CLINICAL AND RADIOLOGIC CLINICAL AND RADIOLOGIC EVALUATION OF THE PATIENTS EVALUATION OF THE PATIENTS

EXAMINATED WITH FORE-EXAMINATED WITH FORE-DIAGNOSIS OF PULMONARY DIAGNOSIS OF PULMONARY

EMBOLISMEMBOLISM

*Oğuzhan Karaoğlu,***Oğuzhan Karaoğlu,**Kemal Can Tertemiz,Kemal Can Tertemiz,*Erkan Yılmaz,**Atila *Erkan Yılmaz,**Atila AkkoçluAkkoçlu* Dokuz Eylul University Faculty of Medicine, Radiology * Dokuz Eylul University Faculty of Medicine, Radiology DepartmentDepartment** Dokuz Eylul University Faculty of Medicine, Pulmonary ** Dokuz Eylul University Faculty of Medicine, Pulmonary MedicineMedicine

Pulmonary embolism (PE) is a Pulmonary embolism (PE) is a frequently seen diseasefrequently seen disease

PE diagnosis and treatment are PE diagnosis and treatment are difficult and also PE has a high difficult and also PE has a high mortality ratemortality rate

The mortality rate of PEThe mortality rate of PE Non-diagnosed cases 30%Non-diagnosed cases 30% Diagnosed case 10%Diagnosed case 10%

70% of the PE outcomes 70% of the PE outcomes secondary to lower extremity deep secondary to lower extremity deep venous thrombosis (DVT)venous thrombosis (DVT)

Thrombosis in deep veins of Thrombosis in deep veins of femoral region have 50% PE riskfemoral region have 50% PE risk

Imaging methods for diagnosing Imaging methods for diagnosing PEPE Chest X-rayChest X-ray V/Q scintigraphy V/Q scintigraphy Pulmonary CT angiographyPulmonary CT angiography Thorax MR angiography Thorax MR angiography Conventional angiographyConventional angiography

Pulmonary CT Pulmonary CT AngiographyAngiography

Pulmonary CT angiography has more Pulmonary CT angiography has more than 90% sensitivity and spesifity in than 90% sensitivity and spesifity in PE cases PE cases

But in subsegmental arteries But in subsegmental arteries sensitivity decreases to 63% and sensitivity decreases to 63% and specifity to 89%specifity to 89%

Pulmonary CT angiography is the Pulmonary CT angiography is the first line method for analysing cases first line method for analysing cases suspected from PEsuspected from PE

Pulmonary CT Pulmonary CT AngiographyAngiography

LimitationsLimitations Deficiency of detecting embolism in Deficiency of detecting embolism in

subsegmental and smaller arteriessubsegmental and smaller arteries Respiratory artefacts due to deficiency Respiratory artefacts due to deficiency

of controlling respiration in dyspneic of controlling respiration in dyspneic cases cases

Difficult to perform in renal insufficient Difficult to perform in renal insufficient patients because of high doze contrastpatients because of high doze contrast

Pulmonary CT Pulmonary CT AngiographyAngiography

Additional advantages other than Additional advantages other than showing the thrombusshowing the thrombus Lung parenchymaLung parenchyma MediastinumMediastinum Pleura ve thorasic wall pathologies Pleura ve thorasic wall pathologies

can be seencan be seen Response to the treatment can be Response to the treatment can be

detecteddetected

For diagnosing of DVTFor diagnosing of DVT Coloured doppler USColoured doppler US MR venographyMR venography Conventional venous angiography Conventional venous angiography CT venography CT venography Impedance pletismographyImpedance pletismography

In femoropopliteal region sensitivity In femoropopliteal region sensitivity is 95% and specifity is 99% for is 95% and specifity is 99% for showing venous thrombosis showing venous thrombosis

It is not a gold standart for DVT It is not a gold standart for DVT diagnosis, but it is accepted as a diagnosis, but it is accepted as a standart method in clinical usestandart method in clinical use

Coloured Doppler USColoured Doppler US

Coloured Doppler USColoured Doppler US LimitationsLimitations

Suboptimal analysis because of Suboptimal analysis because of obesity and oedemaobesity and oedema

