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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Righini M, Robert-Ebadi H, Le Gal G. Diagnosis of acute pulmonary embolism. [Review]. J Thromb Haemost. 15(7):1251-1261, 2017 07. Review/Other-Dx N/A To review and discuss the challenges of diagnosing pulmonary embolism (PE), recent major improvements made in diagnostic strategies, as well as some unresolved issues. No results stated in the abstract. 4
2. Anderson FA, Cohen AT, Heit JA. Estimated Annual Number of Incident and Recurrent, Non-Fatal and Fatal Venous Thromboembolism (VTE) Events in the US. Blood 2005;106:910-10. Review/Other-Dx N/A To estimate the total annual number of non-fatal and fatal deep vein thrombosis (DVT) and pulmonary embolism (PE) events (incident and recurrent) in the United States. VTE-related deaths were estimated at 296,370 annually. Of these deaths, 21,223 (7%) patients were diagnosed with VTE and treated, 101,032 (34%) were sudden fatal PE and 174,115 (59%) followed undetected PE. Approximately two-thirds of symptomatic VTE events were hospital-acquired and one-third were community-acquired. 4
3. Leung AN, Bull TM, Jaeschke R, et al. An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy.[Reprint in Radiology. 2012 Feb;262(2):635-46; PMID: 22282185]. American Journal of Respiratory & Critical Care Medicine. 184(10):1200-8, 2011 Nov 15. Review/Other-Dx N/A To provide guidance on this important health issue, a multidisciplinary panel of major medical stakeholders was convened to develop evidence-based guidelines for evaluation of suspected pulmonary embolism in pregnancy using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system Overall, the quality of the underlying evidence for all recommendations was rated as very low or low, with some of the evidence considered for recommendations extrapolated from studies of the general population. Despite the low-quality evidence, strong recommendations were made for three specific scenarios: performance of chest radiography (CXR) as the first radiation-associated procedure; use of lung scintigraphy as the preferred test in the setting of a normal CXR; and performance of computed-tomographic pulmonary angiography (CTPA) rather than digital subtraction angiography (DSA) in a pregnant woman with a nondiagnostic ventilation-perfusion (V/Q) result. 4
4. Stein PD, Hull RD, Saltzman HA, Pineo G. Strategy for diagnosis of patients with suspected acute pulmonary embolism. Chest. 1993;103(5):1553-1559. Review/Other-Dx 887 patients A position paper that describes how investigators from both groups (Prospective Investigation of Pulmonary Embolism Diagnosis [PIOPED] and Canadian study groups) have utilized the combined scientific database in order to rationalize seemingly polarized diagnostic recommendations into a single practical algorithm. 108/640 patients of whom the diagnosis of PE was uncertain would have shown proximal DVT. In 239/640 patients, tests for DVT would have been negative and the risks of PE in these patients are calculated to be less than 10%. Therefore, for 347/640 patients, confident recommendations for treatment or no treatment could have been given without pulmonary angiography. Accordingly, in the PIOPED study group of 887 patients, the need for pulmonary angiography would have been reduced from 640 (72%) to 293 patients (33%). A diagnostic strategy that includes the clinical evaluation, V/Q scan, and evaluation for DVT would decrease the number of patients who require pulmonary angiography from 72% to 33%. 4
5. Hanley M, Steigner ML, Ahmed O, et al. ACR Appropriateness Criteria® Suspected Lower Extremity Deep Vein Thrombosis. J Am Coll Radiol 2018;15:S413-S17. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for suspected lower extremity deep vein thrombosis. No results stated in abstract. 4
6. Ceriani E, Combescure C, Le Gal G, et al. Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost 2010;8:957-70. Meta-analysis 29 studies The aim of this meta-analysis is to compare the accuracy of the principal clinical prediction rules (CPRs) for pulmonary embolism (PE) pretest probability estimation and review their level of validation. We identified 9 CPR and included 29 studies representing 31215 patients. Pooled prevalence of PE for three-level scores (low, intermediate or high clinical probability) was: low, 6% (95% CI, 4-8), intermediate, 23% (95% CI, 18-28) and high, 49% (95% CI, 43-56) for the Wells score; low, 13% (95% CI, 8-19), intermediate, 35% (95% CI, 31-38) and high, 71% (95% CI, 50-89) for the Geneva score; low, 9% (95% CI, 8-11), intermediate, 26% (95% CI, 24-28) and high, 76% (95% CI, 69-82) for the revised Geneva score. Pooled prevalence for two-level scores (PE likely or PE unlikely) was 8% (95% CI,6-11) and 34% (95% CI,29-40) for the Wells score, and 6% (95% CI, 3-9) and 23% (95% CI, 11-36) for the Charlotte rule. Good
7. Douma RA, Mos IC, Erkens PM, et al. Performance of 4 clinical decision rules in the diagnostic management of acute pulmonary embolism: a prospective cohort study. Ann Intern Med. 154(11):709-18, 2011 Jun 07. Observational-Dx 807 patients To directly compare the performance of 4 clinical decision rules (CDRs) (Wells rule, revised Geneva score, simplified Wells rule, and simplified revised Geneva score) in combination with D-dimer testing to exclude pulmonary embolism (PE). Prevalence of PE was 23%. The proportion of patients categorized as PE-unlikely ranged from 62% (simplified Wells rule) to 72% (Wells rule). Combined with a normal d-dimer result, the CDRs excluded PE in 22% to 24% of patients. The total failure rates of the CDR and d-dimer combinations were similar (1 failure, 0.5% to 0.6% [upper-limit 95% CI, 2.9% to 3.1%]). Even though 30% of patients had discordant CDR outcomes, PE was not detected in any patient with discordant CDRs and a normal d-dimer result. 2
8. Lucassen W, Geersing GJ, Erkens PM, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med. 2011;155(7):448-460. Meta-analysis 52 studies, 55,268 patients To compare the test characteristics of gestalt (a physician's unstructured estimate) and clinical decision rules for evaluating adults with suspected PE and assess the failure rate of gestalt and rules when used in combination with d-dimer testing. Clinical decision rules and gestalt can safely exclude PE when combined with sensitive d-dimer testing. The authors recommend standardized rules because gestalt has lower specificity, but the choice of a particular rule and d-dimer test depend on both prevalence and setting. M
9. Emergency Department Patients With Chest Pain Writing Panel, Rybicki FJ, Udelson JE, et al. 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J. Am. Coll. Radiol.. 13(2):e1-e29, 2016 Feb. Review/Other-Dx N/A To discuss the practice guidelines of appropriate utilization of cardiovascular imaging in emergency department patients with chest pain based off the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. No results stated in the abstract. 4
10. Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE. Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. Radiology. 1993;189(1):133-136. Observational-Dx 1,063 patients: PE was confirmed angiographically in 383 patients and excluded in 680 patients To determine the sensitivity, specificity, and PPV and NPV of chest radiographic findings in patients suspected of having acute PE. The chest radiograph was interpreted as normal in only 12% of patients with PE. The most common chest radiographic finding in patients with PE was atelectasis and/or parenchymal areas of increased opacity; however, the prevalence was not significantly different from that in patients without PE. Oligemia (the Westermark sign), prominent central pulmonary artery (the Fleischner sign), pleural-based area of increased opacity (the Hampton hump), vascular redistribution, pleural effusion, elevated diaphragm, and enlarged hilum were also poor predictors of PE. The value is to exclude diagnoses that mimic PE and aid in V/Q scan interpretation. 3
11. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/body-cta.pdf. Review/Other-Dx N/A Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. No abstract available. 4
12. Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010;363(3):266-274. Review/Other-Dx N/A To review the optimal diagnostic strategy and management of acute PE. Diagnostic workup should be tailored to the severity of the clinical presentation on the basis of whether the patient’s condition is hemodynamically stable or unstable. In patients with hemodynamic stability, the diagnosis of PE should follow a sequential diagnostic workup consisting of clinical probability assessment, D-dimer testing, and (if necessary) MDCT or ventilation–perfusion scanning. 4
13. Gandara E, Wells PS. Diagnosis: use of clinical probability algorithms. Clin Chest Med. 2010;31(4):629-639. Review/Other-Dx N/A To review role of clinical prediction rules in the diagnostic process and their clinical application into diagnostic algorithms. Evidence suggests that patients with suspected PE are managed better with a diagnostic strategy that includes clinical pretest probability assessment, D-dimer test, and/or imaging. 4
14. Gimber LH, Travis RI, Takahashi JM, Goodman TL, Yoon HC. Computed Tomography Angiography in Patients Evaluated for Acute Pulmonary Embolism with Low Serum D-dimer Levels: A Prospective Study. Perm J. 2009;13(4):4-10. Observational-Dx 347 patients with D-dimer level =1.0 µg/mL Prospective observational study to evaluate roles for clinical probability and CTA in emergency department patients suspected of acute PE but having a low serum D-dimer level. In one participant, CTA showed a PE that was agreed on by both the initial and study radiologists. In six participants, the initial findings were reported as positive for PE but were not interpreted as positive by the study radiologist. In none of these participants was PE diagnosed on the basis of clinical probability, of findings on ancillary studies and three-month follow-up examination, or by another radiologist, unaware of findings, acting as a tiebreaker. Pulmonary CTA findings positive for acute embolism should be viewed with caution, especially if the suspected PE is in a distal segmental or subsegmental artery in a patient with a serum D-dimer level of =1.0 µg/mL. Furthermore, the Wells criteria may be of limited additional value in this group of patients with low D-dimer levels because most will have low or intermediate clinical probability of PE. 1
15. Gupta RT, Kakarla RK, Kirshenbaum KJ, Tapson VF. D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. AJR Am J Roentgenol. 193(2):425-30, 2009 Aug. Observational-Dx 627 patients Prospective study to test the efficacy of clinical risk algorithms and a quantitative immunoturbidimetric D-dimer assay in the evaluation of patients undergoing pulmonary CTA for suspected acute PE. CTA showed that 28 patients had PE (6 in the low-probability group, 17 in the intermediate-probability group, and 5 in the high-probability group). The sensitivity, NPV, and specificity of the D-dimer assay were 100%, 100%, and 25% (low-clinical-probability group); 100%, 100%, and 33% (intermediate-probability group); and 80%, 80%, and 37% (high-probability group). Data support the use of a quantitative D-dimer assay as a first-line test in evaluation for PE when the clinical probability of the presence of PE is low or intermediate. The sensitivity and NPV were 100% for these cases. More than 26% of CTA examinations might have been avoided if the D-dimer assay had been used as a first-line test in the care of patients at low or intermediate risk. Because of the small sample size, the D-dimer assay is not recommended as a first-line test in the evaluation of patients at high risk. 3
16. Kabrhel C. Outcomes of high pretest probability patients undergoing d-dimer testing for pulmonary embolism: a pilot study. J Emerg Med. 2008;35(4):373-377. Observational-Dx 541 patients enrolled; 130 patients had Wells Score >4 and 33 patients had Wells Score >6 (not mutually exclusive) To prospectively assess the test characteristics of the ELISA (enzyme-linked immunosorbent assay) D-dimer in the diagnosis of clinically significant PE in emergency department patients with high pretest probability for the disease. Of subjects with Wells Score >4, 23 (18%) were diagnosed with PE and 40 (31%) had a negative D-dimer. No patient with Wells Score >4 (sensitivity 100%, 95% CI, 82%-100%; specificity 37%, 95% CI, 28%-47%) or Wells Score >6 (sensitivity 100%, 95% CI, 63%-100%; specificity 56%, 95% CI, 35%-76%) who had a negative D-dimer was diagnosed with PE. The likelihood ratio for a negative D-dimer was 0 for both the Wells >4, and Wells >6 groups, however, the upper limits of the CI around the post-test probability for PE were 16% and 33%, respectively, for these high probability groups. In this pilot study, the rapid ELISA D-dimer had high sensitivity and NPV even when applied to patients with high pretest probability for PE. However, with the post-test probability of PE still as high as 16%-33% in the negative D-dimer groups, this precludes applying the results to patient care at present. Further testing is warranted to determine whether these findings can be safely incorporated into practice. 3
17. Hirohashi T, Yoshinaga K, Sakurai T, et al. [Study of the echocardiographic diagnosis of acute pulmonary thromboembolism and risk factors for venous thromboembolism]. J Cardiol. 2006;47(2):63-71. Observational-Dx 75 patients known with VTE, 101 suspected for VTE, 50 control subjects To identify the relationship of risk factors for atherosclerosis with VTE and the utility of TTE in acute pulmonary thromboembolism. The incidence of hyperlipidemia in the VTE group was statistically higher than that in the control group (OR 2.16, 95% CI, 1.43-3.08). Additionally, the incidence of obesity was higher in the VTE and N groups than in the control group (OR was 2.76, 95% CI, 1.67-4.37). The incidence of tricuspid regurgitation, RV dilation, and pulmonary hypertension in acute pulmonary thromboembolism was statistically greater than that in NC group. Hyperlipidemia and obesity may be risk factors for VTE. However, obese patients can manifest similar findings to VTE. Although TTE is not recommended as a diagnostic or screening test in acute pulmonary thromboembolism, it should be used as an ancillary test. 3
18. Hull RD, Hirsh J, Carter CJ, et al. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med. 1983;98(6):891-899. Review/Other-Dx 139 consecutive patients: (74 men, 65 women) Prospective, multicenter study of V/Q scanning, pulmonary angiography, and venography in consecutive patients with clinically suspected PE and abnormal perfusion scans to determine the right approach to diagnosing PE. Ventilation scanning increased the probability of PE in patients with large perfusion defects and ventilation mismatch, but a V/Q match was not helpful in ruling out PE. Small perfusion defects with mismatch had neither sufficiently high nor low probability to be of diagnostic value. The observed frequency of proximal vein thrombosis (19% to 51%) and its association with the range of V/Q defects have important implications for management of PE. Pulmonary angiography and venography is required in most patients with perfusion abnormalities because the probability of PE is neither sufficiently high nor low to confirm or exclude PE. 4
19. Stein PD, Henry JW, Gottschalk A. Mismatched vascular defects. An easy alternative to mismatched segmental equivalent defects for the interpretation of ventilation/perfusion lung scans in pulmonary embolism. Chest. 1993;104(5):1468-1471. Observational-Dx 383 with acute PE, 681 patients which PE was excluded To test the hypothesis that V/Q in patients with suspected acute PE can be evaluated on the basis of the total number of mismatched vascular defects, irrespective of whether such defects are moderate or large size segmental defects. Predictive value of the cumulative number of mismatched moderate size segmental defects was nearly the same as that of mismatched large segmental defects. This suggests that the diagnostic value of mismatched moderate size segmental defects is the same as mismatched large segmental defects. Lung scans evaluated on the basis of the number of mismatched vascular defects (moderate and/or large segmental defects) were compared with V/Q scans evaluated on the basis of the number of mismatched segmental equivalents. The number of mismatched vascular defects is as powerful for the assessment of V/Q scans as the number of mismatched segmental equivalents. The number of mismatched vascular defects, however, is easier to interpret, and permits a more objective evaluation. 3
