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A 40-year-old African-American woman presented to the emergency room (ER) with right upper extremity pain for 3 hours after sleeping overnight on that side. She was diagnosed with basilic vein thrombosis; in the ER, she was tachycardic with minimal ambulation, prompting CT pulmonary angiogram, which confirmed right-sided pulmonary embolism. Bilateral upper and lower extremity venous Dopplers did not show any acute deep venous thrombosis. She received appropriate anticoagulation. Risk factors are a smoker and recently started contraceptive pills.

We have updated recommendations on 12 controversial topics that were published in the 2013 National Consensus on the diagnosis, risk stratification and treatment of patients with pulmonary embolism (PE). A comprehensive review of the literature was performed for each topic, and each recommendation was evaluated in two teleconferences. For diagnosis, we recommend against using the Pulmonary Embolism Rule Out Criteria (PERC) rule as the only test to rule out PE, and we recommend using a D-dimer cutoff adjusted to age to rule out PE. We suggest using computed tomography pulmonary angiogram as the imaging test of choice for the majority of patients with suspected PE. We recommend using direct oral anticoagulants (over vitamin K antagonists) for the vast majority of patients with acute PE, and we suggest using anticoagulation for patients with isolated subsegmental PE. We recommend against inserting an inferior cava filter for the majority of patients with PE, and we recommend using full-dose systemic thrombolytic therapy for PE patients requiring reperfusion. The decision to stop anticoagulants at 3 months or to treat indefinitely mainly depends on the presence (or absence) and type of risk factor for venous thromboembolism, and we recommend against thrombophilia testing to decide duration of anticoagulation. Finally, we suggest against extensive screening for occult cancer in patients with PE.

PURPOSE This study evaluated clinician adherence to the American College of Physicians Best Practice Advice for diagnosis of pulmonary embolism. DESIGN A prospective, single-center, descriptive design was utilized. METHODS A heterogeneous sample of 111 hemodynamically stable adult inpatients with a computed tomography pulmonary angiogram ordered was consented. Electronic medical records were reviewed for demographic and clinical variables to determine adherence. The 6 individual best practice statements and the overall adherence were evaluated by taking the sum of "yes" answers divided by the sample size. RESULTS Overall adherence was 0%. Partial adherence was observed with clinician-recorded clinical decisions rules and obtaining d-dimer (3.6% [4/111] and 10.2% [9/88], respectively) of low/intermediate probability scorers. Age adjustment of d-dimer was not recorded. Computed tomography pulmonary angiogram was the first diagnostic test in 89.7% (79/88) in low/intermediate probability patients. CONCLUSION In hemodynamically stable, hospitalized adults, adherence to best practice guidelines for diagnosis of pulmonary embolism was minimal. Clinical utility of the guidelines in hospitalized adults needs further evaluation. Systems problems (eg, lack of standardized orders, age-adjusted d-dimer values, information technology support) likely contributed to poor guideline adherence.

Background We aimed to identify risk factors and risk scoring models to help identify post-traumatic pulmonary embolisms (PE). Methods We performed a retrospective review (2014–2019) of all adult trauma patients admitted to our Level I trauma center that received a CT pulmonary angiogram (CTPA) for a suspected PE. A systematic literature search found eleven risk scoring models, all of which were applied to these patients. Scores of patients with and without PE were compared. Results Of the 235 trauma patients that received CTPA, 31 (13%) showed a PE. No risk scoring model had both a sensitivity and specificity above 90%. The Wells Score had the highest area under the curve (0.65). After logistic regression, no risk scoring model variables were independently associated with PE. Conclusions In trauma patients with clinically suspected PE, clinical variables and current risk scoring models do not adequately differentiate patients with and without PE.

