cm–1) [14]. Radiology 2005; 237: 329-337. Significance values were set at p ≤ 0.05. Patient age, week of gestation, vascular opacification in Hounsfield units, KIVC, effective dose, and image noise are expressed as mean values ± SD. Yilmaz Ö, Üstün ED, Kayan M, et al. One study that showed transient interruption of the contrast bolus in group B was considered diagnostic at the time of image acquisition and met both subjective and objective criteria of “good” and “adequate” at study reinterpretation. Finally, study groups A and B were not similar in size; fewer pulmonary CTA studies were performed of pregnant patients during the second half of the study duration as part of a revised departmental protocol advocating lung scintigraphy as the preferred study in pregnant patients. Pulmonary embolism (PE) was clinically described in the early 1800s, and von Virchow first described the connection between venous thrombosis and PE. KIVC values range from 0 to 1.0; a high KIVC (> 0.8) indicates a larger contribution from the IVC to the right heart relative to the SVC and suggests the presence of transient interruption of the contrast bolus by unopacified blood from the IVC, whereas healthy control subjects have average KIVC values of approximately 0.5 [17]. DISCUSSION. The remaining 17 patients had normal radiologic findings. CT angiography of the chest (CTA chest) is a cross-sectional diagnostic examination that can be performed ECG-gated or non-ECG gated. In group B, two patients had nondiagnostic studies. Imaging Pulmonary Infection: Classic Signs and Patterns, Review. exercise was to investigate if a change in CT pulmonary angiography (CTPA) scanning protocol resulted in improved opacification of the pulmonary arteries. Although bias was limited by blinding readers to the clinical details and the initial pulmonary CTA report, readers were not blinded to the imaging protocol used. The first 28 CTA studies were performed of 25 pregnant patients using a standard pulmonary CTA imaging protocol (Table 1) similar to that used on nonpregnant patients (group A). The first 28 CTA studies were performed of 25 pregnant patients using a standard pulmonary CTA imaging protocol (Table 1) similar to that used on nonpregnant patients (group A). Further imaging may be necessary, consisting of either repeat CT pulmonary angiography with an increased delay or pulmonary angiography. How I do it: CT pulmonary angiography. When used in conjunction with validated clinical decision tools like modified Wells criteria, CT-angiography is highly sensitive (good at detecting PE when it's there and ruling it out when it's not) and specific (generating few false-positive results). The aim of this study was to analyze the dose reduction and image quality achieved by using 80 kV instead of 100 kV in CT pulmonary angiography protocols. The percentage of image noise for all CTA studies was calculated using a validated equation [16]. Readers were not blinded to the CTA protocol used. Diagnostic quality of CT pulmonary angiography in pulmonary thromboembolism: A comparison of three different kV values. In addition to these hemodynamic alterations during pregnancy, IVC pressure increases because of the gravid uterus. Several study limitations are acknowledged. Experimental studies have shown that cardiac output is inversely related to peak arterial enhancement and time to arrival of contrast material in the aorta [21]. Pulmonary embolism is the third most common acute cardiovascular disease, after myocardial infarction and stroke, and results in an estimated 200,000-300,000 hospitalizations and 37,000-44,000 deaths per year in the United States [].In 1980, Godwin et al. There was a strong positive relationship between mean pulmonary arterial attenuation and good objective image quality (r = 0.67, p = 0.001). Furthermore, specific variations between both patient groups that may affect vascular opacification including cardiac function, height, and weight were not recorded at the time of image reinterpretation. Use of high pitch, 3.2 in 70 kVp protocol should be … Imaging of Pulmonary Embolism Gamal Agmy. Lung scintigraphy is not susceptible to the hemodynamic effects of pregnancy and remains a reliable tool for excluding PE in patients with normal findings on chest radiography while additionally conferring a lower maternal radiation dose than pulmonary CTA [12, 13]. Heyer CM, Mohr PS, Lemburg SP, Peters SA, Nicolas V (2007) Image quality and radiation exposure at pulmonary CT angiography with 100- or 120-kVp protocol: prospective randomized study. In addition to these hemodynamic alterations during pregnancy, IVC pressure increases because of the gravid uterus. by Julius Renne et al. The objective evaluation classified mean pulmonary arterial opacification as good (≥ 210 HU), acceptable (170–209 HU), or poor (≤ 169 HU), as described in a recent study [15]. In pregnant patients with suspected PE, a pulmonary CTA protocol optimized for use in pregnancy that includes a high flow rate, a high volume, and high concentration of contrast medium and shallow held inspiration significantly increases the rate of diagnostic adequacy and pulmonary