20. Coche E, Verschuren F, Keyeux A, et al. Diagnosis of acute pulmonary embolism in outpatients: comparison of thin-collimation multi-detector row spiral CT and planar ventilation-perfusion scintigraphy. Radiology. 2003;229(3):757-765. Observational-Dx 94 non-consecutive patients To compare MDCT to V/Q scan for diagnosis of PE. Sensitivity of thin-collimation MDCT and V/Q scintigraphy for the detection of PE was 96% (27/28; CI, 82%, 99%) and 98% (65/66; CI, 92%, 99%), respectively. Specificity of CT and V/Q scintigraphy was 86% (24/28; CI, 67%, 96%) and 88% (58/66; CI, 77%, 94%), respectively. Examinations with spiral CT yielded conclusive results more often than examinations with planar V/Q scintigraphy (P<.05). Five V/Q scintigrams and spiral CT scans were discordant. Twelve pulmonary angiographic examinations were performed. Angiographic findings were concordant in 10 (91%) of 11 patients with conclusive CT scans in whom pulmonary angiography was attempted. CT was used to establish an alternative diagnosis in 19 (29%) of 66 patients in whom PE was excluded. Thin-collimation MDCT is more accurate than V/Q scintigraphy in the diagnosis of acute PE in outpatients. Furthermore, CT provides alternative diagnoses for patients without PE on high-quality transverse or near-isotropic reformatted images. 1
21. Erdman WA, Peshock RM, Redman HC, et al. Pulmonary embolism: comparison of MR images with radionuclide and angiographic studies. Radiology. 1994;190(2):499-508. Observational-Dx 86 patients: x-ray angiography (n=34), V/Q scans and concurrent clinical impression (n=30) To assess the accuracy and potential of MR in the evaluation of suspected PE. Blinded, prospective interpretations of multiphasic, cardiac-gated spin-echo MRI were compared with retrospective chart review. Subgroup with angiographic proof - MRI had sensitivity of 90%, specificity of 77%, PPV of 86%, and NPV of 83%. In 21 patients with intermediate probability of PE on V/Q scans and angiograms, MRI enabled diagnosis of PE in 12/12 patients (sensitivity 100%) and absence of PE in 7/9 patients (specificity 78%). MRI reliably depicts large and medium-size pulmonary emboli, regardless of infiltrates or effusion. 2
22. Hiorns MP, Mayo JR. Spiral computed tomography for acute pulmonary embolism. Can Assoc Radiol J. 2002;53(5):258-268. Review/Other-Dx N/A Review data on the use of CTA for PE. Spiral CT is a good confirmatory test, though will be recognized as the primary imaging modality in the future. 4
23. Katsouda E, Mystakidou K, Rapti A, et al. Evaluation of spiral computed tomography versus ventilation/perfusion scanning in patients clinically suspected of pulmonary embolism. In Vivo. 2005;19(5):873-878. Observational-Dx 63 patients To prospectively evaluate the diagnostic accuracy of V/Q scan vs CTA. Spiral CT: sensitivity, 92.9%, specificity, 85.7% PPV, 92.9%, NPV, 85.7%. V/Q scans: sensitivity, 57.1%, specificity, 42.9%, PPV, 66.7%, NPV, 33.3%. 3
24. Kluge A, Muller C, Hansel J, Gerriets T, Bachmann G. Real-time MR with TrueFISP for the detection of acute pulmonary embolism: initial clinical experience. Eur Radiol. 14(4):709-18, 2004 Apr. Observational-Dx 39 consecutive patients Prospective study to evaluate the feasibility and diagnostic value of real-time MRI (True fast imaging with steady-state precession) vs MRA for PE. Compared with MRA, the sensitivities and specificities of real time sequences for PE were 93% and 100% (per examination), 96% and 100% (lobar artery PE), and 97% and 100% (segmental artery PE), respectively. Compared with scintigraphy, the sensitivity and specificity of real time-MRI were 83% and 100%, respectively. The MRA reached 100% sensitivity and specificity in this subgroup. Diagnosis of PE by real-time MRI is feasible and offers the advantage of rapid imaging times, decreasing artifact from respiratory motion common in MRA. 3
25. Loud PA, Katz DS, Bruce DA, Klippenstein DL, Grossman ZD. Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography. Radiology. 2001;219(2):498-502. Observational-Dx 650: 308 with US gold standard used in analysis Study to determine the frequency and location of DVT at CT venography after CT pulmonary angiography using US as gold standard. Combined CT venography and pulmonary angiography can accurately depict the femoropopliteal deep veins. CT sensitivity 97% and specificity 100% for femoropopliteal thrombosis. 1
26. Cham MD, Yankelevitz DF, Shaham D, et al. Deep venous thrombosis: detection by using indirect CT venography. The Pulmonary Angiography-Indirect CT Venography Cooperative Group. Radiology 2000;216:744-51. Observational-Dx 541 patients (233 female, 308 male) To assess the clinical benefits of performing indirect computed tomographic (CT) venography after pulmonary CT angiography to detect deep venous thrombosis (DVT) in patients suspected of having a pulmonary embolism. DVT was found at indirect CT venography in 45 (8%), and pulmonary embolism was found at pulmonary CT angiography in 91 (17%) of 541 patients. Among the 45 patients with DVT, DVT occurred in 16 patients who had no pulmonary embolism at pulmonary CT angiography, which increased the diagnosis of thromboembolic disease by 18%. Among 116 patients who underwent US and indirect CT venography, 15 had DVT at US, and in all 15, DVT also was seen at indirect CT venography. In four additional cases, DVT was seen at only indirect CT venography. 2
27. Hunsaker AR, Zou KH, Poh AC, et al. Routine pelvic and lower extremity CT venography in patients undergoing pulmonary CT angiography. AJR Am J Roentgenol. 190(2):322-6, 2008 Feb. Observational-Dx 829 patients To assess the utility of performing routine pelvic and lower extremity CT venography along with pulmonary CT angiography in all patients evaluated for PE. Venous thromboembolism, PE, and DVT occurred in 152 (18.3%), 124 (15.0%), and 61 (7.3%) of 829 patients, respectively. Between the high-risk and low-risk groups, prevalence of venous thromboembolism was 114 (25.6%) of 446 and 38 (9.9%) of 383 patients, respectively (P<0.001); prevalence of PE was 92 (20.6%) of 446 and 32 (8.3%) of 383 patients, respectively (P<0.001). Isolated DVT was found in 28 (3.4%) of 829 patients. The incremental value of CT venography for the entire cohort was 3.4%, 0.72% in the low-risk group (6/829) and 2.6% (22/829) in the high-risk group. For outcome variable venous thromboembolism, malignancy and previous venous thromboembolism were statistically significant (P=0.04 and P<0.001, respectively); for PE, malignancy and previous venous thromboembolism were statistically significant (P=0.03 and P=0.005, respectively); for DVT, only previous venous thromboembolism was statistically significant (P<0.001). 3
28. Hirai LK, Takahashi JM, Yoon HC. A prospective evaluation of a quantitative D-dimer assay in the evaluation of acute pulmonary embolism. J Vasc Interv Radiol. 2007;18(8):970-974. Observational-Dx 361 consecutive patients A prospective study designed to determine if a screening quantitative serum D-dimer measurement of 1.0 microg/mL or less precludes pulmonary CTA in patients with possible acute PE. There were 310 patients who had negative pulmonary CTA results and 50 patients who had indeterminate CTA results. Only one patient had positive pulmonary CTA findings. Minimum 3-month follow-up information was available for 349 patients, none of whom reported subsequent PE, including those with indeterminate pulmonary CTA results. The use of a screening D-dimer measurement of 1.0 microg/mL or less precludes pulmonary CTA in patients with possible acute PE. The use of this quantitative D-dimer assay would decrease radiation exposure, contrast medium toxicity, cost, and time for patients seen in the emergency medicine department. 1
29. Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med. 354(22):2317-27, 2006 Jun 01. Observational-Dx 824 patients A prospective, multicenter investigation of the accuracy of multidetector CTA alone and combined with venous-phase imaging for the diagnosis of acute PE by using a composite reference test to confirm or rule out the diagnosis of PE. Among 824 patients with a reference diagnosis and a completed CT study, CTA was inconclusive in 51 because of poor image quality. Excluding such inconclusive studies, the sensitivity of CTA was 83% and the specificity was 96%. PPVs were 96% with a concordantly high or low probability on clinical assessment, 92% with an intermediate probability on clinical assessment, and nondiagnostic if clinical probability was discordant. CTA-venous-phase imaging was inconclusive in 87/824 patients because the image quality of either CTA or CTA-venous-phase imaging was poor. The sensitivity of CTA-venous-phase imaging for PE was 90%, and specificity was 95%. CTA-venous-phase imaging was also nondiagnostic with a discordant clinical probability. 2