Background This study was conducted to evaluate the relationship of age-adjusted D-dimer value with different coefficients in diagnosis of pulmonary embolism (PE) in geriatric patients. Methods The emergency admissions of the patients aged 65 and over with suspected PE during 2018 were reviewed retrospectively. The demographic characteristics, laboratory tests and radiologic findings of computed tomography pulmonary angiogram (CTPA) or single photon emission computed tomography ventilation/perfusion scintigraphy (V/Q) were recorded. The characteristics of the patients with PE were statistically compared with the patients without PE. The specificity and sensitivity for higher cut-off levels (age × 10-15) were presented. Results PE was detected in 39.2% (n = 246) of 628 patients aged 65 years and older included in the study. The multivariate analysis revealed that higher D-dimer level (OR = 1,00011; p 0.001) and BUN level (OR = 1.025; p = 0.013) were independent risk factors for PE diagnosis in elderly patients. Diagnostic statistics for D-dimer cut-off levels selected from ROC analysis and calculated values as 10-15 times of age showed that if the D-dimer cut-off value used is chosen higher, lower sensitivity rates are obtained. Our results also indicated that the patients with malignancy, renal failure, central PE on CTPA and PE with high probability on SPECT VQ were presented with higher D-dimer values. Conclusion Our results do not support the use of higher D-dimer cut-off levels such as 15 times the age in geriatric population. The impact of the location of PE and comorbidities on the outcomes of these patients must be clarified for determining cut-offs with higher specificity.

Pulmonary vein thrombosis (PVT) is a potentially life-threatening condition that is often underdiagnosed or undetected. PVT resulting from a non-surgical cause has been rarely reported, especially in patients without any risk factors. Here, we present a case of an elderly patient with a ventricular permanent pacemaker (PPM) who was found to have features suggestive of PVT on contrasted-enhanced computed tomography pulmonary angiogram (CTPA). We hypothesize that a ventricular PPM could alter flow dynamics in the pulmonary vein predisposing to PVT. This case highlights the importance of atypical presentations and considering broad differentials, particularly in the elderly. A high index of suspicion is necessary for an early diagnosis to prevent further deterioration of the patient.

Patients who have undergone a Fontan's procedure have an abnormal circulation that presents a unique challenge when performing computed tomography pulmonary angiograms. In a standard imaging protocol, contrast is injected into the upper limb veins that feed into the superior vena cava. In Fontan's patients the Computed tomography pulmonary angiograms bypasses the heart and preferentially fills the right lung, with only a small amount of mixture of contrast and noncontrast blood in the pulmonary arteries. In this article, we present the case of a 35-year-old female complaining of chest and abdominal pain with oxygen saturations of 85% on room air. Computed tomography pulmonary angiograms showed suboptimal imaging of the left lung and apparent filling defects in the right lung suggesting a radiological diagnosis of a pulmonary embolism. The abnormal flow and distribution of contrast in the pulmonary arteries can result in a false positive diagnosis of pulmonary embolism. To overcome this, experts advise using a dual-injection of contrast via upper and lower limb central veins to achieve optimal imaging.

International audience; Background: There have been reports of procoagulant activity in patients with COVID-19. Whether there is an association between pulmonary embolism (PE) and COVID-19 in the emergency department (ED) is unknown. The aim of this study was to assess whether COVID-19 is associated with PE in ED patients who underwent a computed tomographic pulmonary angiogram (CTPA).Methods: A retrospective study in 26 EDs from six countries. ED patients in whom a CTPA was performed for suspected PE during a 2-month period covering the pandemic peak. The primary endpoint was the occurrence of a PE on CTPA. COVID-19 was diagnosed in the ED either on CT or reverse transcriptase-polymerase chain reaction. A multivariable binary logistic regression was built to adjust with other variables known to be associated with PE. A sensitivity analysis was performed in patients included during the pandemic period.Results: A total of 3,358 patients were included, of whom 105 were excluded because COVID-19 status was unknown, leaving 3,253 for analysis. Among them, 974 (30%) were diagnosed with COVID-19. Mean (±SD) age was 61 (±19) years and 52% were women. A PE was diagnosed on CTPA in 500 patients (15%). The risk of PE was similar between COVID-19 patients and others (15% in both groups). In the multivariable binary logistic regression model, COVID-19 was not associated with higher risk of PE (adjusted odds ratio = 0.98, 95% confidence interval = 0.76 to 1.26). There was no association when limited to patients in the pandemic period.Conclusion: In ED patients who underwent CTPA for suspected PE, COVID-19 was not associated with an increased probability of PE diagnosis. These results were also valid when limited to the pandemic period. However, these results may not apply to patients with suspected COVID-19 in general.

