Safety of multidetector computed tomography pulmonary angiography to exclude pulmonary embolism in patients with a likely pretest clinical probability

Abstract

Background In patients with suspected pulmonary embolism (PE) classified as having a likely or high pretest clinical probability, the need to perform additional testing after a negative multidetector computed tomography pulmonary angiography (CTPA) finding remains a matter of debate. Objectives To assess the safety of excluding PE by CTPA without additional imaging in patients with a likely pretest probability of PE. Patients/Methods We retrospectively analyzed patients included in two multicenter management outcome studies that assessed diagnostic algorithms for PE diagnosis. Results Two thousand five hundred and twenty-two outpatients with suspected PE were available for analysis. Of these 2522 patients, 845 had a likely clinical probability as assessed by use of the simplified revised Geneva score. Of all of these patients, 314 had the diagnosis of PE excluded by a negative CTPA finding alone without additional testing, and were left without anticoagulant treatment and followed up for 3 months. Two patients presented with a venous thromboembolism (VTE) during follow-up. Therefore, the 3-month VTE risk in likely-probability patients after a negative CTPA finding alone was 2/314 (0.6%; 95% confidence interval [CI] 0.2-2.3%). Conclusions In outpatients with suspected PE and a likely clinical probability as assessed by use of the simplified revised Geneva score, CTPA alone seems to be able to safely exclude PE, with a low 3-month VTE rate, which is similar to the VTE rate following the gold standard, i.e. pulmonary angiography.

EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond

“…Another available benchmark is follow-up of patients for recurrence of PE as a predictor of false negative results. An equivalent of sensitivity was calculated on the basis of a 3-month follow-up in 14,545 patients where PE was excluded by CTPA [48, 94, 95, 133–138] and in another 1865 patients where this was done by V/P SPECT [52, 74, 75, 139]:…”

Outcomes following a negative computed tomography pulmonary angiography according to pulmonary embolism prevalence: a meta‐analysis of the management outcome studies

“…Two studies used a single and multidetector scanner and in five studies the type of scanner was not specified. CTPA was most commonly performed as part of a diagnostic algorithm in patients with positive D-dimers or a non-low pretest clinical probability (n = 12) [6,7,21,23,24,26,29,31,[38][39][40][41]. In five studies, venous ultrasound was systematically performed as part of the diagnostic algorithm [21,25,27,33,36].…”

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and † †Service de tive studies are required to validate the appropriate diagnostic algorithm for this subgroup of patients.Computed tomography angiography in pulmonary embolism 1109 CDR, clinical decision risk score; CT, computed tomography; CTPA, computed tomographic pulmonary angiography; PE, pulmonary prevalence; MSCT, multi-slice computed tomography; DVUS, deep venous ultrasound; CTV, venous-phase multidetector computed tomographic venography; PA, pulmonary angiography; V/Q, ventilation-perfusion lung scintigraphy.*Data from the two Righini studies [7,37] were extracted from the data presented in another article [41]

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“…*Data from the two Righini studies [7,37] were extracted from the data presented in another article [41]…”

The year 2017 in cardiology: aorta and peripheral circulation

“…Pulmonary embolism was excluded with CTPA in 37% of patients with likely clinical probability, and the 3-month VTE risk was 0.6%, indicating that a negative CTPA safely excludes PE in this patient group. 47 The prevalence of PE in patients presenting with syncope has been highly debated this year, following the PESIT trial, reported last year, 39 describing a 17% rate of PE in syncope cases referred to emergency rooms, after excluding cases with evident aetiology. A meta-analysis including 6608 emergency department patients and 975 patients hospitalized for syncope reported a PE prevalence <1%.…”