30. van Rossum AB, Pattynama PM, Mallens WM, Hermans J, Heijerman HG. 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. 1998;8(1):90-96. Observational-Dx 123 patients To compare the diagnostic value of helical CT vs that of V/Q scintigraphy. Sensitivity and specificity were 49% and 74% for the V/Q strategy and 75% and 90% for the CT strategy, respectively (P=0.01). 3
31. Qahtani SA, Kandeel AY, Breault S, Jouannic AM, Qanadli SD. Prevalence of Acute Coronary Syndrome in Patients Suspected for Pulmonary Embolism or Acute Aortic Syndrome: Rationale for the Triple Rule-Out Concept. J Clin Med Res 2015;7:627-31. Observational-Dx 467 patients The aims of the study were to evaluate the prevalence of acute coronary syndrome (ACS) among patients presenting with atypical chest pain who are evaluated for acute aortic syndrome (AAS) or pulmonary embolism (PE) with computed tomoangiography (CTA) and discuss the rationale for the use of triple rule-out (TRO) protocol for triaging these patients. Four hundred and sixty-seven patients were evaluated: 396 (84.8%) patients for clinical suspicion of PE and 71 (15.2%) patients for suspicion of AAS. The prevalence of ACS and AAS was low among the PE patients: 5.5% and 0.5% respectively (P = 0.0001), while the prevalence of ACS and PE was 18.3% and 5.6% among AAS patients (P = 0.14 and P = 0.34 respectively). 3
32. Hofmann LV, Lee DS, Gupta A, et al. Safety and hemodynamic effects of pulmonary angiography in patients with pulmonary hypertension: 10-year single-center experience. AJR 2004;183:779-86. Observational-Dx 202 patients To examine the incidence of complications and change in pulmonary artery pressure in patients with pulmonary hypertension who were undergoing pulmonary angiography. Two hundred two of 612 patients who underwent pulmonary angiography had pulmonary hypertension. Moderate pulmonary hypertension was present in 155 patients (77%) and severe pulmonary hypertension, in 47 patients (23%). Three (2.0%) of four complications were fatal. The complication rate was higher in patients with severe pulmonary hypertension compared with patients with moderate pulmonary hypertension but not statistically significant (6.3% vs 0.6%, p = 0.63). Patients with complications had a higher mean ASA score than those without complications (4.0 vs 3.0, p = 0.03). Patients with lung transplants had the greatest increase in pulmonary artery pressure after pulmonary angiography compared with all other clinical indications (16.75 +/- 12.97 mm Hg vs 5.46 +/- 6.86 mm Hg, p = 0.003). 3
33. Stein PD, Athanasoulis C, Alavi A, et al. Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation 1992;85:462-8. Observational-Dx 1,111 patients The present study evaluates the risks and diagnostic validity of pulmonary angiography in patients who underwent angiography in the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). Complications were death in five (0.5%), major nonfatal complications in nine (1%), and less significant or minor in 60 (5%). More fatal or major nonfatal complications occurred in patients from the medical intensive care unit than elsewhere: five of 122 (4%) versus nine of 989 (1%) (p less than 0.02). Pulmonary artery pressure, volume of contrast material, and presence of PE did not significantly affect the frequency of complications. Renal dysfunction, either major (requiring dialysis) or less severe, occurred in 13 of 1,111 (1%). Patients who developed renal dysfunction after angiography were older than those who did not have renal dysfunction: 74 +/- 13 years versus 57 +/- 17 years (p less than 0.001). Angiograms were nondiagnostic in 35 of 1,111 (3%), and studies were incomplete in 12 of 1,111 (1%), usually because of a complication. Surveillance after negative angiograms showed PE in four of 675 (0.6%). Angiograms, interpreted on the basis of consensus readings, resulted in an unchallenged diagnosis in 96%. 3
34. Kluge A, Luboldt W, Bachmann G. Acute pulmonary embolism to the subsegmental level: diagnostic accuracy of three MRI techniques compared with 16-MDCT. AJR Am J Roentgenol. 187(1):W7-14, 2006 Jul. Observational-Dx 62 patients To assess the individual and combined usefulness of MRI techniques in cases of acute PE and to compare the usefulness of these techniques with that of 16-MDCT (reference standard). Per-patient basis: sensitivities of real-time MRI, MRA, MR perfusion imaging, and the combined protocol were 85%, 77%, 100%, and 100%, respectively. Specificities were 98%, 100%, 91%, and 93%. The kappa values in a comparison of the MR techniques with CT were 0.89, 0.87, 0.86, and 0.9. Per-embolus basis: sensitivities of real-time MRI, MRA, and MR perfusion imaging for lobar PE were 79%, 62%, and 100%, respectively. Sensitivities for segmental PE were 86%, 83%, and 97%, respectively. MR perfusion imaging had a sensitivity of 93% for subsegmental PE. 8/9 incidental findings revealed on CT were also subsequently diagnosed with real-time MRI. The combined MR protocol is both reliable and sensitive in comparison with 16-MDCT in the diagnosis of PE. MR perfusion imaging is sensitive for the detection of PE, whereas real-time MR and MRA are specific. 2
35. Kluge A, Mueller C, Strunk J, Lange U, Bachmann G. Experience in 207 combined MRI examinations for acute pulmonary embolism and deep vein thrombosis. AJR Am J Roentgenol. 2006;186(6):1686-1696. Observational-Dx 221 consecutive patients: (119 men, 102 women; mean age 51 years; range, 31-86 years) To prospectively assess the feasibility and quality of combined MRI exams consisting of thoracic MRI for suspected PE and MR venography for DVT, to assess the diagnostic yield of a combined examination for detecting thromboembolism compared with each component alone, and to retrospectively assess the concordance of duplex US and MR venography. Among 207 combined examinations, PE was diagnosed in 76 and DVT in 78 examinations. Thirteen patients without PE showed DVT; thus, MR venography detected 17% additional cases of thromboembolism. Agreement with duplex US was good at the upper leg (kappa = 0.87-0.89) but moderate at the pelvis (kappa = 0.59-0.65). 2
36. Oudkerk M, van Beek EJ, Wielopolski P, et al. Comparison of contrast-enhanced magnetic resonance angiography and conventional pulmonary angiography for the diagnosis of pulmonary embolism: a prospective study. Lancet. 2002;359(9318):1643-1647. Observational-Dx 141 patients: 61 men, 80 women (median age of 53 years: range 16-87), 2 reviewers Prospectively evaluate MRA compared to conventional pulmonary angiography (reference standard) for the diagnosis of PE. MRA identified 27/35 patients with proven PE (sensitivity 77%, 95% CI, 61-90). Sensitivity of MRA for isolated subsegmental, segmental, and central or lobar PE was 40%, 84%, and 100%, respectively (P<0.01 for isolated subsegmental vs segmental or larger PE). MRA is sensitive and specific for central/lobar and segmental PE, similar to data for CTA, though diagnostic value diminishes more peripherally. 1
37. Toosi MS, Merlino JD, Leeper KV. Prognostic value of the shock index along with transthoracic echocardiography in risk stratification of patients with acute pulmonary embolism. Am J Cardiol. 2008;101(5):700-705. Observational-Dx 159 patients Review echocardiographic features to assess value of the shock index along with TTE in risk stratification of patients with acute PE. Sensitivity and NPV of diastolic LV impairment (E/A wave <1), RV hypokinesis, RV/LV >1, and end-diastolic RV diameter >3 cm for in-hospital mortality were 100%. 3
38. Pleszewski B, Chartrand-Lefebvre C, Qanadli SD, et al. Gadolinium-enhanced pulmonary magnetic resonance angiography in the diagnosis of acute pulmonary embolism: a prospective study on 48 patients. Clin Imaging. 30(3):166-72, 2006 May-Jun. Observational-Dx 48 consecutive patients: 28 women and 20 men, with a mean age 55 years (range, 22-84 years), Catheter angiography (n=15), CTA (n=34), V/Q (n=45) To prospectively compare the diagnostic value of MRA with a diagnostic strategy, taking into account catheter angiography, CTA, and lung scintigraphy in patients with clinically suspected PE. Pulmonary MRA had a sensitivity of 82% and a specificity of 100% with slightly less sensitivity than CTA. In the diagnostic algorithm of PE, pulmonary MRA should be considered as an alternative to CTA when iodine contrast injection or radiation is a significant matter. 3