Computed tomography pulmonary angiogram (CTPA) is widely considered the gold standard for diagnosis of pulmonary embolism (PE) with previous studies demonstrating high sensitivity and specificity. Despite this, nondiagnostic and indeterminate CTPA rates of 5%-26% remain a concern. As part of a continuing quality assurance program, a new weight-adjusted contrast dose and increased administration rate CTPA protocol was studied with an aim to improve diagnostic accuracy of PE evaluation.A total of 2,398 CTPA examinations were reviewed to assess pulmonary arterial enhancement and PE yield in this retrospective study. Between 1 August 2014 and 1 August 2015, 1,133 patients received a fixed-volume (60 mL) contrast dose technique at 4 mL/s (protocol A). A new protocol was then implemented as part of a continuing quality assurance program. Between 15 September 2015 and 15 September 2016, 1,265 patients received a weight-adjusted contrast dose (1 mL/kg) and increased administration rate (5 mL/s) CTPA technique (protocol B). Studies were classed into categories based on quality of study; diagnostic: HU211, nondiagnostic: HU211 and PE yield; positive, negative, and indeterminate. These variables were compared with cross-sectional surface area to assess the relationship between patient habitus, CTPA diagnostic quality, and PE yield.A weight-adjusted contrast dose and increased administration rate CTPA protocol (protocol B) resulted in a significant increase in mean PA enhancement (P.0001), 55.23% decrease in nondiagnostic studies and 43.04% decrease in indeterminate studies. Protocol B demonstrated increased positive and negative CTPA rates with decreased indeterminate rates from 12.38% to 7.04%. Comparison with cross-sectional area demonstrated significant increase in proportion of diagnostic studies and reduction in nondiagnostic and indeterminate CTPAs using protocol B in obese patients.A weight-adjusted contrast dose and increased administration rate CTPA protocol can significantly increase PA enhancement, especially in obese patients, resulting in greater high-quality and fewer nondiagnostic and indeterminate CTPA examinations. A CTPA protocol with a higher rate of conclusive examinations can provide greater confidence in PE evaluation for reporting radiologists and accurate clinical decision-making pathways for referring physicians.

COVID-19 patients suffering sudden worsening of clinical conditions have an atypical peripheral pulmonary arterial obstruction at computed tomography pulmonary angiogram (CTPA), poorly associated to deep venous thrombosis (DVT), suspicious for thrombotic in situ nature rather than embolic.

A 52-year-old man presented with palpitations and dyspnea. Extensive bilateral pulmonary emboli (PEs) were identified on computed tomography pulmonary angiogram. Transthoracic echocardiography demonstrated a mobile bi-atrial thrombus straddling the interatrial septum. Consensus decision of a multidisciplinary pulmonary embolus response team was made for emergency thrombectomy of the pulmonary and intra-cardiac clot. Intraoperatively, a patent foramen ovale was identified and repaired. He had an excellent outcome and was discharged home on oral anticoagulation. In this unique case of a bi-atrial thrombus and sub-massive PEs, we demonstrate the utility of dedicated pulmonary embolus response teams in providing rapid and individualized management decisions for complex PE patients.

