesophageal Usually Not Appropriate O
Radiography chest Usually Not Appropriate ☢
Arteriography pulmonary Usually Not Appropriate ☢☢☢☢
Arteriography pulmonary with right heart catheterization Usually Not Appropriate ☢☢☢☢
MRI heart function and morphology without and with IV contrast Usually Not Appropriate O
MRI heart function and morphology without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Adult. Known chronic thromboembolic disease. Surveillance.
Procedure Appropriateness Category Relative Radiation Level
CTA pulmonary arteries with IV contrast Usually Appropriate ☢☢☢
US echocardiography transthoracic resting May Be Appropriate (Disagreement) O
Arteriography pulmonary May Be Appropriate ☢☢☢☢
Arteriography pulmonary with right heart catheterization May Be Appropriate (Disagreement) ☢☢☢☢
MRA chest with IV contrast May Be Appropriate O
MRA chest without and with IV contrast May Be Appropriate (Disagreement) O
MRI heart function and morphology without and with IV contrast May Be Appropriate (Disagreement) O
MRI heart function and morphology without IV contrast May Be Appropriate O
V/Q scan lung May Be Appropriate (Disagreement) ☢☢☢
V/Q scan with SPECT or SPECT/CT lung May Be Appropriate (Disagreement) ☢☢☢
US echocardiography transesophageal Usually Not Appropriate O
Radiography chest Usually Not Appropriate ☢
MRA chest without IV contrast Usually Not Appropriate O
CT chest with IV contrast Usually Not Appropriate ☢☢☢
CT chest without and with IV contrast Usually Not Appropriate ☢☢☢
CT chest without IV contrast Usually Not Appropriate ☢☢☢
CT heart function and morphology with IV contrast Usually Not Appropriate ☢☢☢☢

Panel Members
Rahul D. Renapurkar, MD, MBBSa; Prabhakar Shantha Rajiah, MDb; Twyla B. Bartel, DO, MBAc; Ahmed H. El-Sherief, MDd; Christopher J. Francois, MDe; Kate Hanneman, MD, MPHf; Joe Y. Hsu, MDg; Christopher D. Jackson, MDh; Veronica Lenge de Rosen, MDi; Lucy M. Safi, DOj; Lilia M. Sierra-Galan, MDk; Phillip M. Young, MDl; Michael A. Bolen, MDm.
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
A. Arteriography pulmonary
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
B. Arteriography pulmonary with right heart catheterization
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
C. CT chest with IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
D. CT chest without and with IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
E. CT chest without IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
F. CT heart function and morphology with IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
G. CTA pulmonary arteries with IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
H. MRA chest with IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
I. MRA chest without and with IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
J. MRA chest without IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
K. MRI heart function and morphology without and with IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
L. MRI heart function and morphology without IV contrast
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
M. Radiography chest
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
N. US echocardiography transesophageal
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
O. US echocardiography transthoracic resting
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
P. V/Q scan lung
Variant 1: Adult. Known history of acute pulmonary embolism. Suspected recurrent or residual embolic disease. Initial imaging.
Q. V/Q scan with SPECT or SPECT/CT lung
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
A. Arteriography pulmonary
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
B. Arteriography pulmonary with right heart catheterization
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
C. CT chest with IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
D. CT chest without and with IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
E. CT chest without IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
F. CT heart function and morphology with IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
G. CTA pulmonary arteries with IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
H. MRA chest with IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
I. MRA chest without and with IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
J. MRA chest without IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
K. MRI heart function and morphology without and with IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
L. MRI heart function and morphology without IV contrast
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
M. Radiography chest
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
N. US echocardiography transesophageal
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
O. US echocardiography transthoracic resting
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
P. V/Q scan lung
Variant 2: Adult. Known chronic thromboembolic disease. Surveillance.
Q. V/Q scan with SPECT or SPECT/CT lung
Summary of Highlights
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations

Relative Radiation Level*

Adult Effective Dose Estimate Range

Pediatric Effective Dose Estimate Range

O

0 mSv

 0 mSv

☢

<0.1 mSv

<0.03 mSv

☢☢

0.1-1 mSv

0.03-0.3 mSv

☢☢☢

1-10 mSv

0.3-3 mSv

☢☢☢☢

10-30 mSv

3-10 mSv

☢☢☢☢☢

30-100 mSv

10-30 mSv

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”
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The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.