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Deep Venous Thrombosis with Suspected Pulmonary Embolism

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Deep Venous Thrombosis with Suspected Pulmonary Embolism Thoracic Imaging Peter A. Loud, MD Deep Venous Thrombosis Douglas S. Katz, MD Dennis A. Bruce, MD with Suspected Pulmonary Donald L. Klippenstein, MD Zachary D. Grossman, MD Embolism: Detection with Combined CT Venography Index terms: Computed tomography (CT), 1 angiography, 9*.129142, and Pulmonary Angiography 9*.12915, 9*.12916 Embolism, pulmonary, 60.72 Pulmonary angiography, 944.12914, 944.12915, 944.12916 PURPOSE: To determine the frequency and location of deep venous thrombosis at Veins, thrombosis, 9*.751, 9*.12914 computed tomographic (CT) venography after CT pulmonary angiography in a large series of patients clinically suspected of having pulmonary embolism and to Radiology 2001; 219:498–502 compare the accuracy of CT venography with lower-extremity venous sonography. Abbreviation: MATERIALS AND METHODS: Venous phase images were acquired from the DVT ϭ deep venous thrombosis diaphragm to the upper calves after completion of CT pulmonary angiography in 650 patients (373 women, 277 men; age range, 18–99 years; mean age, 63 years) 1 From the Department of Radiology, to determine the presence and location of deep venous thrombosis. Results of CT Roswell Park Cancer Institute, Elm and Carlton Sts, Buffalo, NY 14263 (P.A.L., venography were compared with those of bilateral lower-extremity venous sonog- D.L.K., Z.D.G.), and the Department raphy in 308 patients. of Radiology, Winthrop University Hospital, Mineola, NY (D.S.K., D.A.B.). RESULTS: A total of 116 patients had pulmonary embolism and/or deep venous From the 1999 RSNA scientific assem- thrombosis, including 27 patients with pulmonary embolism alone, 31 patients with bly. Received July 7, 2000; revision re- quested August 19; revision received deep venous thrombosis alone, and 58 patients with both. Among 89 patients with October 4; accepted October 11. Ad- deep venous thrombosis, thrombosis was bilateral in 26, involved the abdominal or dress correspondence to P.A.L. (e- pelvic veins in 11, and was isolated to the abdominal or pelvic veins in four. In mail: [email protected]). patients in whom sonographic correlation was available, CT venography had a 2 9*. Vascular system, location unspec- sensitivity of 97% and a specificity of 100% for femoropopliteal deep venous ified. thrombosis. © RSNA, 2001 CONCLUSION: Combined CT venography and pulmonary angiography can accu- rately depict the femoropopliteal deep veins, permitting concurrent testing for venous thrombosis and pulmonary embolism. CT venography also defines pelvic or abdominal thrombus, which was seen in 17% of patients with deep venous throm- bosis. Pulmonary thromboembolism is a feared complication of deep venous thrombosis (DVT). The mortality rate in untreated cases is 25%–30%, whereas the mortality rate in treated cases decreases to 5%–8% (1). More than 90% of pulmonary emboli arise from deep veins of the legs and pelvis, and the primary risk factor for recurrent pulmonary embolism is the Author contributions: Guarantors of integrity of entire study, presence of residual proximal venous thrombosis (2,3). P.A.L., D.S.K.; study concepts, P.A.L.; Unfortunately, both pulmonary embolism and DVT are conditions that are notoriously study design, P.A.L., D.S.K.; literature difficult to diagnose clinically. Diagnostic algorithms for the evaluation of suspected research, P.A.L.; clinical studies, P.A.L., thromboembolism have traditionally included ventilation-perfusion lung scanning and D.S.K.; data acquisition and analysis/ interpretation, P.A.L., D.S.K.; statistical conventional pulmonary angiography to evaluate the lungs and lower-extremity sonog- analysis, P.A.L.; manuscript prepara- raphy to evaluate the leg veins, but they have recently evolved to include computed tion and definition of intellectual con- tomography (CT) (4). CT pulmonary angiography is increasingly being used to evaluate tent, P.A.L.; manuscript editing and suspected pulmonary embolism because it accurately defines emboli to the level of seg- revision/review, all authors; manu- script final version approval, P.A.L., mental pulmonary arteries and reveals other nonembolic causes of thoracic symptoms D.S.K. (5–7). Because pulmonary embolism and venous thrombosis are different aspects of the same 498 disease, a single study that accurately de- with a section thickness of 3–5 mm and a Sensitivity, specificity, and positive fines both processes would be a valuable pitch of 1.8 or 2.0 from the diaphragm to and negative predictive values from CT addition to the diagnostic regimen. Com- the aortic arch during a single breath venography, compared with lower-ex- bined CT venography and pulmonary hold, beginning 20–25 seconds after the tremity venous sonography, were calcu- angiography was reported in 1998 (8). start of contrast medium infusion. At lated. Cases with CT-depicted DVT iso- This test, which consists of