39. Huisman MV, Klok FA. Magnetic resonance imaging for diagnosis of acute pulmonary embolism: not yet a suitable alternative to CT-PA. J Thromb Haemost. 2012;10(5):741-742. Review/Other-Dx N/A A commentary on the study to evaluate the performance of current MRI technology in comparison to 64-row CT-PA in diagnosing a PE. No results stated in abstract. 4
40. Sostman HD, Jablonski KA, Woodard PK, et al. Factors in the technical quality of gadolinium enhanced magnetic resonance angiography for pulmonary embolism in PIOPED III. Int J Cardiovasc Imaging. 28(2):303-12, 2012 Feb. Review/Other-Dx N/A To perform a retrospective analysis of the data collected in the PIOPED III study by assessing the relationship to the proportion of examinations deemed "uninterpretable" by central readers to the clinical centers, MR equipment platform and vendors, degree of vascular opacification in different orders of pulmonary arteries; type, frequency and severity of image artifacts; patient co-morbidities, symptoms and signs; and reader characteristics. Centers, MR equipment vendor and platform, degree of vascular opacification, and motion artifacts influenced the likelihood of central reader determinations that images were "uninterpretable". Neither the reader nor patient characteristics (age, body mass index, respiratory rate, heart rate) correlated with the likelihood of determining examinations "uninterpretable". Vascular opacification and motion artifact are the principal factors influencing MRA interpretability. Some centers obtain better images more consistently, but the reasons for differences between centers are unclear. 4
41. Schiebler ML, Nagle SK, Francois CJ, et al. Effectiveness of MR angiography for the primary diagnosis of acute pulmonary embolism: clinical outcomes at 3 months and 1 year. J Magn Reson Imaging. 38(4):914-25, 2013 Oct. Observational-Dx 190 patients To determine the effectiveness of MR angiography for pulmonary embolism (MRA-PE) in symptomatic patients. There were 190 MRA-PE exams performed with 97.4% (185/190) of diagnostic quality. There were 148 patients (120 F: 28 M) that had both a diagnostic MRA-PE exam and 1 complete year of EMR follow-up. There were 167 patients (137 F: 30 M) with 3 months or greater follow-up. We found 83% (139/167) and 81% (120/148) MRA-PE exams negative for PE at 3 months and 1 year, respectively. Positive exams for PE were seen in 14% (23/167). During the 1-year follow-up period, five patients (false negative) were diagnosed with DVT (5/148 = 3.4 %), and one of these patients also experienced a non-life-threatening PE. The negative predictive value (NPV) for MRA-PE was 97% (92-99; 95% CI) at 3 months and 96% (90-98; 95% CI) with 1 year of follow-up. 3
42. Venkatesh AK, Kline JA, Courtney DM, et al. Evaluation of pulmonary embolism in the emergency department and consistency with a national quality measure: quantifying the opportunity for improvement. Arch Intern Med. 2012;172(13):1028-1032. Observational-Dx 5940 patients To perform a prospective, multicenter observational study of ED patients evaluated for PE to quantify the prevalence of avoidable imaging in ED patients with suspected PE. Imaging was performed in 2238 low-risk patients (38%), of whom 811 had no D-dimer testing, and 394 had negative D-dimer test results. Imaging was avoidable, according to the NQF measure, in 1205 patients (32%; 95% CI, 31%-34%). Avoidable imaging owing to not ordering a D-dimer test was associated with age (odds ratio [OR], 1.15 per decade; 95% CI, 1.10-1.21). Avoidable imaging owing to imaging after a negative D-dimer test result was associated with inactive malignant disease (OR, 1.66; 95% CI, 1.11-2.49). 3
43. Pasin L, Zanon M, Moreira J, et al. Magnetic Resonance Imaging of Pulmonary Embolism: Diagnostic Accuracy of Unenhanced MR and Influence in Mortality Rates. Lung. 195(2):193-199, 2017 04. Observational-Dx 93 patients To evaluate the diagnostic value for pulmonary embolism (PE) of the True fast imaging with steady-state precession (TrueFISP) mangetic resonance imaging (MRI), a method that allows the visualization of pulmonary vasculature without breath holding or intravenous contrast. Two patients could not undergo the real-time MRI and were excluded from the study. PE prevalence was 22%. During the 1-year follow-up period, eight patients died, whereas PE was responsible for 12.5% of cases. Between patients who developed PE, only 5% died due to this condition. There were no differences between MR and CT embolism detection in these subjects. MR sequences had a sensitivity of 85%, specificity was 98.6% and accuracy was 95.6%. Agreement between readers was high (?= 0.87). 2
44. Stein PD, Chenevert TL, Fowler SE, et al. Gadolinium-enhanced magnetic resonance angiography for pulmonary embolism: a multicenter prospective study (PIOPED III). Ann Intern Med. 152(7):434-43, W142-3, 2010 Apr 06. Experimental-Dx 371 patients Prospective multicenter study to investigate performance characteristics of MRA, with or without MR venography, for diagnosing PE. Reference standard diagnosis or exclusion was made by using various tests, including CTA and venography, V/Q, venous US, d-dimer assay, and clinical assessment. MRA averaged across centers, was technically inadequate in 25% of patients (92/371). The proportion of technically inadequate images ranged from 11% to 52% at various centers. Including patients with technically inadequate images, MRA identified 57% (59/104) with PE. Technically adequate MRA had a sensitivity of 78% and a specificity of 99%. Technically adequate MRA and venography had a sensitivity of 92% and a specificity of 96%, but 52% of patients (194/370) had technically inadequate results. MRA should be considered only at centers that routinely perform it well and only for patients for whom standard tests are contraindicated. MRA and MR venography combined have a higher sensitivity than MRA alone in patients with technically adequate images, but it is more difficult to obtain technically adequate images with the 2 procedures. 2
45. Haidary A, Bis K, Vrachliotis T, Kosuri R, Balasubramaniam M. Enhancement performance of a 64-slice triple rule-out protocol vs 16-slice and 10-slice multidetector CT-angiography protocols for evaluation of aortic and pulmonary vasculature. J Comput Assist Tomogr. 31(6):917-23, 2007 Nov-Dec. Observational-Dx 50 patients To compare the enhancement of the pulmonary and aortic vasculature between a biphasic injection 64-slice, a single-phase injection 16-slice, and a single-phase injection 10-slice MDCTA protocols. Individual mean pulmonary arterial and aortic attenuation values were statistically significantly less than 250 HU for the 16- and 10-slice protocols and statistically significantly more than 250 HU for the 64-slice protocols (P<0.05). Mean pooled pulmonary attenuation values were more than 250 HU in 18% (9/50) of the 16-slice and in 93% (39/42) of the 64-slice protocols. Mean pooled aortic attenuation values were more than 250 HU in 18.4% (9/49) of the 10- and 16-slice and in 100%. The triple rule-out 64-slice biphasic injection breath hold CTA protocol provides significantly higher attenuation of aortic and pulmonary vasculature compared with our current 10- and 16-slice protocols. 3
46. van der Meer RW, Pattynama PM, van Strijen MJ, et al. Right ventricular dysfunction and pulmonary obstruction index at helical CT: prediction of clinical outcome during 3-month follow-up in patients with acute pulmonary embolism. Radiology. 2005;235(3):798-803. Observational-Dx 120 consecutive patients To retrospectively quantify RVD and the pulmonary artery obstruction index at helical CT on the basis of various criteria proposed in the literature and to assess the predictive value of these CT parameters for mortality within 3 months after the initial diagnosis of PE. CT signs of RVD (RV/LV ratio, >1.0) were seen in 69 patients (57.5%). During follow-up, 7 patients died of PE. Both the RV/LV ratio and the obstruction index were shown to be significant risk factors for mortality within 3 months (P=.04 and .01, respectively). No such relationship was found for the ratio of the pulmonary artery to ascending aorta diameters (P=.66) or for the shape of the interventricular septum (P=.20). The PPV for PE-related mortality with an RV/LV ratio greater than 1.0 was 10.1% (95% CI, 2.9%, 17.4%). NPV for an uneventful outcome with an RV/LV ratio of 1.0 or less was 100% (95% CI, 94.3%, 100%). There was a 11.2-fold increased risk of dying of PE for patients with an obstruction index of 40% or higher (95% CI, 1.3, 93.6). Markers of RVD and pulmonary vascular obstruction, assessed with helical CT at baseline, help predict mortality during follow-up. 3
