State-of-the-Art Pulmonary CT Angiography for Acute Pulmonary Embolism.

OBJECTIVE Pulmonary CT angiography (CTA) is the imaging modality of choice in suspected acute pulmonary embolism (PE). Current pulmonary CTA techniques involve ever lower doses of contrast medium and radiation along with advanced postprocessing applications to enhance image quality, diagnostic accuracy, and provide added value in patient management. The objective of this article is to summarize these current developments and discuss the appropriate use of state-of-the-art pulmonary CTA. CONCLUSION Pulmonary CTA is well established as a fast and reliable means of excluding or diagnosing PE. Continued developments in CT system hardware and postprocessing techniques will allow incremental reductions in radiation and contrast material requirements while improving image quality. Advances in risk stratification and prognostication from pulmonary CTA examinations should further refine its clinical value while minimizing the potential harm from overutilization and overdiagnosis.

[1]  Ernst Klotz,et al.  Approaches to CT perfusion imaging in pulmonary embolism. , 2005, Seminars in roentgenology.

[2]  Thomas Henzler,et al.  Dual-energy CT: radiation dose aspects. , 2012, AJR. American journal of roentgenology.

[3]  U. Schoepf,et al.  Detection of coronary artery stenosis with sub-milliSievert radiation dose by prospectively ECG-triggered high-pitch spiral CT angiography and iterative reconstruction , 2013, European Radiology.

[4]  Konstantin Nikolaou,et al.  Dual energy CT for the assessment of lung perfusion--correlation to scintigraphy. , 2008, European journal of radiology.

[5]  T. Lehnert,et al.  Dual energy CT pulmonary blood volume assessment in acute pulmonary embolism – correlation with D-dimer level, right heart strain and clinical outcome , 2011, European Radiology.

[6]  U. Schoepf,et al.  Right Ventricular Enlargement on Chest Computed Tomography: A Predictor of Early Death in Acute Pulmonary Embolism , 2004, Circulation.

[7]  C. Saade,et al.  Exponentially Decelerated Contrast Media Injection Rate Combined With a Novel Patient-Specific Contrast Formula Reduces Contrast Volume Administration and Radiation Dose During Computed Tomography Pulmonary Angiography , 2016, Journal of computer assisted tomography.

[8]  L. Haramati,et al.  Increased diagnosis of pulmonary embolism without a corresponding decline in mortality during the CT era. , 2008, Clinical radiology.

[9]  L. Goodman,et al.  Diagnosis and Management of Isolated Subsegmental Pulmonary Embolism: Review and Assessment of the Options , 2012, Clinical and applied thrombosis/hemostasis : official journal of the International Academy of Clinical and Applied Thrombosis/Hemostasis.

[10]  P. Wells,et al.  VIDAS D-dimer in combination with clinical pre-test probability to rule out pulmonary embolism , 2008, Thrombosis and Haemostasis.

[11]  R. Lanzman,et al.  CT pulmonary angiography: simultaneous low-pitch dual-source acquisition mode with 70 kVp and 40 ml of contrast medium and comparison with high-pitch spiral dual-source acquisition with automated tube potential selection. , 2016, The British journal of radiology.

[12]  C. Park,et al.  The feasibility of sub-millisievert coronary CT angiography with low tube voltage, prospective ECG gating, and a knowledge-based iterative model reconstruction algorithm , 2015, The International Journal of Cardiovascular Imaging.

[13]  L Desbiolles,et al.  Advanced virtual monoenergetic images: improving the contrast of dual-energy CT pulmonary angiography. , 2015, Clinical radiology.

[14]  B. Yeh,et al.  Pulmonary embolism detection with dual-energy CT: experimental study of dual-source CT in rabbits. , 2009, Radiology.

[15]  Piotr Pruszczyk,et al.  Guidelines on the Diagnosis and Management of Acute Pulmonary Embolism , 2008 .

[16]  M. Reiser,et al.  Effectiveness of Automated Quantification of Pulmonary Perfused Blood Volume Using Dual-Energy CTPA for the Severity Assessment of Acute Pulmonary Embolism , 2013, Investigative radiology.

[17]  S. Stevens,et al.  Radiation and chest CT scan examinations: what do we know? , 2012, Chest.

