Real‐time risk stratification of patients with acute pulmonary embolism by grading the reflux of contrast into the inferior vena cava on computerized tomographic pulmonary angiography

Abstract

Summary. Objective: To investigate whether fast grading of reflux of contrast to the inferior vena cava (IVC) on computerized tomographic pulmonary angiography (CTPA) is a potential biomarker for real‐time risk stratification. Methods: We retrospectively identified 343 patients investigated for possible pulmonary embolism (PE) by CTPA at our medical center between September 2004 and March 2006. A total of 145 consecutive patients with PE (age 67 ± 19 years) and 168 consecutive ones with negative CTPAs (age 64 ± 20 years) fulfilled entry criteria. CTPAs were evaluated for retrograde reflux of contrast to the IVC by fast visual grading from 1 to 6 using the original axial images. Pulmonary obstruction index, the diameters of right and left ventricles and pulmonary artery, and patient survival data were recorded as well. Results: Twenty‐nine (20.0%) patients with positive CTs and 23 (13.7%) patients with negative CTs had substantial degrees (≥4) of reflux of contrast to the IVC (P = 0.14). The Kaplan–Meier 30‐day survival curves demonstrated significant reduction in survival in individuals with PE and grade ≥4 reflux of contrast to the IVC compared with lower grades (P = 0.008), but not in patients with grade ≥4 and no PE on CTPA (P = 0.26). The other cardiovascular parameters showed no significant correlation with survival in patients with and without PE. Conclusion: Substantial grades of reflux of contrast to the IVC during CTPA could predict early mortality in patients with acute PE. Rapid grading of reflux of contrast from the original axial CTPA images can be used for real‐time risk stratification in patients with acute PE.

Serial imaging after pulmonary embolism and correlation with functional limitation at 12 months: Results of the ELOPE Study

“…Similar to CTO, reflux in the inferior vena cava has been associated with 30‐day mortality following acute PE 20. However, pulmonary artery diameter, which has been associated with clot burden, has not demonstrated direct association with adverse PE outcomes 21.…”

Usefulness of Combined Assessment With Computed Tomographic Signs of Right Ventricular Dysfunction and Cardiac Troponin T for Risk Stratification of Acute Pulmonary Embolism

“…The initial clinical diagnosis of PE was confirmed in the presence of Ն1 filling defect in the pulmonary artery tree (Figure 1), including the subsegmental level. 2 The severity of reflux of contrast medium into the inferior vena cava or hepatic veins was graded according to a previously published scale 14 : 1 ϭ no reflux; 2 ϭ trace of reflux into the inferior vena cava only; 3 ϭ reflux into the inferior vena cava, but not the hepatic veins; 4 ϭ reflux into the inferior vena cava and proximal hepatic veins; 5 ϭ reflux into the inferior vena cava and hepatic veins down to the midportion of the liver; and 6 ϭ reflux into the inferior vena cava with opacification of distal hepatic veins ( Figure 1). The degree of contrast medium reflux was grouped into nonsubstantial (grades 1 to 3) and substantial (grades 4 to 6) reflux.…”

The association between the embolic load and atrial size in acute pulmonary embolism

“…The presence and location of arterial clots as well as the degree of arterial obstruction were scored using the system proposed by Qanadli et al [12] and reported previously by our group [15]. Briefly, this scoring system includes 20 segmental pulmonary artery branches.…”

“…We took advantage of a previously reported cohort [15] and retrospectively studied 190 patients who were investigated for possible PE by CTPA at our center. Fifteen patients with incomplete CTPA, clinical or survival data were excluded, leaving a total study cohort of 137 consecutive patients with PE on CTPAs performed between 1 October 2004 and 31 March 2006, and a control group that was comprised of 38 consecutive patients with CTPAs that were negative for PE (15 December 2004 and11 February 2005).…”

“…The presence or absence of PE on the CTPA studies, the RV and LV diameters on a fourchamber reformat and PE clot load score were assessed on a dedicated workstation (MxView; Philips Medical Systems) and collected from our previous report [15].…”