CLINICAL AND RADIOLOGIC EVALUATION OF THE PATIENTS EXAMINATED WITH FORE-DIAGNOSIS OF PULMONARY EMBOLISM

1. CLINICAL AND RADIOLOGIC EVALUATION OF THE PATIENTS EXAMINATED WITH FORE-DIAGNOSIS OF PULMONARY EMBOLISM *Oğuzhan Karaoğlu,**Kemal Can Tertemiz,*Erkan Yılmaz,**Atila Akkoçlu * Dokuz Eylul University Faculty of Medicine, Radiology Department ** Dokuz Eylul University Faculty of Medicine, Pulmonary Medicine

2. Pulmonary embolism (PE) is a frequently seen disease • PE diagnosis and treatment are difficult and also PE has a high mortality rate • The mortality rate of PE • Non-diagnosed cases 30% • Diagnosed case 10%

3. 70% of the PE outcomes secondary to lower extremity deep venous thrombosis (DVT) • Thrombosis in deep veins of femoral region have 50% PE risk

4. Imaging methods for diagnosing PE • Chest X-ray • V/Q scintigraphy • Pulmonary CT angiography • Thorax MR angiography • Conventional angiography

5. Pulmonary CT Angiography • Pulmonary CT angiography has more than 90% sensitivity and spesifity in PE cases • But in subsegmental arteries sensitivity decreases to 63% and specifity to 89% • Pulmonary CT angiography is the first line method for analysing cases suspected from PE

6. Pulmonary CT Angiography • Limitations • Deficiency of detecting embolism in subsegmental and smaller arteries • Respiratory artefacts due to deficiency of controlling respiration in dyspneic cases • Difficult to perform in renal insufficient patients because of high doze contrast

7. Pulmonary CT Angiography • Additional advantages other than showing the thrombus • Lung parenchyma • Mediastinum • Pleura ve thorasic wall pathologies can be seen • Response to the treatment can be detected

8. For diagnosing of DVT • Coloured doppler US • MR venography • Conventional venous angiography • CT venography • Impedance pletismography

9. Coloured Doppler US • In femoropopliteal region sensitivity is 95% and specifity is 99% for showing venous thrombosis • It is not a gold standart for DVT diagnosis, but it is accepted as a standart method in clinical use

10. Coloured Doppler US • Limitations • Suboptimal analysis because of obesity and oedema • Transducer, device setup and position of the patient can effect the image quality • Iliac and superficial femoral veins can not be analysed enough • The experience of the radiologist

11. CT Venography • CT venography have 100% sensitivity and 96% specifity when compared with conventional venography • CT venography can show better the elonging the thrombosis to pelvic veins and ve inferior vena cava • CT venography needs 80% lower doze contrast campared with conventional venography

12. Combined CT Anjiography and CT Venography • Performing pulmonary CT anjiography and lower extremity CT venography simultaneously became a popular method • Venous system is scaned between diaphragm and popliteal region following pulmonary CT anjiography, 3-3,5 minutes after injecting the contrast material. (cross section thickness 5-10 mm and interval 1-5 cm) • This method has 89-100% sensitivity and 94-100% specifity

13. CT Venography • Limitations • Parametres like cross section thickness, interval and scaning methods are not standart • Discriminating acute and chronic thrombosis is usualy possible but it is difficult in some cases

14. Method • Beetween November 2006 – Jully 2007 80 cases suspected of PE and decided to perform pulmonary CT anjiography are included to the study • For PE risk scorring • Well Scale • Miniati Method • Geneva Rules

15. GENEVA RULES MINIATI METHOD WELL SCALE

16. Pulmonary CT anjiography and lower extremity CT venography performed simultaneously to all cases • Before or after pulmonary CT anjiography lower extremity doppler US is performed

17. Results • 80 cases are included • 42 (52%) male, 38 (48%) female • Mean age 60 years • In 19 (23%) cases PE detected with pulmonary CT anjiography • DVT is detected in 15 (18,7%) cases with CT venography and 9 (11%) cases with coloured doppler US

18. PE rates according to PE clinical risk scorings

19. No PE or DVT determined in cases with low risk accordirg for more than one scoring • In 6 cases with normal coloured doppler US DVT diagnosed with CT venography and 5 of them also diagnosed PE • DVT evidence is mostly showed in femoral region

22. Comparing Doppler US and CT Venography about DVT • Sensitivity %100 • Specifity %91

23. CT Venography and Pulmonary CT Anjiography Results

24. In both lungs; right posteriorbasal (21;19%) and left posteriorbasal (14;16%) segments were mostly thrombus seen segments • The contribution of CT venography to thromboembolic events was found 5%. In literature this rate is 2-4,3%

25. Pathologies other than PE in CT angiography * Atherosklerosis in aorta, lymp node, mass, ** Atelectasis, fibrotic changings, mass, metastasis, emphysema…

26. Discussion • DVT rate and localisations are found similar with literature in PE cases • CT venography has a high sensitivity while diagnosing DVT (Sensitivity was 100% if coloured doppler US is acceped as a gold standart)

27. Advantages of CT venography while diagnosing DVT according to doppler US • Obesity • Lower extremity oedema • Cases with plaster

28. Well scoring was the most reliable method while exculding PE • High risk was estimated in PE cases mostly with Well scoring and Miniati method (similar) • High correlation is found between CT venography and coloured doppler US sonuçları (With Spearman correlation test r= 0.741, p<0.001) • All DVT diagnosis with coloured doppler US are also diagnosed with CT venography

29. Case

30. PE in bilateral lower lobe arteries and segmental branches

31. Dilatation and thrombosis of right iliac vein Thrombosis in right femoral vein

32. Thrombosis in right popliteal vein Thrombosis in femoral vein

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