[18]  E. Neri,et al.  80-kV pulmonary CT angiography with 40 mL of iodinated contrast material in lean patients: comparison of vascular enhancement with iodixanol (320 mg I/mL)and iomeprol (400 mg I/mL). , 2012, AJR. American journal of roentgenology.

[19]  T. Vogl,et al.  High-pitch Dual-source Computed Tomography Pulmonary Angiography in Freely Breathing Patients , 2012, Journal of thoracic imaging.

[20]  Long Jiang Zhang,et al.  Contrast-induced nephropathy in CT: incidence, risk factors and strategies for prevention , 2016, European Radiology.

[21]  M. Reiser,et al.  Dual-energy CT for the assessment of contrast material distribution in the pulmonary parenchyma. , 2009, AJR. American journal of roentgenology.

[22]  S. Schoenberg,et al.  Prognostic value of perfusion defect volume at dual energy CTA in patients with pulmonary embolism: correlation with CTA obstruction scores, CT parameters of right ventricular dysfunction and adverse clinical outcome. , 2012, European journal of radiology.

[23]  Long Jiang Zhang,et al.  Dual energy computed tomography demonstrated lung ventilation/perfusion mismatch in a 19-year-old patient with pulmonary embolism. , 2012, Circulation.

[24]  Long Jiang Zhang,et al.  Pulmonary embolism and renal vein thrombosis in patients with nephrotic syndrome: prospective evaluation of prevalence and risk factors with CT. , 2014, Radiology.

[25]  U. Schoepf,et al.  Reduced radiation dose and improved image quality at cardiovascular CT angiography by automated attenuation-based tube voltage selection: intra-individual comparison , 2014, European Radiology.

[26]  N. Gourtsoyiannis E3-European Excellence in Education , 2003, European Radiology.

[27]  Alexander Crispin,et al.  Subsegmental pulmonary emboli: improved detection with thin-collimation multi-detector row spiral CT. , 2002, Radiology.

[28]  C. Roy,et al.  Iterative reconstruction in single source dual-energy CT pulmonary angiography: Is it sufficient to achieve a radiation dose as low as state-of-the-art single-energy CTPA? , 2015, European journal of radiology.

[29]  R. Fanous,et al.  Image quality and radiation dose of pulmonary CT angiography performed using 100 and 120 kVp. , 2012, AJR. American journal of roentgenology.

[30]  S. Schoenberg,et al.  Pulmonary embolism: CT signs and cardiac biomarkers for predicting right ventricular dysfunction , 2011, European Respiratory Journal.

[31]  O. Rutschmann,et al.  Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. , 2014, JAMA.

[32]  J. Remy,et al.  Reduced-dose low-voltage chest CT angiography with Sinogram-affirmed iterative reconstruction versus standard-dose filtered back projection. , 2013, Radiology.

[33]  Andrew D. Auerbach,et al.  Helical CT Pulmonary Angiography Predictors of In-Hospital Morbidity and Mortality in Patients With Acute Pulmonary Embolism , 2003, Journal of thoracic imaging.

[34]  S. Schindera,et al.  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. , 2011, AJR. American journal of roentgenology.

[35]  Richard D. White,et al.  ACR Appropriateness Criteria® acute chest pain--suspected pulmonary embolism. , 2012, Journal of thoracic imaging.

[36]  Matthias Niethammer,et al.  CT perfusion imaging of the lung in pulmonary embolism. , 2003, Academic radiology.

[37]  J. Jeudy,et al.  Use of a Hybrid Iterative Reconstruction Technique to Reduce Image Noise and Improve Image Quality in Obese Patients Undergoing Computed Tomographic Pulmonary Angiography , 2013, Journal of thoracic imaging.

[38]  Joon Beom Seo,et al.  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. , 2010, AJR. American journal of roentgenology.

[39]  U. Schoepf,et al.  Feasibility of prospectively ECG-triggered high-pitch coronary CT angiography with 30 mL iodinated contrast agent at 70 kVp: initial experience , 2014, European Radiology.

[40]  S. Schoenberg,et al.  Where do we stand? Functional imaging in acute and chronic pulmonary embolism with state-of-the-art CT. , 2015, European journal of radiology.