arterial opacification and decreases the incidence of transient interruption of the contrast bolus by unopacified blood from the IVC. J Vasc Interv Radiol . In the past decade, CT pulmonary angiography has been increasingly used as the primary diagnostic imaging examination after chest radiography for the evaluation of patients with suspected PE. The flow rate was kept constant at 6 mL/s throughout the procedure, and contrast administration was followed by a 50-mL IV saline flush. The pulmonary vasculature may be evaluated with various invasive and noninvasive methods. TABLE 1: Pulmonary CT Angiography Contrast Medium Administration Parameters, Each study was then assessed for the presence or absence of a transient interruption of the contrast bolus by unopacified blood from the IVC. A Combination of Normal-Dose Corticomedullary Phase With Low-Dose Unenhanced and Excretory Phases, Review. Two other patients underwent lung scintigraphy after an initial nondiagnostic CTA. The current standard of care for members with suspected pulmonary embolism is a spiral CT scan, also called a CTA, CT PA (computed tomography pulmonary angiography), MDCT (multidector CT) or helical CT scan. It is a preferred choice of imaging in the diagnosis of PE due to its minimally invasive nature for the patient, whose only requirement for the scan is an intravenous line. IVC pressure is particularly high when the pregnant patient is in the supine position, where a sixfold increase in pressure has been observed in the third trimester [22]. There was a strong negative correlation between mean KIVC values in both the RA and RV and mean pulmonary arterial opacification (r = –0.54 and –0.52, respectively; p = 0.0001). Although this protocol optimized for imaging pregnant patients significantly improved pulmonary CTA image quality, two of the 20 patients in group B had nondiagnostic studies. Transient interruption of the contrast bolus by unopacified blood from the IVC was a causative factor in one case and the second nondiagnostic study was caused by poor peak arterial enhancement. The reported rates of indeterminate CTA studies in pregnant patients vary, ranging from 5.6% to 35.7% [4, 7, 15, 20]; this variation may be due to different study sizes and imaging protocols that vary by the volume of injected contrast material and the breathing instructions given. Pulmonary Vein Mapping Trachea/Airway Lifespan, Rhode Island’s first health system, is a comprehensive, integrated, academic health system affiliated with The Warren Alpert Medical School of Brown University. One of these patients had a diagnostic study that excluded PE, and the other two patients had nondiagnostic repeat studies. Conclusions: Low-dose CT pulmonary angiography can be achieved with use of low kVp (80 and 100) and high-pitch protocol with significant reduction in radiation dose while maintaining diagnostic images of PE. 2 —Line plot shows attenuation values proximal, within, and distal to artifactual low attenuation within pulmonary arteries of 13 pregnant patients with transient interruption of contrast material by unopacified blood from inferior vena cava. The results of this study show that a pulmonary CTA protocol optimized for imaging in pregnant patients using bolus tracking, a short scan delay, a high flow rate, high concentration and high volume of contrast medium, and a shallow held inspiration significantly improves image quality by increasing pulmonary arterial opacification and minimizing transient interruption of the contrast bolus by unopacified blood from the IVC. The mean image percentage noise measurements were lower in group A than in group B (1.52 vs 1.79, respectively; p = 0.04) despite similar CT exposure parameters. Conversely, an indeterminate rate of 35.7% was described in a smaller study of 25 patients in which a lower volume of 75 mL of iodinated contrast material and held maximal inspiration were used [7]. To retrospectively compare semi-qualitative and quantitative CT pulmonary angiography (CTPAs) image metrics testing diagnostic performance between protocols performed by 20 or 40 ml of contrast medium (CM) in patients with suspected pulmonary embolism (PE). Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. Historically, catheter-directed pulmonary angiography has been used most commonly for the diagnosis of suspected pulmonary embolism (PE). Its main use is to diagnose pulmonary embolism (PE). Suspected Pulmonary Embolism: A Management Study . Fig. When a portion of a pulmonary artery was noted to be lower in attenuation than adjacent areas of increased attenuation proximally and distally (Fig. In these equations, the relative IVC contributions to the RA and RV were calculated by equating attenuation (C) in Hounsfield units in these chambers to a weighted average of the attenuations of the SVC and IVC assuming that the SVC and IVC are the sole contributors of flow to the right heart. Image quality was evaluated with objective and subjective criteria. Jones SE, Wittram C. The indeterminate CT pulmonary angiogram: imaging characteristics and patient clinical outcome. Forty-eight pulmonary CTA examinations were performed of 45 