Pulmonary embolism (PE) care has traditionally been fragmented. The newly introduced Pulmonary Embolism Response Team (PERT) model provides streamlined care based on expedient, multi-disciplinary decision-making. This study aimed to quantify the impact of PERT, as part of a hospital-wide PE treatment protocol, on clinical outcomes.Consecutive adult patients with acute PE diagnosed via computed tomography pulmonary angiogram (CTPA) were included. The PERT and treatment protocol were introduced in January 2015. Patient characteristics, therapies, quality measures of CTPA reporting, and clinical outcomes of PE patients treated for 2 years before and after implementation of these changes were evaluated. Primary endpoints were median length of stay in intensive care (ICU) and survival to discharge.A total of 321 consecutive PE patients were enrolled, of which 154 (treated in 2013-2014) and 167 (2015-2016) patients formed the historical control and study groups, respectively. Implementation of the algorithm was associated with less variance in anticoagulation and improved reporting of right heart strain parameters on CTPA. The ICU stay was reduced from a median of 5 to 2 days (p 0.01). Eligible massive PE patients receiving reperfusion increased from 30% to 92% (p = 0.01), with mean delay from diagnosis to reperfusion decreasing from 763 to 181 minutes (p 0.01). Bleeding complications were not increased, but overall survival to discharge remained unchanged.Introducing a PERT and treatment protocol reduced ICU stay, enhanced quality measures, and improved access of massive PE patients to reperfusion therapies, without increasing bleeding complications or health care costs.

Objective To determine the cause of a markedly raised D-dimer among patients in whom a diagnosis of pulmonary embolism (PE) has been excluded by CT pulmonary angiogram (CTPA) with particular reference to new cases of cancer and aortic dissection. Methods One thousand consecutive patients, suspected of PE, who had undergone CTPA and for whom a D-dimer had been requested, were seen between 2012 and 2016. Retrospectively we examined the case records of all those in the top quintile of the D-dimer distribution whose CTPA was negative for PE. D-dimer in the top quintile ranged from 7.5 to 260 times upper limit normal. Results Eighty-five patients fulfilled our inclusion criteria. The likely causes of their very high D-dimer were infection (n=35, 41.2%), cardiovascular disease (n=12, 14.1% including two patients with previously undiagnosed aortic dissection), surgery or trauma (n=12, 14.1%), new or active cancer (n=9, 10.6% comprising six new cancers and three patients with cancers diagnosed previously that were considered to be active) and miscellaneous causes (n=17, 20.0%). Thirty-five patients (43.5%) died over a 2-year follow-up. Kaplan-Meier survival analysis showed poorer outcomes for patients with new or active cancer, when compared with those with no known cancer (p Conclusions We have shown that a small proportion of patients suspected of PE whose D-dimers are markedly elevated have diagnoses we would not want to miss including previously unsuspected cancer and aortic dissection. Further studies will be required to define the optimal workup of patients with extremely high D-dimer who do not have venous thromboembolism

Introduction Congenital left inferior vena cava (IVC) with hemiazygos continuation and drainage into the superior vena cava (SVC) is a rare IVC variant and is associated with venous thrombo-embolism. This is the report of a case of hemiazygos continuation of the left IVC receiving catheter directed thrombolysis (CDT) for pulmonary embolism. Report A 72 year old woman presented with progressive dyspnoea, and CT images confirmed the diagnosis of pulmonary embolism. The unusual route of the IVC was observed during the right heart catherisation and CDT. CDT was then performed with a left femoral venous approach. The patient tolerated the procedure well, and the follow up pulmonary angiogram showed no residual thrombus. Discussion The use of CDT for pulmonary embolism in patients with left IVC with hemiazygos continuation and drainage into the SVC has been reported rarely. Awareness of this diagnosis is critical during right heart catheterisation to prevent devastating complications. However, with careful manipulation, right heart catheterisation and CDT can be achieved successfully. Pulmonary embolism in patients with left IVC with hemiazygos continuation and drainage into the SVC can be treated with CDT safely and effectively with caution. It is wise to remember the different anatomical variations during IVC catheterisation., Highlights • Congenital left IVC with hemiazygos continuation and draining to the SVC is rare and linked to venous thromboembolism (VTE). • IVC variant related pulmonary embolism can be treated with CDT. CDT through femoral vein access is feasible and safe for IVC variant related pulmonary embolism.

