The OPTICA study (Optimised Computed Tomography Pulmonary Angiography in Pregnancy Quality and Safety study): Rationale and design of a prospective trial assessing the quality and safety of an optimised CTPA protocol in pregnancy

Gillespie, Ciara; Foley, Shane; Rowan, Michael J.; Ewins, Karl; NíAinle, Fionnuala; MacMahon, Peter

doi:10.1016/j.thromres.2019.03.007

Cited by 19 publications

(18 citation statements)

References 36 publications

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“…At present, both the American College of Radiology, the European Society of Cardiology (ESC) and Fleischner Society recommend CTPA as the first line test in patients with suspected APE, while the Fleischner Society even suggests it as the new gold standard (38,58). According to 2015 ESC/ERS guidelines, CTPA is part of the diagnostic algorithm in patients with suspected CTEPH, but V/Q scan remains the recommended first-line screening option and conventional pulmonary angiography is still recommended for presurgical assessment (10).…”

Section: Computed Tomography Pulmonary Angiographymentioning

confidence: 99%

Do radiologists detect chronic thromboembolic disease on computed tomography?

et al. 2019

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Background: Acute pulmonary embolism (APE) is a potentially severe medical condition with blood clots obstructing the pulmonary arterial vasculature. In most cases the APE resolves without any sequelae after anticoagulation therapy. In some patients, however, the emboli do not resolve upon treatment and the remnants cause increased vascular resistance, a condition known as chronic thromboembolic pulmonary hypertension (CTEPH). Both APE and CTEPH have a non-specific clinical presentation and imaging is an important part of the diagnosis. In APE computed tomography pulmonary angiography (CTPA) is the diagnostic gold standard, although the method is not suitable for all patients. CTPA has a high specificity for CTEPH, but the sensitivity remains under debate. At present CTPA is not recommended as a first line test among patients with a clinical suspicion of CTEPH. Purpose: To investigate unestablished imaging modalities in the diagnosis of APE (Study I) and CTEPH (Study III) including learning aspects (Study II) and knowledge (Study IV) of theses among radiologists. Regarding APE we studied magnetic resonance imaging (MRI) and in CTEPH we studied CTPA. Material and methods: Studies I-II were based on a prospective collection of 70 unenhanced MRI exams with CTPA as the gold standard. In Studies III-IV we used a retrospective material based on 43 CTPA exams from patients with confirmed CTEPH referred for presurgical assessment at a specialist centre, with a matched control with suspected APE. Results: All MRI exams were of diagnostic quality. Specificity was 100% for both readers and sensitivity 90% and 93% respectively with a nearly perfect inter-reader agreement (kappa 0.97) (Study I). Residents interpreting the MRI exams within the training program reached a clinically acceptable level after approximately 50 examinations and review time was halved during the training program (Study II). The sensitivity for CTEPH on CTPA reviewed by two experts was 100% and the specificity 100% (Study III), while the sensitivity based on the original reports from the same cases was 26% (Study IV). Conclusions: Unenhanced MRI has a high sensitivity and specificity for APE (Study I) and residents can learn to interpret such exams by using a self-directed training program (Study II). Enhanced CTPA has a high sensitivity when reviewed by experienced radiologists (Study III), but among radiologists in general the sensitivity is low (Study IV). LIST OF SCIENTIFIC PAPERS I. Detection of pulmonary embolism using repeated MRI acquisitions without respiratory gating: A preliminary study.

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Section: Computed Tomography Pulmonary Angiographymentioning

confidence: 99%

Do radiologists detect chronic thromboembolic disease on computed tomography?

et al. 2019

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“…While this is beneficial for all patients, young and pregnant women stand to benefit the most. Bismuth breast shields can reduce radiation dosage by 26–41% [ 5 ], but have varied use internationally—within the United States of America, for example, these shields are not routinely used in practice [ 26 ]. For a fetus, the radiation dosage associated with a mother’s CTPA is significantly less than the levels required to produce teratogenic effects [ 27 ]; however, little is known about the long-term risk and potential genetic damage induced [ 28 ].…”