pregnant patients (age range, 17–41 years; mean age, 31 years; gestation range, 18–39 weeks; mean gestation, 30 weeks) with suspected PE. There was a strong positive relationship between mean pulmonary arterial attenuation and good objective image quality (r = 0.67, p = 0.001). Subjective image quality was also significantly better in group B. Eighteen of 20 CTA studies (90%) in group B were classified as adequate, indicating good pulmonary arterial enhancement and no significant noise or motion artifact, compared with 18 of 28 studies (64%) in group A (p = 0.03). NB: This article is intended to outline some general principles of protocol design. The mean pulmonary attenuation was also higher in group B than in group A: 321 ± 148 HU compared with 178 ± 67 HU (p = 0.0001). The second patient had a nondiagnostic study, but right upper lobe consolidation was shown and a concomitant PE was thought to be unlikely on clinical grounds; no further imaging was performed. The increase in cardiac output in pregnancy may lead to decreased peak arterial enhancement and a shorter contrast material arrival time. A total of 102 CTPAs performed by 20 ml (ultra-low volume: ULV) and 74 CTPAs performed by 40 ml (low volume: LV) protocol … A Combination of Normal-Dose Corticomedullary Phase With Low-Dose Unenhanced and Excretory Phases, Review. [Dual-source CT scanners provide high-pitch dual source protocols … Pulmonary artery attenuation values and the relative contribution of the IVC to the right heart were calculated by the former reader. European Respiratory Journal Sep 2012, 40 (Suppl 56) P1499; Share This Article: Copy. The flow rate was kept constant at 4 mL/s throughout the procedure. Pulmonary embolism ppt resmigs. CTA Chest (pulmonary angiogram) Reviewed By: Rachael Edwards, MD; Dan Verdini, MD; Brett Mollard, MD Last Reviewed: July 2019 Contact: (866) 761-4200, Option 1 In accordance with the ALARA principle, TRA policies and protocols promote the utilization of radiation dose reduction techniques for all CT examinations. There was a strong positive relationship between mean pulmonary arterial attenuation and good subjective image quality (r = 0.55, p = 0.001). Attenuation measurements in Hounsfield units were made at the lower superior vena cava (SVC), upper IVC, right atrium (RA), and right ventricle (RV). There were no reported complications as a result of pulmonary CTA in either group. Although this difference was not statistically significant, the slightly lower radiation dose in group B may have been due to shallow inspiration and resultant decreased z-axis coverage. Image quality was evaluated with objective and subjective criteria. Of the CTA studies with the artifact, the average relative IVC contributions (KIVC) to the RA and RV were 84.4% and 84.7%, respectively, whereas the average KIVC values for those CTA studies without the artifact were 46.9% and 52.7% (p < 0.0001), respectively. This effect, known as the “thoracoabdominal pump,” is likely to be prominent in pregnancy because of inherently raised IVC pressures. This study tests the hypothesis that the empiric protocol more consistently produces diagnostic quality images of both the pulmonary arteries and the aorta with lower radiation exposure. Pregnant women undergoing the specified low-dose CTPA protocol for suspected pulmonary embolism (PE), agreed across study sites with equivalent computed-tomography (CT) capabilities, will be included. In pregnant patients with suspected PE, a pulmonary CTA protocol optimized for use in pregnancy that includes a high flow rate, a high volume, and high concentration of contrast medium and shallow held inspiration significantly increases the rate of diagnostic adequacy and pulmonary arterial opacification and decreases the incidence of transient interruption of the contrast bolus by unopacified blood from the IVC. The difference in mean age between group A and group B (32.7 vs 29.2 years, respectively) achieved statistical significance (p = 0.05). The specific feature of this protocol is to place the region of interest (ROI) (bolus detection) in the superior vena cava. CT pulmonary angiogram (or CTPA) is a special test used primarily to look for the presence of pulmonary embolism (blood clots in the lung).. How is a CTPA performed? Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. CTA studies were reinterpreted by consensus of two radiologists with 4 and 18 years of experience in chest CT using a standard workstation (Leonardo, Siemens Healthcare). TABLE 2: Opacification of the Pulmonary Arteries on CT Angiography. When pulmonary CTA is performed of pregnant patients using a deep held inspiration, the relative contribution of the IVC to the right heart can increase and can lead to interruption of the contrast bolus entering the right heart from the SVC [7]. Several study limitations are acknowledged. cerebral angiography – to check the blood vessels in and around the brain ; pulmonary angiography – to check the blood vessels supplying the lungs ; renal angiography – to check the blood vessels supplying the kidneys ; Occasionally, angiography may be done using scans instead of X-rays. CT pulmonary angiogram (CTPA) is a medical diagnostic test that employs computed tomography (CT) angiography to obtain an image of the pulmonary arteries. 