Transducer, device setup and Transducer, device setup and position of the patient can effect position of the patient can effect the image quality the image quality

Iliac and superficial femoral veins Iliac and superficial femoral veins can not be analysed enoughcan not be analysed enough

The experience of the radiologistThe experience of the radiologist

CT VenographyCT Venography CT venography have 100% CT venography have 100%

sensitivity and 96% specifity when sensitivity and 96% specifity when compared with conventional compared with conventional venography venography

CT venography can show better the CT venography can show better the elonging the thrombosis to pelvic elonging the thrombosis to pelvic veins and ve inferior vena cava veins and ve inferior vena cava

CT venography needs 80% lower CT venography needs 80% lower doze contrast campared with doze contrast campared with conventional venographyconventional venography

Combined CT Combined CT Anjiography and CT Anjiography and CT

VenographyVenography Performing pulmonary CT anjiography and Performing pulmonary CT anjiography and

lower extremity CT venography lower extremity CT venography simultaneously became a popular method simultaneously became a popular method

Venous system is scaned between diaphragm Venous system is scaned between diaphragm and popliteal region following pulmonary CT and popliteal region following pulmonary CT anjiography, 3-3,5 minutes after injecting the anjiography, 3-3,5 minutes after injecting the contrast material. (cross section thickness 5-contrast material. (cross section thickness 5-10 mm and interval 1-5 cm) 10 mm and interval 1-5 cm)

This method has 89-100% sensitivity and 94-This method has 89-100% sensitivity and 94-100% specifity100% specifity

CT VenographyCT Venography LimitationsLimitations

Parametres like cross section Parametres like cross section thickness, interval and scaning thickness, interval and scaning methods are not standart methods are not standart

Discriminating acute and chronic Discriminating acute and chronic thrombosis is usualy possible but it thrombosis is usualy possible but it is difficult in some casesis difficult in some cases

MethodMethod Beetween November 2006 – Jully 2007 Beetween November 2006 – Jully 2007

80 cases suspected of PE and 80 cases suspected of PE and decided to perform pulmonary CT decided to perform pulmonary CT anjiography are included to the studyanjiography are included to the study

For PE risk scorring For PE risk scorring Well ScaleWell Scale Miniati Method Miniati Method Geneva RulesGeneva Rules

GENEVA RULES

WELL SCALE

MINIATI METHOD

Pulmonary CT anjiography and lower Pulmonary CT anjiography and lower extremity CT venography performed extremity CT venography performed simultaneously to all casessimultaneously to all cases

Before or after pulmonary CT Before or after pulmonary CT anjiography lower extremity doppler anjiography lower extremity doppler US is performedUS is performed

ResultsResults 80 cases are included 80 cases are included 42 (52%) male, 38 (48%) female42 (52%) male, 38 (48%) female Mean age 60 yearsMean age 60 years In 19 (23%) cases PE detected with In 19 (23%) cases PE detected with

pulmonary CT anjiographypulmonary CT anjiography DVT is detected in 15 (18,7%) cases DVT is detected in 15 (18,7%) cases

with CT venography and 9 (11%) with CT venography and 9 (11%) cases with coloured doppler UScases with coloured doppler US

PE rates according to PE rates according to PE clinical risk PE clinical risk

scoringsscorings CLINICAL RISK SCORINGSCLINICAL RISK SCORINGS

RISKRISK Well ScaleWell Scale Geneva RulesGeneva Rules Miniati MethodMiniati Method

HighHigh 10/6 (%60)10/6 (%60) 6/1 (%17)6/1 (%17) 9/6 (%67)9/6 (%67)

MediumMedium 29/13 (%44)29/13 (%44) 38/9 (%23)38/9 (%23) 36/11 (%30)36/11 (%30)

LowLow 41/0 (%0)41/0 (%0) 36/9 (%25)36/9 (%25) 35/2 (%5)35/2 (%5)

TotalTotal 80/1980/19 80/1980/19 80/1980/19

No PE or DVT determined in cases with No PE or DVT determined in cases with low risk accordirg for more than one low risk accordirg for more than one scoringscoring

In 6 cases with normal coloured doppler In 6 cases with normal coloured doppler US DVT diagnosed with CT venography US DVT diagnosed with CT venography and 5 of them also diagnosed PE and 5 of them also diagnosed PE