47. Ghaye B. Peripheral pulmonary embolism on multidetector CT pulmonary angiography. JBR-BTR. 2007;90(2):100-108. Review/Other-Dx N/A To review the indications for treatment of isolated subsegmental PE. Since its introduction in 1992, the sensitivity and specificity of CTPA increased due to reduced collimation and faster rotation time. The main limitation of single-detector row CTPA was diagnosis of PE at the subsegmental level, similar to other diagnostic techniques, such as pulmonary angiography, V/Q lung scan and MR. The advent of multi-detector row CT technology has increased the analysability of pulmonary vessels distal to the segmental level. Multi-detector row CTPA detects more subsegmental PE than single-detector row CTPA. The incidence of isolated subsegmental PE is between 5-15%, depending of the population investigated. Currently there is no straightforward admitted guidelines for treatment of subsegmental PE 4
48. Johnson TR, Nikolaou K, Wintersperger BJ, et al. ECG-gated 64-MDCT angiography in the differential diagnosis of acute chest pain. AJR Am J Roentgenol. 188(1):76-82, 2007 Jan. Observational-Dx 55 patients To assess the diagnostic value of an ECG-gated 64-MDCTA protocol for simultaneous assessment of the pulmonary arteries, coronary arteries, and aorta within a single breath-hold. Findings on CTA were compared with those on X-ray coronary angiography in 20 patients. Cause of chest pain correctly diagnosed in 37/55 patients. The protocol proved helpful in the differential diagnosis of ACP. 1
49. Schertler T, Frauenfelder T, Stolzmann P, et al. Triple rule-out CT in patients with suspicion of acute pulmonary embolism: findings and accuracy. Acad Radiol. 16(6):708-17, 2009 Jun. Observational-Dx 125 patients To prospectively investigate the diagnostic value of triple rule-out CT in patients suspected of having acute pulmonary embolism. Triple rule-out CT was normal in 53 (42%) patients. Overall sensitivity, specificity, and PPV and NPV of triple rule-out CT for cardiovascular disease were 100% (95% CI, 90%-100%), 98% (95% CI, 94%-100%), 95% (95% CI, 82%-99%), and 100% (95% CI, 97%-100%, respectively). 1
50. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996;78:469-73. Observational-Dx 126 patients To analyze the regional pattern of right ventricular (RV) dysfunction on transthoracic echocardiograms in patients with and without acute pulmonary embolism. Patients with acute pulmonary embolism had a distinct regional pattern of RV dysfunction, with akinesia of the mid-free wall (centerline excursion: -0.2 +/- 0.8 mm, p = 0.0001 vs normal) but normal motion at the apex (centerline excursion: 5.7 +/- 0.8 mm, p = NS vs normal). In contrast, patients with primary pulmonary hypertension had abnormal wall motion in all regions (p <0.03 vs normal). This echocardiographic finding of normal wall motion at the apex and abnormal wall motion in the mid-free wall in acute pulmonary embolism was then tested in a "validation" cohort of 85 patients (group 2), consisting of hospitalized patients with RV dysfunction from any cause, including 13 patients with acute pulmonary embolism. The finding had a 77% sensitivity and a 94% specificity for the diagnosis of acute pulmonary embolism, with a positive predictive value of 71% and a negative predictive value of 96%. 2
51. Mediratta A, Addetia K, Medvedofsky D, Gomberg-Maitland M, Mor-Avi V, Lang RM. Echocardiographic Diagnosis of Acute Pulmonary Embolism in Patients with McConnell's Sign. Echocardiography. 33(5):696-702, 2016 May. Observational-Dx 161 patients To evaluate in patients with "McConnell's sign" (McCS), whether echocardiographic parameters of global and regional RV function could differentiate between patients with and without acute pulmonary embolism (aPE). Fifty-five of eighty-one (68%) had PE (McCS + PE), while 26 of 81 (32%) did not (McCS - PE). Compared to NL, global and segmental RV strain were lower in patients with McCS, contrary to the notion of normal apical function. In McCS + PE, compared to McCS - PE: (1) PASP, fractional area change and TR were significantly lower; (2) strain magnitude was significantly lower globally and in basal and apical segments. Individual parameters had similar diagnostic accuracy by ROC analysis, which further improved by combining parameters. In McCS - PE, 69% of patients had pulmonary hypertension (PH). 3
52. Kjaergaard J, Schaadt BK, Lund JO, Hassager C. Quantitative measures of right ventricular dysfunction by echocardiography in the diagnosis of acute nonmassive pulmonary embolism. J Am Soc Echocardiogr. 2006;19(10):1264-1271. Observational-Dx 300 consecutive patients To evaluate the incremental diagnostic information from quantitative measures of RV size, pressure, and function by TTE. Among measures of RV anatomy, RV pressure estimates, and estimates of global and regional RV function with significant diagnostic information in a logistic regression analysis, the acceleration time of RV outflow less than 89 milliseconds, the ratio of RV to LV diameter greater than 0.78, RV outflow tract fractional shortening less than 35%, and signs of RV strain on electrocardiogram had independent, incremental diagnostic information (area under the ROC curve = 0.81). If D-dimer greater than 4.1 mmol/L was included, the area under the curve increased to 0.88. The NPV and PPV if any 2 of 3 factors in the final model were present were 88% and 70%, respectively. TTE is able to identify differential diagnoses and enhance pretest probability of PE significantly. TTE could therefore be considered as an integral part of the initial diagnostic workup of patients suspected of PE, especially if definitive diagnostic imaging has limited availability. 1
53. Lechleitner P, Riedl B, Raneburger W, Gamper G, Theurl A, Lederer A. Chest sonography in the diagnosis of pulmonary embolism: a comparison with MRI angiography and ventilation perfusion scintigraphy. Ultraschall Med. 2002;23(6):373-378. Observational-Dx 55 patients with signs of PE: 41 women, 14 men To compare the diagnostic value of chest US and V/Q scan, vs MRA. Chest US may be used as a diagnostic adjunct, but cannot exclude PE. 2
54. Mathis G, Bitschnau R, Gehmacher O, et al. Chest ultrasound in diagnosis of pulmonary embolism in comparison to helical CT. Ultraschall Med. 1999;20(2):54-59. Observational-Dx 117 patients with signs of PE: 68 women, 49 men To evaluate the diagnostic value of TTE for the diagnosis of PE. Chest US had sensitivity of 94%, specificity 87%, PPV 92%, NPV 91%, accuracy 91%. Spiral CT had sensitivity of 85%, specificity and PPV of 100%, NPV of 83% and an accuracy of 92%. Chest US can improve the diagnosis of PE. 2
55. Patel JJ, Chandrasekaran K, Maniet AR, Ross JJ, Jr., Weiss RL, Guidotti JA. Impact of the incidental diagnosis of clinically unsuspected central pulmonary artery thromboembolism in treatment of critically ill patients. Chest. 1994;105(4):986-990. Review/Other-Dx 14: (8 heart failure patients, 2 cardiogenic shock patients, 2 atrial septal defect patients, 1 aortic dissection patient, 1 pneumonia patient) To determine whether TEE is useful in the evaluation of PE. TTE showed right heart strain in 8 patients but did not visualize PE in any of the patients. The TEE diagnosis of occult central pulmonary artery thromboembolism changed treatment in all 14 patients. Presence of risk factors for PE and right heart strain on TTE should alert the physician to suspect PE. If and when TEE is performed in patients with acute cardiopulmonary disorders with risk factors for PE and right heart strain, the physician should evaluate the main pulmonary artery and its branches for central pulmonary artery thromboemboli. 4