OBJECTIVES We aimed to evaluate the ability of emergency medicine (EM) residents to measure tricuspid annular plane systolic excursion (TAPSE) by M-Mode ultrasound. METHODS Four EM residents with prior focused cardiac ultrasound (FOCUS) experience participated in 10 hours of hands-on training and then performed TAPSE measurements in adult patients at high risk of having pulmonary emboli (PE) between December 2020 and April 2021. Patients underwent bedside echocardiography by cardiology residents, and a CT pulmonary angiogram (CTPA) was performed to confirm the diagnosis. The agreement between EM and cardiology residents was assessed by intraclass correlation coefficient (ICC). RESULTS Sixty-six patients were included (mean age = 58.7 ± 16.7 years), of which 28 patients (42.8%) had positive CTPA. The mean TAPSE, measured by EM residents was 16.36 ± 1.59 mm in the PE positive group and 21.68 ± 2.87 mm in the PE negative group (P-value =

To evaluate mosaic perfusion patterns and vascular lesions in patients with chronic thromboembolic pulmonary hypertension (CTEPH) using C-Arm computed tomography (CACT) compared to computed tomography pulmonary angiography (CTPA). We included 41 patients (18 female; mean age 59.9 ± 18.3 years) with confirmed CTEPH who underwent CACT and CTPA within 21 days (average 5.3 ± 5.2). Two readers (R1; R2) independently evaluated datasets from both imaging techniques for mosaic perfusion patterns and presence of CTEPH-typical vascular lesions. The number of pulmonary arterial segments with typical findings was evaluated and the percentage of affected segments was calculated and categorized: cons vs. CTPAcons) was calculated using the ICC. Inter-observer agreement was excellent for central vascular lesions (ICC > 0.87) and the percentage of affected segments (ICC > 0.76) and good for the perceptibility of mosaic perfusion (ICC > 0.6) and attribution of the pattern of mosaic perfusion (ICC > 0.6) for both readers on CACT and CTPA. Inter-modality agreement was excellent for the perceptibility of mosaic perfusion (ICC = 1), the present perfusion pattern (ICC = 1) and central vascular lesions (ICC = 1). However, inter-modality agreement for the percentage of affected segments was fair (ICC = 0.50), with a greater proportion of identified affected segments on CACTcons. CACT demonstrates a high agreement with CTPA regarding the detection of mosaic perfusion. CACT detects a higher number of peripheral vascular lesions compared to CTPA.

Teaching point: The use of dual-energy instead of conventional single-energy computed tomography pulmonary angiogram can provide additional value concerning the diagnosis of COVID-19 and its complications, especially in the detection of small pulmonary embolism.

Background: COVID-19 (CV19) is a multisystem disease associated with increased risk of coagulopathy and thus, pulmonary embolism (PE). However, detailed PE data remains largely understudied, mainly after hospital discharge. Aim: Evaluate PE occurrence among CV19 pneumonia pts and describe their risk factors and clinical characteristics. Methods: We performed a retrospective analysis (using descriptive statistics, t-Student, Mann-Whitney and Chi-Square tests) of 86 consecutive CV19 pneumonia pts followed in an outpatient setting (CV19 Pulmonology Consultation) post-hospitalization, between 05/2020 and 01/2021. PE diagnosis was based on international guidelines, regardless of the documentation by CT pulmonary angiogram. Clinical, laboratory, radiological and respiratory support data were analysed. Results: Mean age was 57±14 years and the majority was male (54; 63%). PE was diagnosed in 27 cases (31%), with a median time of 9 IQR 6-11 days since CV19 symptoms onset. At PE diagnosis, most pts (16; 59%) were not receiving prophylactic/therapeutic anticoagulant therapy. Patients in PE-group showed higher D-dimers level [1201 IQR 663-7246 vs 834 IQR 554-1317 ng/ml; p

