Routine pelvic and lower extremity CT venography in patients undergoing pulmonary CT angiography.

OBJECTIVE The purpose of our study was to assess the utility of performing routine pelvic and lower extremity CT venography (CTV) along with pulmonary CT angiography (CTA) in all patients evaluated for pulmonary embolism. MATERIALS AND METHODS Eight hundred twenty-nine consecutive patients (281 men and 548 women) underwent CTA-CTV for pulmonary embolism. Reports were evaluated as follows: positive or negative for pulmonary embolism with or without deep venous thrombosis (DVT) or with nondiagnostic CTV. Coexisting factors of malignancy, previous venous thromboembolism (VTE), recent surgery, and cardiovascular disease comprised the high-risk group of 446 patients. The remaining 383 patients formed the low-risk group. Statistical analysis included four binary predictors (previous VTE, malignancy, cardiovascular disease, and surgery) and three binary outcome variables (pulmonary embolism, DVT, and VTE). Chi-square test and univariate and multivariate regression analyses were performed. RESULTS VTE, pulmonary embolism, 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 VTE was 114 (25.6%) of 446 and 38 (9.9%) of 383 patients, respectively (p < 0.001); prevalence of pulmonary embolism 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 CTV for the entire cohort was 3.4%, 0.72% in the low-risk group (six of 829) and 2.6% (22 of 829) in the high-risk group. For outcome variable VTE, malignancy and previous VTE were statistically significant (p = 0.04 and p < 0.001, respectively); for pulmonary embolism, malignancy and previous VTE were statistically significant (p = 0.03 and p = 0.005, respectively); for DVT, only previous VTE was statistically significant (p < 0.001). CONCLUSION CTV should not be performed routinely in all patients evaluated for pulmonary embolism and may only be useful in patients with a high probability of pulmonary embolism, including those with a history of VTE and possible malignancy.

[1]  G. Kovacs,et al.  Excluding Pulmonary Embolism at the Bedside without Diagnostic Imaging: Management of Patients with Suspected Pulmonary Embolism Presenting to the Emergency Department by Using a Simple Clinical Model and d-dimer , 2001, Annals of Internal Medicine.

[2]  P. Wells.  Pulmonary embolism: a clinician's perspective. , 2008, Seminars in nuclear medicine.

[3]  J. Kline,et al.  Indirect computed tomography venography: a report of vascular opacification , 2010, Emergency Radiology.

[4]  G. Adam,et al.  Evaluation of the Deep Venous System in Patients With Suspected Pulmonary Embolism With Multi‐detector CT: A Prospective Study in Comparison to Doppler Sonography , 2003, Journal of computer assisted tomography.

[5]  A. Nchimi,et al.  Does multi-detector row CT pulmonary angiography reduce the incremental value of indirect CT venography compared with single-detector row CT pulmonary angiography? , 2006, Radiology.

[6]  S. Goldhaber,et al.  Acute pulmonary embolism: part I: epidemiology and diagnosis. , 2006, Circulation.

[7]  A. Alavi,et al.  The clinical course of pulmonary embolism. , 1992, The New England journal of medicine.

[8]  D. Katz,et al.  Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography. , 2001, Radiology.

[9]  C J Carter,et al.  Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. , 1983, Annals of internal medicine.

[10]  Ami A. Shah,et al.  Deep venous thrombosis: detection by using indirect CT venography. The Pulmonary Angiography-Indirect CT Venography Cooperative Group. , 2000, Radiology.

[11]  C. Henschke,et al.  Thromboembolic disease detection at indirect CT venography versus CT pulmonary angiography. , 2005, Radiology.

[12]  Pamela K Woodard,et al.  CT venography: a necessary adjunct to CT pulmonary angiography or a waste of time, money, and radiation? , 2009, Radiology.

[13]  A. Baron,et al.  Thromboembolic disease: comparison of combined CT pulmonary angiography and venography with bilateral leg sonography in 70 patients. , 2000, AJR. American journal of roentgenology.

[14]  K. Zou,et al.  Receiver-Operating Characteristic Analysis for Evaluating Diagnostic Tests and Predictive Models , 2007, Circulation.

[15]  A. Bilici,et al.  64-MDCT pulmonary angiography and CT venography in the diagnosis of thromboembolic disease. , 2009, AJR. American journal of roentgenology.

[16]  Pamela K Woodard,et al.  Multidetector computed tomography for acute pulmonary embolism. , 2006, The New England journal of medicine.

[17]  D. Katz,et al.  Combined CT venography and pulmonary angiography: how much venous enhancement is routinely obtained? , 2001, AJR. American journal of roentgenology.

[18]  C J Carter,et al.  Diagnostic value of ventilation-perfusion lung scanning in patients with suspected pulmonary embolism. , 1985, Chest.

[19]  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.

[20]  M Gent,et al.  Use of a Clinical Model for Safe Management of Patients with Suspected Pulmonary Embolism , 1998, Annals of Internal Medicine.

[21]  S. Konstantinides.  Acute Pulmonary Embolism , 2012, Manual of Cardiovascular Medicine.

[22]  P. Investigators,et al.  Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). , 1990 .

[23]  W M O'Fallon,et al.  Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. , 1998, Archives of internal medicine.

[24]  Arnaud Perrier,et al.  Accuracy or outcome in suspected pulmonary embolism. , 2006, The New England journal of medicine.

[25]  D. Katz,et al.  Combined CT venography and pulmonary angiography in suspected thromboembolic disease: diagnostic accuracy for deep venous evaluation. , 2000, AJR. American journal of roentgenology.

[26]  Samuel Z Goldhaber,et al.  Acute pulmonary embolism: part I: epidemiology, pathophysiology, and diagnosis. , 2003, Circulation.

[27]  V. Griesshaber,et al.  Combined CT Pulmonary Angiography and Venography for Diagnosis of Pulmonary Embolism and Deep Vein Thrombosis: Radiation Dose , 2001, Journal of thoracic imaging.

[28]  M. Revel,et al.  Multidetector-row computed tomography in suspected pulmonary embolism. , 2005, The New England journal of medicine.