56. Sostman HD, Coleman RE, DeLong DM, Newman GE, Paine S. Evaluation of revised criteria for ventilation-perfusion scintigraphy in patients with suspected pulmonary embolism. Radiology. 1994;193(1):103-107. Review/Other-Dx 104 patients with suspected PE To evaluate accuracy of revised PIOPED criteria over original. Revised criteria are more accurate; even higher with experienced readers. 4
57. Webber MM, Gomes AS, Roe D, La Fontaine RL, Hawkins RA. Comparison of Biello, McNeil, and PIOPED criteria for the diagnosis of pulmonary emboli on lung scans. AJR Am J Roentgenol. 1990;154(5):975-981. Observational-Dx 96 patients To determine which of the various “probability” schemes (for PE) is best. The Biello and McNeil criteria showed the most favorable likelihood ratio for predicting an angiogram not showing pulmonary emboli. Analysis of ROC curves yielded the greatest area under the ROC curve for the Biello criteria, but there were no statistically significant differences among the three sets of criteria. The rating scheme proposed by Biello, et al is a good compromise. 3
58. Anderson DR, Kahn SR, Rodger MA, et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: a randomized controlled trial. JAMA 2007;298:2743-53. Experimental-Tx 1417 patients To determine whether the widely adopted new technology of uncertain sensitivity (CTPA) was at least as safe as the standard technology V(dot)Q(dot ) scanning at not missing the detection of clinically important pulmonary embolism. Seven hundred one patients were randomized to CTPA and 716 to V(dot)Q(dot scanning. Of these, 133 patients (19.2%) in the CTPA group vs 101 (14.2%) in the V(dot)Q(dot scan group were diagnosed as having pulmonary embolism in the initial evaluation period (difference, 5.0%; 95% confidence interval [CI], 1.1% to 8.9%) and were treated with anticoagulant therapy. Of those in whom pulmonary embolism was considered excluded, 2 of 561 patients (0.4%) randomized to CTPA vs 6 of 611 patients (1.0%) undergoing V(dot)Q(dot scanning developed venous thromboembolism in follow-up (difference, -0.6%; 95% CI, -1.6% to 0.3%) including one patient with fatal pulmonary embolism in the V(dot)Q(dot group. In this study, CTPA was not inferior to V(dot)Q(dot scanning in ruling out pulmonary embolism. However, significantly more patients were diagnosed with pulmonary embolism using the CTPA approach. Further research is required to determine whether all pulmonary emboli detected by CTPA should be managed with anticoagulant therapy. 1
59. Greenspan RH, Ravin CE, Polansky SM, McLoud TC. Accuracy of the chest radiograph in diagnosis of pulmonary embolism. Invest Radiol. 1982;17(6):539-543. Observational-Dx 152 patients; 9 interpreters To determine the sensitivity and specificity of the chest radiograph for the diagnosis of PE. The average true-positive ratio (sensitivity) was 0.33, with a range of 0.52-0.88. The average true-negative ratio (specificity) was 0.59, with a range of 0.31-0.80. The false-positive and false-negative ratios were respectively, 0.21 (range 0.05-0.39) and 0.41 (range 0.15-0.70). A predictive index, reflecting the overall accuracy of diagnosis, was calculated for the entire group and was 0.40, with a range of 0.17-0.57. There appeared to be no correlation between training or experience and accuracy of performance in this study. 4
60. Leblanc M, Leveillee F, Turcotte E. Prospective evaluation of the negative predictive value of V/Q SPECT using 99mTc-Technegas. Nucl Med Commun 2007;28:667-72. Observational-Dx 584 patients To verify the negative predictive value of pulmonary ventilation/perfusion scintigraphy with single photon emission computed tomography (V/Q SPECT) in ruling out pulmonary thromboembolism. One hundred and eight patients (19%) had a positive pulmonary thromboembolism reading, 18 (3%) an indeterminate study, and 458 (78%) patients had a negative reading for pulmonary thromboembolism. There were 189 patients with an abnormal chest X-ray. The mean follow-up time was 165 days. Of the 458 patients classified as negative for pulmonary thromboembolism, patients receiving chronic anticoagulation for other causes were excluded from follow-up (n=53), which left 405 patients for final analysis. There were no pulmonary thromboembolism-related deaths in the negative group. Six patients were identified as false negatives. The negative predictive value is estimated at 98.5%. 2
61. Grifoni S, Vanni S, Magazzini S, et al. Association of persistent right ventricular dysfunction at hospital discharge after acute pulmonary embolism with recurrent thromboembolic events. Arch Intern Med. 2006;166(19):2151-2156. Observational-Dx 301 consecutive patients To evaluate the prognostic value of RVD persistence at hospital discharge with regard to the likelihood of recurrent VTE. Patients with RVD persistence showed an increased risk of recurrent VTE (14 patients, 9.2% patient-years) compared with those without RVD (15 patients, 3.1% patient-years) or RVD regression (3 patients, 1.1% patient-years) (P=.001). 6/8 deaths related to PE occurred in patients with RVD persistence. At multivariate analysis, adjusted by anticoagulant treatment duration, RVD persistence was an independent predictor of recurrent VTE (hazard ratio, 3.79; P<.001). Persistent RVD at hospital discharge after an acute PE is associated with recurrent VTE. 1
62. Isidoro J, Gil P, Costa G, Pedroso de Lima J, Alves C, Ferreira NC. Radiation dose comparison between V/P-SPECT and CT-angiography in the diagnosis of pulmonary embolism. Phys Med. 41:93-96, 2017 Sep. Review/Other-Dx N/A To compare two routine protocols at our institution, computed tomography (CT) pulmonary angiography (CTPA) and ventilation/Perfusion single photon emission computed tomography (V/P-SPECT), in terms of radiation dose to the most exposed organs (lungs and breast) and to the embryo/fetus in the case of pregnant patients. Embryo/fetus absorbed doses are similar for CTPA and V/P-SPECT and bellow 1 mGy. The calculated dose to the lungs (breast) was 1.3–10.6 (27–136) times higher from CTPA when compared with V/P-SPECT. 4
63. Halpenny D, Park B, Alpert J, et al. Low dose computed tomography pulmonary angiography protocol for imaging pregnant patients: Can dose reduction be achieved without reducing image quality?. Clin Imaging. 44:101-105, 2017 Jul - Aug. Observational-Dx 75 patients To assess the effect of low dose computed tomography pulmonary angiography (CTPA) on radiation dose in pregnant patients. Effective dosewas lower in the phase 2 group (0.95 v 1.66mSv; p < 0.001). Quantitative noise was lower in the phase 1 group (p < 0.001). 3
64. Devaraj A, Sayer C, Sheard S, Grubnic S, Nair A, Vlahos I. Diagnosing acute pulmonary embolism with computed tomography: imaging update. [Review]. J Thorac Imaging. 30(3):176-92, 2015 May. Review/Other-Dx N/A To outline key aspects of the recent literature regarding the following issues: patient selection for imaging, the optimization of computed tomography pulmonary angiography (CTPA) image quality and dose, preferred pathways for pregnant patients and other subgroups, and the role of CTPA beyond diagnosis. No results stated in abstract. 4
65. Righini M, Robert-Ebadi H, Elias A, et al. Diagnosis of Pulmonary Embolism During Pregnancy: A Multicenter Prospective Management Outcome Study. Ann Intern Med. 169(11):766-773, 2018 12 04. Observational-Dx 395 patients To prospectively validate a diagnostic strategy in pregnant women with suspected pulmonary embolism (PE). 441 women were assessed for eligibility, and 395 were included in the study. Among these, PE was diagnosed in 28 (7.1%) (proximal deep venous thrombosis found on ultrasonography [n = 7], positive CTPA result [n = 19], and high-probability V/Q scan [n = 2]) and excluded in 367 (clinical probability and negative D-dimer result [n = 46], negative CTPA result [n = 290], normal or low-probability V/Q scan [n = 17], and other reason [n = 14]). Twenty-two women received extended anticoagulation during follow-up, mainly for previous venous thromboembolic disease. The rate of symptomatic venous thromboembolic events was 0.0% (95% CI, 0.0% to 1.0%) among untreated women after exclusion of PE on the basis of negative results on the diagnostic work-up. 2
66. American College of Radiology. ACR Committee on Drugs and Contrast Media. Manual on Contrast Media. Available at: https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf. Review/Other-Dx N/A Guidance document to assist radiologists in recognizing and managing the small but real risks inherent in the use of contrast media. No abstract available. 4