Section: Discussionmentioning

confidence: 99%

“…The most significant risk is the exposure to ionizing radiation. This is of particular concern in young and/or pregnant women, because of a potential long-term increased risk of breast cancer and possible harm to the fetus [ 5 ]. Additionally, there is a cumulative risk from repeat scans, as one-third of patients who undergo a CTPA for the first time will undergo a second CTPA within the subsequent five years [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

The Effect of Limiting the Scan Range of Computed Tomography Pulmonary Angiography (to Reduce Radiation Exposure) on the Detection of Pulmonary Embolism: A Systematic Review

et al. 2021

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(1) Background: Computed tomography pulmonary angiography (CTPA) is the standard imaging test for the evaluation of acute pulmonary embolism (PE), but it is associated with patients’ exposure to radiation. Studies have suggested that radiation exposure can be reduced without compromising PE detection by limiting the scan range (the z-axis, going from up to down); (2) Methods: A literature search was conducted in MEDLINE and EMBASE on 17 July 2021. Studies were included if they enrolled patients who had undergone a CTPA and described the yield of PE diagnoses, number of missed filling defects and/or other diagnoses using a reduced z-axis in comparison to a full-length scan. To assess risk of bias, we modified an existing risk of bias tools for observational studies, the Newcastle-Ottawa Scale. Results were synthesized in a narrative review. Primary outcomes were the number of missed PE diagnoses (based on at least one filling defect) and filling defects; the secondary outcome was the number of other missed findings; (3) Results: Eleven cohort studies and one case-control study were included reporting on a total of 3955 scans including 1025 scans with a diagnosis of PE. Six different reduced scan ranges were assessed; the most studied was from the top of the aortic arch to below the heart, in which no PEs were missed (seven studies). One sub-segmental PE was missed when the scan coverage was 10 cm starting from the bottom of the aortic arch and 14.7 cm starting from the top of the arch. Five studies that reported on other findings all found that other diagnoses were missed with a reduced z-axis. Most of the included studies had a high risk of bias; (4) Conclusions: CTPA scan coverage reduction from the top of aortic arch to below the heart reduced radiation exposure without affecting PE diagnoses, but studies were generally at high risk of bias.

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“…Several studies have reported comparable accuracy of CTPA and low dose perfusion scanning for detection of acute PE in pregnant women but the mean maternal and fetal radiation doses have been reported to be lower with low dose perfusion scanning (no ventilation component). 68,71 Small perfusion defects should be interpreted with caution in pregnant patients with a known history of asthma. In these instances, the ventilation component should be completed or further evaluation with CTPA if it remains unclear whether small perfusion defects are due to acute PE or matched defects due to asthma.…”

Section: Investigation Of Acute Pulmonary Embolism In Pregnancymentioning

confidence: 99%

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 1: Acquisition and Safety Considerations

et al. 2021

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Acute pulmonary embolism (APE) is a well-recognized cause of circulatory system compromise and even demise which can frequently present a diagnostic challenge for the physician. The diagnostic challenge is primarily due to the frequency of indeterminate presentations as well as several other conditions which can have a similar clinical presentation. This often obliges the physician to establish a firm diagnosis due to the potentially serious outcomes related to this disease. Computed tomography pulmonary angiography (CTPA) has increasingly cemented its role as the primary investigation tool in this clinical context and is widely accepted as the standard of care due to several desired attributes which include great accuracy, accessibility, rapid turn-around time and the ability to suggest an alternate diagnosis when APE is not the culprit. In Part 1 of this guidance document, a series of up-to-date recommendations are provided to the reader pertaining to CTPA protocol optimization (including scan range, radiation and intravenous contrast dose), safety measures including the departure from breast and gonadal shielding, population-specific scenarios (pregnancy and early post-partum) and consideration of alternate diagnostic techniques when clinically deemed appropriate.

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The OPTICA study (Optimised Computed Tomography Pulmonary Angiography in Pregnancy Quality and Safety study): Rationale and design of a prospective trial assessing the quality and safety of an optimised CTPA protocol in pregnancy

Cited by 19 publications

References 36 publications

Do radiologists detect chronic thromboembolic disease on computed tomography?

Do radiologists detect chronic thromboembolic disease on computed tomography?

The Effect of Limiting the Scan Range of Computed Tomography Pulmonary Angiography (to Reduce Radiation Exposure) on the Detection of Pulmonary Embolism: A Systematic Review

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 1: Acquisition and Safety Considerations

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