[41]  Jan-Erik Scholtz,et al.  Comprehensive Comparison of Virtual Monoenergetic and Linearly Blended Reconstruction Techniques in Third-Generation Dual-Source Dual-Energy Computed Tomography Angiography of the Thorax and Abdomen , 2016, Investigative radiology.

[42]  W. Kalender,et al.  Image quality of ultra-low radiation exposure coronary CT angiography with an effective dose <0.1 mSv using high-pitch spiral acquisition and raw data-based iterative reconstruction , 2013, European Radiology.

[43]  C. Fink,et al.  CT imaging of acute pulmonary embolism. , 2011, Journal of cardiovascular computed tomography.

[44]  J. Leipsic,et al.  Reduced iodine load at CT pulmonary angiography with dual-energy monochromatic imaging: comparison with standard CT pulmonary angiography--a prospective randomized trial. , 2012, Radiology.

[45]  Image quality of low-energy pulmonary CT angiography: comparison with standard CT. , 2011, AJR. American journal of roentgenology.

[46]  G. Casola,et al.  Pulmonary embolism at CT angiography: implications for appropriateness, cost, and radiation exposure in 2003 patients. , 2010, Radiology.

[47]  F. Klok,et al.  Advances in the diagnosis and management of acute pulmonary embolism. , 2014, Thrombosis research.

[48]  D. Chakraborty,et al.  An optimised patient-specific approach to administration of contrast agent for CT pulmonary angiography , 2013, European Radiology.

[49]  Long Jiang Zhang,et al.  Dual-energy CT lung ventilation/perfusion imaging for diagnosing pulmonary embolism , 2013, European Radiology.

[50]  J. Leipsic,et al.  State of the Art: Iterative CT Reconstruction Techniques. , 2015, Radiology.

[51]  G. Feuchtner,et al.  Comparison of image quality and radiation dose of different pulmonary CTA protocols on a 128-slice CT: high-pitch dual source CT, dual energy CT and conventional spiral CT , 2012, European Radiology.

[52]  Improving pulmonary vessel image quality with a full model-based iterative reconstruction algorithm in 80kVp low-dose chest CT for pediatric patients aged 0–6 years , 2015, Acta radiologica.

[53]  K. Suga,et al.  Added value of lung perfused blood volume images using dual-energy CT for assessment of acute pulmonary embolism. , 2015, European journal of radiology.

[54]  J de Mey,et al.  Comparison of ventilation-perfusion single-photon emission computed tomography (V/Q SPECT) versus dual-energy CT perfusion and angiography (DECT) after 6 months of pulmonary embolism (PE) treatment. , 2015, European journal of radiology.

[55]  Pieter W Kamphuisen,et al.  Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. , 2006, JAMA.

[56]  U. Schoepf,et al.  Contrast-Induced Acute Kidney Injury: Definition, Epidemiology, and Outcome , 2014, BioMed research international.

[57]  U. Schoepf,et al.  70-kVp High-pitch Computed Tomography Pulmonary Angiography with 40 mL Contrast Agent: Initial Experience. , 2015, Academic radiology.

[58]  U. Schoepf,et al.  Computed tomography of acute pulmonary embolism: state-of-the-art , 2015, European Radiology.

[59]  M. Mourits,et al.  Reducing contrast medium volume and tube voltage in CT angiography of the pulmonary artery. , 2016, Clinical radiology.

[60]  T. Flohr,et al.  Image quality and radiation dose of low tube voltage 3rd generation dual-source coronary CT angiography in obese patients: a phantom study , 2014, European Radiology.

[61]  U. Schoepf,et al.  High-pitch computed tomography pulmonary angiography with iterative reconstruction at 80 kVp and 20 mL contrast agent volume , 2014, European Radiology.

[62]  Mathias Prokop,et al.  CT angiography of pulmonary arteries to detect pulmonary embolism: improvement of vascular enhancement with low kilovoltage settings. , 2006, Radiology.

[63]  Xiang Kong,et al.  Xenon-enhanced dual-energy CT lung ventilation imaging: techniques and clinical applications. , 2014, AJR. American journal of roentgenology.

[64]  Guang Ming Lu,et al.  Dual-energy CT of the lung. , 2012, AJR. American journal of roentgenology.

[65]  Steven Woloshin,et al.  When a test is too good: how CT pulmonary angiograms find pulmonary emboli that do not need to be found , 2013, BMJ.