DVT evidence is mostly showed in DVT evidence is mostly showed in femoral regionfemoral region

   ColouredColoured Dop Dopppler USler US   

  

DVT(+)DVT(+)n % n %

DVT(-)DVT(-)n %n %     n %n %

CT CT VenograpVenographyhy

DVT(+)DVT(+) 9 9 6060

6 406 40 115 5 1919

DVT(-)DVT(-) 00 6565 65 65 8181

   9 9 1111

71 8971 89 8080

CT Venography Coloured Doppler US

Right Left Right Left

Pelvic 3 1 1(2) (1)

Femoral 10 4 6/(4) 2/(2)

Popliteal

4 4 3/(1) 2/(1)

Crural 5 3 1/(4) (3)

Comparing Doppler US and CT Comparing Doppler US and CT Venography about DVTVenography about DVT

SensitivitySensitivity %100%100 Specifity Specifity %91%91

CT Venography and CT Venography and Pulmonary CT Anjiography Pulmonary CT Anjiography

ResultsResults Diagnosis PE with Pulmonary CT AnjiographyDiagnosis PE with Pulmonary CT Anjiography

PE ( + )PE ( + ) PE ( - )PE ( - ) TotalTotal

DiagnosingDiagnosing DVT with CTDVT with CT VenographyVenography

DVT ( + )DVT ( + ) 1111 44 15 (%19)15 (%19)

DVT ( - )DVT ( - ) 88 5757 65 (%81)65 (%81)

ToplamToplam 19 (%23)19 (%23) 61 (%77)61 (%77) 8080

In both lungs; right posteriorbasal In both lungs; right posteriorbasal (21;19%) and left posteriorbasal (21;19%) and left posteriorbasal (14;16%) segments were mostly (14;16%) segments were mostly thrombus seen segmentsthrombus seen segments

The contribution of CT venography to The contribution of CT venography to thromboembolic events was found 5%. thromboembolic events was found 5%. In literature this rate is 2-4,3% In literature this rate is 2-4,3%

Pathologies other than Pathologies other than PE in CT angiographyPE in CT angiography

CasesPulmonary infarct 7Pneumonia 8Mediastinal finding 16Congestive Heart Failure/Cardiomegaly 16COPD 21Pleural effusion 26Additional Findings 35

* Atherosklerosis in aorta, lymp node, mass,** Atelectasis, fibrotic changings, mass, metastasis, emphysema…

DiscussionDiscussion

DVT rate and localisations are found DVT rate and localisations are found similar with literature in PE casessimilar with literature in PE cases

CT venography has a high sensitivity CT venography has a high sensitivity while diagnosing DVTwhile diagnosing DVT

(Sensitivity was 100% if coloured (Sensitivity was 100% if coloured doppler US is acceped as a gold doppler US is acceped as a gold standart)standart)

Advantages of CT venography while Advantages of CT venography while diagnosing DVT according to diagnosing DVT according to doppler USdoppler US ObesityObesity Lower extremity Lower extremity oedemaoedema Cases with plasterCases with plaster

Well scoring was the most reliable method Well scoring was the most reliable method while exculding PEwhile exculding PE

High risk was estimated in PE cases mostly High risk was estimated in PE cases mostly with Well scoring and Miniati method with Well scoring and Miniati method (similar) (similar)

High correlation is found between CT High correlation is found between CT venography and coloured doppler US venography and coloured doppler US sonuçları (With Spearman correlation test sonuçları (With Spearman correlation test r= 0.741, p<0.001)r= 0.741, p<0.001)

All DVT diagnosis with coloured doppler US All DVT diagnosis with coloured doppler US are also diagnosed with CT venographyare also diagnosed with CT venography

CaseCase

PE in bilateral lower lobe arteries and segmental branches

Dilatation and thrombosis of right iliac vein

Thrombosis in right femoral vein

Thrombosis in right popliteal vein

Thrombosis in femoral vein

For determining the localisation of For determining the localisation of CT venography in imaging algoritm CT venography in imaging algoritm of PE and standart analysing of PE and standart analysing parametres we need more big parametres we need more big studies with dose and cost analysisstudies with dose and cost analysis