helical CT both hospitals, transverse venous images, lated to the calf veins, iliac veins, and pulmonary angiography followed by ve- 5–10 mm thick, were acquired at 5-cm vena cava were excluded from these cal- nous phase CT performed from the dia- intervals during approximately 40 sec- culations, as sonography of these areas phragm to the calves, allows concurrent onds from the diaphragm to the upper was not routinely performed. evaluation of pulmonary embolism and calves. At one hospital, the venous study DVT. This technique uses the venous en- began 31⁄2 minutes after the start of con- hancement that follows rapid peripheral trast material infusion and included im- RESULTS venous infusion of iodinated contrast ages acquired from the upper calves up to medium for helical CT pulmonary an- the diaphragm. At the other, the venous Among 650 patients examined, 534 giography and therefore requires no ad- study began 3 minutes after contrast ma- (82%) showed no evidence of pulmonary ditional contrast medium to image the terial administration and included im- embolism or DVT. Among 116 (18%) deep veins. Findings of several subse- ages acquired from the diaphragm to the with positive CT scans—that is, those quent studies (9–11) in which CT venog- upper calves. Both protocols, therefore, with evidence of pulmonary embolism raphy was compared with lower-extrem- were used to image the femoropopliteal and/or DVT—58 had both pulmonary ity sonography have indicated that it is veins between 3 and 4 minutes after the embolism and DVT (Fig 1), 27 had pul- accurate for the evaluation of femoro- administration of contrast material. A to- monary embolism without DVT, and 31 popliteal DVT. tal of 18–20 venous images were typi- had DVT without pulmonary embolism The purpose of this study was to deter- cally obtained. (Fig 2). mine the frequency and location of DVT All CT scans were evaluated for DVT by In 26 of the 89 patients with DVT, with combined CT venography and pul- one of three radiologists (P.A.L., D.S.K., thrombus in the lower extremities was monary angiography in 650 consecutive D.L.K.) blinded to the results of any pre- bilateral. The most proximal location of patients referred for evaluation of sus- vious venous imaging. All radiologists thrombus defined at CT venography was pected pulmonary embolism. In a subset were fellowship trained in body imaging the calf veins or popliteal vein in 25, the of 308 patients, we compared the results and had an additional 4–8 years in prac- superficial femoral vein in 18, the com- with those of lower-extremity venous son- tice. Criteria for a diagnosis of DVT were mon femoral vein in 31, the iliac veins in ography. an intraluminal filling defect or localized five, and the inferior vena cava in 10 (Fig nonopacification of a venous segment. 3). DVT was found only in the superficial The location of DVT was recorded in all femoral vein in one patient and only in MATERIALS AND METHODS patients. In 85 patients, pulmonary em- the common femoral vein in two. Four bolism was diagnosed at helical CT pul- patients had thrombus only in the iliac Between September 1997 and April 2000, monary angiography. veins or inferior vena cava. 650 consecutive patients suspected of hav- The results of all patients undergoing A total of 308 patients underwent bilat- ing pulmonary embolism (373 women, bilateral lower-extremity venous sonog- eral lower-extremity sonography within 24 277 men; age range, 18–99 years; mean raphy within 24 hours before or after CT hours of CT. In this group, femoropopli- age, 63 years) underwent CT venography examination were reviewed. Sonography teal DVT was found at CT in 63 patients, and pulmonary angiography. The two was performed as part of the patient’s and DVT was found at sonography in 65. participating institutions were Winthrop clinical evaluation and involved the use There were two false-negative CT scans. University Hospital, Mineola, NY, and of a standard compression and Doppler Undetected thrombus in the superficial Roswell Park Cancer Institute, Buffalo, technique from the popliteal trifurcation and common femoral veins in these pa- NY, which contributed 509 and 141 cases, to the inguinal level, which included the tients represented short areas of clot, pre- respectively. The patient population in- popliteal vein and the superficial, deep, sumably missed due to the 5-cm section cluded 71 patients from an earlier prelim- and common femoral veins (12). Sono- interval used. In both patients, pulmonary inary study (10). Other patients were graphic findings were considered positive embolism was seen at helical CT pulmo- excluded during that period due to contra- if thrombus prevented complete collapse nary angiography. The sonograms of four indications to contrast medium adminis- of the vein during manual compression patients were initially interpreted as neg- tration, such as allergy or renal insuffi- and caused a lack of flow at Doppler ex- ative for femoropopliteal DVT. The cor- ciency, and unavailable venous access.
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