67. Al Lawati K, Aljazeeri J, Bates SM, Chan WS, De Wit K. Ability of a single negative ultrasound to rule out deep vein thrombosis in pregnant women: A systematic review and meta-analysis. J Thromb Haemost 2020;18:373-80. Meta-analysis 8 studies To determine the ability of single negative ultrasound (US) to exclude deep vein thrombosis (DVT) in symptomatic pregnant women. Eight studies (seven prospective and one retrospective) were included. An overlap among study populations was identified in four of the manuscripts. Two authors performed data re-extraction from these hard copy research charts. Risk of bias was low for the included populations and method of measurement, and low or high for completeness of follow up. A total of 635 pregnant patients with symptoms of DVT had an initial negative US examination. Of those, six were diagnosed with DVT during repeat serial testing (0.94%) and three developed DVT or PE during 3-month follow-up after serial ultrasonography (0.47%). The pooled false-negative rate of a single ultrasound was 1.27% (95% confidence interval, 0.42-2.56), I2 = 27%. Good
68. Quinn RJ, Nour R, Butler SP, et al. Pulmonary embolism in patients with intermediate probability lung scans: diagnosis with Doppler venous US and D-dimer measurement. Radiology. 1994;190(2):509-511. Observational-Dx 36 patients To examine the usefulness of lower limb Doppler venous compression US and serum D-dimer measurements in diagnosis of PE in patients with intermediate probability lung scans. Pulmonary angiography demonstrated PE in 15 (41%) of 36 patients. US had sensitivity of 13%, specificity 100%. Five (14%) of the 36 patients had normal (<220 micrograms/L) D-dimer levels; none of the five had PE. Sensitivity and specificity of D-dimer values were 100% and 16%, respectively, with NPV of 100%. 2
69. Smith LL, Iber C, Sirr S. Pulmonary embolism: confirmation with venous duplex US as adjunct to lung scanning. Radiology. 1994;191(1):143-147. Review/Other-Dx 285 lung scan and duplex US exams in 267 consecutive patients: (151 men and 134 women aged 17-98 years) Retrospective review to assess the prevalence of DVT with venous duplex US in patients who underwent radionuclide lung scanning for evaluation of clinically suspected PE and to assess the clinical usefulness of this type of US in the selection of patients for anticoagulant therapy. Thrombotic disease was confirmed with US in 7 (21%) of 33 patients with normal lung scans and in 64 (25%) of 252 patients with abnormal lung scans. Duplex US is a useful adjunct to lung scanning. 4
70. Niemann T, Nicolas G, Roser HW, Muller-Brand J, Bongartz G. Imaging for suspected pulmonary embolism in pregnancy-what about the fetal dose? A comprehensive review of the literature. Insights Imaging 2010;1:361-72. Review/Other-Dx 85 studies To give a comprehensive overview of fetal doses reported in the literature when imaging the pregnant woman with suspected pulmonary embolism (PE). Fetal dose in chest computed tomography (CT) ranges between 0.013 and 0.026 mGy in early and 0.06–0.1 mGy in late pregnancy compared with 99mTc-MAA perfusion scintigraphy with a fetal dose of 0.1–0.6 mGy in early and 0.6–0.8 mGy in late pregnancy. 99mTc-aerosol ventilation scintigraphy results in 0.1–0.3 mGy. However, there is concern about female breast irradiation in CT, which is higher than in scintigraphy. CT radiation risks for breast tissue remain unclear. 4
71. Boiselle PM, Reddy SS, Villas PA, Liu A, Seibyl JP. Pulmonary embolus in pregnant patients: survey of ventilation-perfusion imaging policies and practices. Radiology 1998;207:201-6. Review/Other-Dx 327 patients To assess the policies and practices of nuclear medicine facilities as regards ventilation-perfusion (V-P) imaging in pregnant patients suspected of having pulmonary embolus. Of the 1,000 surveys mailed, 327 (33%) completed surveys were returned. Of these 327 respondents, 220 (67%) reported that they perform V-P imaging in pregnant patients suspected of having pulmonary embolus. Of these 220 respondents, 115 (52%) routinely obtain informed consent, and 170 (77%) modify their standard V-P imaging protocol for pregnant patients. The most common modification (135 [79%] of 170 respondents) was reduction of the perfusion agent dose. Reported practice patterns for written policies, informed consent, and modifications did not show statistically significant trends among respondents in varying practice settings or geographic locations. 4
72. Stein PD, Terrin ML, Gottschalk A, Alavi A, Henry JW. Value of ventilation/perfusion scans versus perfusion scans alone in acute pulmonary embolism. Am J Cardiol 1992;69:1239-41. Review/Other-Dx 98 patients To assess the value of ventilation/perfusion (V/Q) scans compared with that of perfusion scans alone in the diagnosis of acute pulmonary embolism (PE). No abstract available. 4
73. Scarsbrook AF, Bradley KM, Gleeson FV. Perfusion scintigraphy: diagnostic utility in pregnant women with suspected pulmonary embolic disease. Eur Radiol 2007;17:2554-60. Observational-Dx 105 patients To determine if the diagnostic utility of perfusion scintigraphy in pregnant patients with suspected pulmonary embolism (PE) could be optimised by careful patient selection and the use of alternative imaging methods in those with an abnormal chest x-ray (CXR) and/or a history of chronic lung disease or asthma. One hundred and five consecutive patients had either perfusion scintigraphy (Q scan) (n = 94), CTPA (n = 9) or both (n = 2), one patient presented twice. Q scans were the first line investigation in 96 (91%) patients. Eighty-nine (92%) scans were normal, seven (7%) were non-diagnostic and one (1%) was high probability. One patient had a thromboembolic event 3 weeks post partum. No adverse events were reported during the follow-up period. Pulmonary embolic disease is uncommon in pregnancy. Perfusion scintigraphy in pregnant patients has an excellent diagnostic yield. The percentage of non-diagnostic scans is much lower than in other patient groups. 3
74. Shahir K, Goodman LR, Tali A, Thorsen KM, Hellman RS. Pulmonary embolism in pregnancy: CT pulmonary angiography versus perfusion scanning. AJR Am J Roentgenol. 195(3):W214-20, 2010 Sep. Observational-Dx 199 pregnant patients had 106 CTPA examinations and 99 perfusion scans To retrospectively evaluate the equivalence of CTPA and perfusion scanning in terms of diagnostic quality and NPV in the imaging of PE in pregnancy. CTPA and perfusion scanning have equivalent clinical NPV (99% for CTPA; 100% for perfusion scanning) and image quality in the care of pregnant patients. The choice of study should therefore be based on other considerations, such as radiation concern, radiographic results, alternative diagnosis, and equipment availability. Reducing the amount of radiation to the maternal breast favors use of perfusion scanning when the radiographic findings are normal and there is no clinical suspicion of an alternative diagnosis. 2
75. American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-fetal.pdf Review/Other-Dx N/A To promote safe and optimal performance of fetal magnetic resonance imaging (MRI). No abstract available. 4
76. American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Pregnant_Patients.pdf. Review/Other-Dx N/A To assist practitioners in providing appropriate radiologic care for pregnant or potentially pregnant adolescents and women by describing specific training, skills and techniques. No abstract available. 4
77. American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/us-ob.pdf Review/Other-Dx N/A To promote the safe and effective use of diagnostic and therapeutic radiology by describing the key elements of standard ultrasound examinations in the first, second, and third trimesters of pregnancy. No abstract available. 4
78. American College of Radiology. ACR Committee on MR Safety. 2024 ACR Manual on MR Safety. Available at: https://www.acr.org/-/media/ACR/Files/Radiology-Safety/MR-Safety/Manual-on-MR-Safety.pdf. Review/Other-Dx N/A Guidance document to promote the use of magnetic resonance (MR) safe practices. No abstract available. 4
79. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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