1,2 Since the 1990s, CT pulmonary angiography (CTPA) has become the method of choice for imaging in suspected PE. Historically, catheter-directed pulmonary angiography has been used most commonly for the diagnosis of suspected pulmonary embolism (PE). The reviewers were blinded to the clinical information or the initial radiologic interpretation. This injection was followed by a 50-mL IV saline flush. Contrasted CT-angiography of the chest, often called a "PE protocol CT," has dramatically improved the diagnosis of pulmonary embolism. In group B, the hemodilutional effects of pregnancy were minimized by using a higher volume of contrast material injected at a higher rate than used in group A. CT pulmonary angiogram (CTPA) is a medical diagnostic test that employs computed tomography (CT) angiography to obtain an image of the pulmonary arteries.Its main use is to diagnose pulmonary embolism (PE). Over the past two decades, however, catheter angiography has become almost entirely supplanted by CT angiography (CTA), which is now the … Three patients did not undergo further imaging and PE was excluded clinically. Significance values were set at p ≤ 0.05. Group B consisted of 20 patients, each of whom underwent one pulmonary CTA study. Three patients underwent repeat pulmonary CTA. The first patient’s pulmonary CTA study showed adequate MPA opacification excluding a central PE, but subsegmental arterial opacification was poor. When used in conjunction with validated clinical decision tools like modified Wells criteria, CT-angiography is highly sensitive (good at detecting PE when it's there and ruling it out when it's not) and specific (generating few false-positive results). Ct angio ppt drksp. Our study was limited by its retrospective nature and small number of patients. In these equations, the relative IVC contributions to the RA and RV were calculated by equating attenuation (C) in Hounsfield units in these chambers to a weighted average of the attenuations of the SVC and IVC assuming that the SVC and IVC are the sole contributors of flow to the right heart. [1, 2] In 1922, Wharton and Pierson reported the first radiographic description of PE. Second, triple rule-out CT protocol is associated with significantly higher radiation dose when compared to the CTPA protocol, but with low diagnostic yield of less than 10%. Each radiology department will have a slightly different method for achieving the same outcome, i.e. 1), attenuation measurements were made in the area of decreased attenuation and in the proximal and distal areas of higher attenuation, as described in the literature [17, 18]. The difference in mean gestation between groups A and B (31 vs 29 weeks) was not statistically significant (p = 0.4). In particular, there was no reported contrast medium extravasation secondary to the higher contrast medium injection rate used in group B. Pulmonary CT Angiography Protocol Adapted to the Hemodynamic Effects of Pregnancy. CT pulmonary angiography in patients with acute or chronic renal insufficiency: Evaluation of a low dose contrast material protocol. pmid:17940308 . Lung scintigraphy is not susceptible to the hemodynamic effects of pregnancy and remains a reliable tool for excluding PE in patients with normal findings on chest radiography while additionally conferring a lower maternal radiation dose than pulmonary CTA [12, 13]. The percentage of image noise for all CTA studies was calculated using a validated equation [16]. A region of-interest measurement may be helpful if the attenuation is greater than 78 HU. Protocol … to Reduce the use of CT Pulmonary Angiography in . The flow rate was kept constant at 4 mL/s throughout the procedure. Conversely, an indeterminate rate of 35.7% was described in a smaller study of 25 patients in which a lower volume of 75 mL of iodinated contrast material and held maximal inspiration were used [7]. The relative contribution of the IVC to the right heart was then evaluated. Bilateral central pulmonary embolism was detected (white arrows). The adequate group included CTA studies with good pulmonary arterial enhancement and without significant noise or motion artifact. Role of CT Pulmonary Angiography. The mean effective dose per scan was lower in group B (4.8 mSv) than in group A (5.3 mSv) (p = 0.09). Vessel opacification was provided by IV injection of 95 mL of iopamidol (Niopam 370) via the antecubital vein. CT pulmonary angiography protocol: Multidetector CT is preferred (at least 16 slices) Caudal-cranial direction: Most emboli are located in the lower lobes and, if the patient breathes during image acquisition, there is more excursion of the lower lobes compared with the upper lobes. The relative contribution of the IVC to the right heart was then evaluated. The increase in cardiac output in pregnancy may lead to decreased peak arterial enhancement and a shorter contrast material arrival time. All reported studies used a contrast medium injection rate of 4 mL/s. 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