Small Pulmonary Artery Defects Are Not Reliable Indicators of Pulmonary Embolism

Miller, Wallace T.; Marinari, Lawrence A.; Barbosa, Eduardo J. Mortani; Litt, Harold; Schmitt, J. Eric; Mahne, Anton; Lee, Victor; Akers, Scott

doi:10.1513/annalsats.201502-105oc

Cited by 51 publications

(37 citation statements)

References 14 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Ghanima et al (2007) found a low inter‐observer agreement of 25%, with a kappa of 0·38 (95% CI 0·0–0·89). Although our data do not allow firm conclusions on the reasons for the difference between the current and prior studies, we hypothesize that the further advancements in CT technology since 2002–2008 [inclusion period of the studies reported by Ghanima et al (2007) and Miller et al (2015)] and the very low number of technically inadequate CT scans in the YEARS study may have contributed to the good inter‐observer agreement found in the current analysis.…”

Section: Discussioncontrasting

confidence: 66%

Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm

et al. 2018

View full text Add to dashboard Cite

SummaryThe rate of identified isolated subsegmental pulmonary embolism (ssPE) has doubled with advances in computed tomography pulmonary angiography (CTPA) technology, but its clinical relevance is debated. The YEARS diagnostic algorithm was shown to safely reduce the number of required CTPAs in the diagnostic management of PE. We hypothesized that the higher threshold for performing CTPA in YEARS was associated with a lower prevalence of ssPE compared to the conventional diagnostic algorithm. We compared 2291 consecutive patients with suspected PE managed according to YEARS to 3306 consecutive control patients managed according to the Wells score for the prevalence of isolated ssPE. In the YEARS cohort, 52% were managed without CTPA, 12% had pulmonary embolism (PE) of which 10% were isolated ssPE, and the 3‐month diagnostic failure rate was 0·35%. In the control cohort, 32% were managed without CTPA, 20% had PE of which 16% were isolated ssPE, and the 3‐month failure rate was 0·73%. The isolated ssPE prevalence was significantly lower in YEARS (absolute difference 6·2% (95% confidence interval [CI] 1·4–10), Odds Ratio 0·58 (95% CI 0·37–0·90). In conclusion, YEARS is associated with a lower prevalence of isolated ssPE, due to reduction in CTPAs by the higher D‐dimer threshold. This was however not associated with a higher risk of recurrent VTE during follow‐up.

show abstract

Section: Discussioncontrasting

confidence: 66%

Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm

et al. 2018

View full text Add to dashboard Cite

show abstract

“…Two recent studies specifically reviewed positive scans using specialist cardiothoracic radiologist reviews found rates of SSPE of 18% (yield 19%- Hutchinson, Eire) and 26% (yield 9%, Miller, USA). [6,38] Both studies found very high rates of probable or definitive false positive diagnoses (56% and 42% respectively) amongst CTPA reported as isolated SSPE or isolated segmental PE. It seems likely that there are differences between sites and regions in radiology reporting practice, with institutional or regional willingness to “miss” PE potentially explaining some of this variation.…”

Section: Discussionmentioning

confidence: 99%

“…It is possible that if utilisation rates doubled and yield routinely dropped to well below 10%, as seems to be the case in significant parts of the USA, that small: large PE ratios may change. [3,38,39]…”

Section: Discussionmentioning

confidence: 99%

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

et al. 2016

View full text Add to dashboard Cite

IntroductionOveruse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4–10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America.AimsTo describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation.MethodsA retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation.ResultsFourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8–15.4%; range 9.3–25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1–58.2%) and SSPE 8.8% (CI: 7.1–10.5%) of positive scans. CTPA usage (0.2–1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions.Discussion/ ConclusionsWe found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5–3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

show abstract

“…51 Considering that there are hundreds of subsegmental arteries, it is unlikely that their radiological assessment is as complete as in the case of the 18 segmental, 5 lobar, and 2 main pulmonary arteries. 49 Quality of imaging is also an important variable affecting scan interpretation. In most cases, the CTPA scans are inconclusive or false positive due to suboptimal vessel opacification, as well as respiratory and heart pulsation artifacts.…”

mentioning

confidence: 99%

“…Obesity and a mucus plug adjacent to the pulmonary artery may also considerably affect the quality of the CTPA images, leading to artifactual findings and overdiagnosis. 48,49,52 It seems unclear if the clinical presentation of symptomatic SSPE is similar to that of more proximal PE. A systematic review, which compared patients with SSPE and those with more proximal PE, reported that patients with SSPE were less likely to complain of dyspnea (66.7% vs 84%, respectively), and most cases in that study untreated patients do not have worse prognosis.…”

mentioning

confidence: 99%

How to manage patients with symptomatic subsegmental pulmonary embolism?

Roberge

Carrier

2020

Polish Archives of Internal Medicine

View full text Add to dashboard Cite

in diameter better than single-detector CTPA. 15-17 Over the years, refined clinical assessment in combination with D-dimer testing and other imaging techniques (eg, CTPA) made invasive strategies (ie, pulmonary angiography) unnecessary in diagnosing PE. 18-26 Due to the greater accessibility of CTPA and its ability to provide information on a possible alternative diagnosis, the use of ventilation-perfusion (V/Q) scanning has also decreased significantly. 27-29 According to a nationwide study performed in the United States, the incidence of PE has increased by 81% since CTPA was introduced. 30 This fact could be explained in different ways. Whereas a true increase in the incidence of PE (eg, due to an increased prevalence of risk factors) is possible, some studies also reported a decrease in the case-fatality rate of PE, associated with a stable or slight decrease in the mortality rate. 30-37 Although this slight improvement in mortality might be due to earlier diagnosis and better management, potential overdiagnosis of less severe PE could also be considered. Multidetector CTPA was reported to detect proportionally more cases of subsegmental pulmonary embolism (SSPE) compared with single-detector CT, and, despite an increased number of diagnoses,

show abstract

Small Pulmonary Artery Defects Are Not Reliable Indicators of Pulmonary Embolism

Cited by 51 publications

References 14 publications

Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm

Lower prevalence of subsegmental pulmonary embolism after application of the YEARS diagnostic algorithm

RESPECT-ED: Rates of Pulmonary Emboli (PE) and Sub-Segmental PE with Modern Computed Tomographic Pulmonary Angiograms in Emergency Departments: A Multi-Center Observational Study Finds Significant Yield Variation, Uncorrelated with Use or Small PE Rates

How to manage patients with symptomatic subsegmental pulmonary embolism?

Contact Info

Product

Resources

About