[66]  Martin Sedlmair,et al.  Assessment of an Advanced Image-Based Technique to Calculate Virtual Monoenergetic Computed Tomographic Images From a Dual-Energy Examination to Improve Contrast-To-Noise Ratio in Examinations Using Iodinated Contrast Media , 2014, Investigative radiology.

[67]  J. Ellis,et al.  Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material: risk stratification by using estimated glomerular filtration rate. , 2013, Radiology.

[68]  R. El Dib,et al.  Anticoagulant treatment for subsegmental pulmonary embolism. , 2016, The Cochrane database of systematic reviews.

[69]  J. Gurney No fooling around: direct visualization of pulmonary embolism. , 1993, Radiology.

[70]  Thomas Flohr,et al.  Spectral optimization of chest CT angiography with reduced iodine load: experience in 80 patients evaluated with dual-source, dual-energy CT. , 2013, Radiology.

[71]  H. Sostman,et al.  Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II Investigators. , 2007, Radiology.

[72]  B. Hamm,et al.  Reducing radiation dose in the diagnosis of pulmonary embolism using adaptive statistical iterative reconstruction and lower tube potential in computed tomography , 2014, European Radiology.

[73]  U. Schoepf,et al.  Contrast-Induced Nephropathy , 2015, Circulation.

[74]  Martine Remy-Jardin,et al.  Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. , 2007, Radiology.

[75]  S. Schoenberg,et al.  Value of monoenergetic low-kV dual energy CT datasets for improved image quality of CT pulmonary angiography. , 2014, European journal of radiology.

[76]  Amelia M Wnorowski,et al.  Diagnostic Yield of Triple-Rule-Out CT in an Emergency Setting. , 2016, AJR. American journal of roentgenology.

[77]  Tim Leiner,et al.  Dose reduction with iterative reconstruction for coronary CT angiography: a systematic review and meta-analysis. , 2016, The British journal of radiology.

[78]  A Vieillard-Baron,et al.  New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. , 2001, AJR. American journal of roentgenology.

[79]  J. Heverhagen,et al.  Prospective randomised comparison of diagnostic confidence and image quality with normal-dose and low-dose CT pulmonary angiography at various body weights , 2014, European Radiology.

[80]  J. Mayo,et al.  Pulmonary CT angiography as first-line imaging for PE: image quality and radiation dose considerations. , 2013, AJR. American journal of roentgenology.

[81]  A. Furber,et al.  Appropriateness of Diagnostic Management and Outcomes of Suspected Pulmonary Embolism , 2006, Annals of Internal Medicine.

[82]  Matthias Renker,et al.  Iterative image reconstruction: a realistic dose-saving method in cardiac CT imaging? , 2013, Expert review of cardiovascular therapy.

[83]  T. Lehnert,et al.  Systematic Comparison of Reduced Tube Current Protocols for High-pitch and Standard-pitch Pulmonary CT Angiography in a Large Single-center Population. , 2016, Academic radiology.

[84]  Fabian Bamberg,et al.  Predictive Value of Computed Tomography in Acute Pulmonary Embolism: Systematic Review and Meta-analysis. , 2015, The American journal of medicine.

[85]  A. Reimann,et al.  Clinical utility of ultra high pitch dual source thoracic CT imaging of acute pulmonary embolism in the emergency department: are we one step closer towards a non-gated triple rule out? , 2013, European journal of radiology.

[86]  A. Sodickson,et al.  Effects of patient size on radiation dose reduction and image quality in low-kVp CT pulmonary angiography performed with reduced IV contrast dose , 2012, Emergency Radiology.

[87]  R. Evans,et al.  Adherence to PIOPED II investigators' recommendations for computed tomography pulmonary angiography. , 2013, The American journal of medicine.

[88]  M. Rodger,et al.  Safety of excluding acute pulmonary embolism based on an unlikely clinical probability by the Wells rule and normal D-dimer concentration: a meta-analysis. , 2010, Thrombosis research.

[89]  Gorka Bastarrika,et al.  CT signs of right ventricular dysfunction: prognostic role in acute pulmonary embolism. , 2011, JACC. Cardiovascular imaging.

[90]  J. Goo,et al.  Dual-energy CT: clinical applications in various pulmonary diseases. , 2010, Radiographics : a review publication of the Radiological Society of North America, Inc.