Computed tomographic pulmonary angiography (CTPA) is the gold standard for pulmonary embolism (PE) diagnosis. However, this diagnosis is susceptible to misdiagnosis. In this study, we aimed to perform a systematic review of current literature applying deep learning for the diagnosis of PE on CTPA. MEDLINE/PUBMED were searched for studies that reported on the accuracy of deep learning algorithms for PE on CTPA. The risk of bias was evaluated using the QUADAS-2 tool. Pooled sensitivity and specificity were calculated. Summary receiver operating characteristic curves were plotted. Seven studies met our inclusion criteria. A total of 36,847 CTPA studies were analyzed. All studies were retrospective. Five studies provided enough data to calculate summary estimates. The pooled sensitivity and specificity for PE detection were 0.88 (95% CI 0.803–0.927) and 0.86 (95% CI 0.756–0.924), respectively. Most studies had a high risk of bias. Our study suggests that deep learning models can detect PE on CTPA with satisfactory sensitivity and an acceptable number of false positive cases. Yet, these are only preliminary retrospective works, indicating the need for future research to determine the clinical impact of automated PE detection on patient care. Deep learning models are gradually being implemented in hospital systems, and it is important to understand the strengths and limitations of these algorithms.

Objectives: Patients with COVID-19 may be at high risk for thrombotic complications due to excess inflammatory response and stasis of blood flow. This study aims to assess the incidence of pulmonary embolism among hospitalized patients with COVID-19, risk factors, and the impact on survival. Methods: A retrospective case-control study was conducted at Al-Noor Specialist Hospital in Saudi Arabia between 15 March 2020 and 15 June 2020. Patients with confirmed COVID-19 diagnosis by a real-time polymerase chain reaction (PCR) and confirmed diagnosis of pulmonary embolism by Computed Tomography pulmonary angiogram (CTPA) formed the case group. Patients with confirmed COVID-19 diagnosis by a real-time polymerase chain reaction (PCR) and without confirmed diagnose of pulmonary embolism formed the control group. Logistic regression analysis was used to identify predictors of pulmonary embolism and survival. Results: A total of 159 patients participated were included in the study, of which 51 were the cases (patients with pulmonary embolism) and 108 patients formed the control group (patients without pulmonary embolism). The incidence of PE among those hospitalized was around 32%. Smoking history, low level of oxygen saturation, and higher D-dimer values were important risk factors that were associated with a higher risk of developing PE (p &lt, 0.05). Higher respiratory rate was associated with higher odds of death, and decreased the possibility of survival among hospitalized patients with PE. Conclusions: Pulmonary embolism is common among hospitalized patients with COVID-19. Preventive measures should be considered for hospitalized patients with smoking history, low level of oxygen saturation, high D-dimer values, and high respiratory rate.

OBJECTIVE The aim of this study was to assess the enhancement of lung parenchyma on dual-energy (DE) computed tomogram (CT) by comparing attenuation between routine post-contrast and dual-energy generated virtual unenhanced (VU) images. METHODS Patients presenting to the Emergency Department who subsequently underwent DE-CT pulmonary angiogram from the 1st to the 30th of November were enrolled. The DE data set obtained was used to generate VU images. Attenuation in Hounsfield units (HU) was measured at two sites for each patient and compared between VU and routine post-contrast (PC) reconstructions. Statistical analysis was performed using paired-samples t-test. RESULTS There is a statistical difference between lung parenchymal attenuation value between the CV and PC images, denser in the PC dataset and also towards the bases, with a mean HU of -841 and -817 (difference of 24) respectively. CONCLUSIONS This study confirms increased lung parenchymal density when comparing PC and VU reconstructions. Based on results, the paper recommends utilising dual-energy capabilities for VU reconstructions in CTPAs to optimise assessment of lung parenchyma.

Objective: The aim of this study was to propose first established diagnostic reference levels (DRLs) in computed tomography (CT) for adults, based on volume-averaged CTDI and dose length product (DLP) metrics in Yazd Province. Materials and Methods: Six multislice CT scanners located at diverse areas of Yazd Province and seven common procedures were selected for the present study. For each procedure, at least twenty patients 18 years and older were sampled at each institution. For each patient, dose report data and scan parameters as well as patient’s information were abstracted from picture archiving and communication system. Results: Proposed DRLs in terms of computed tomography dose index (mGy) and DLP (mGy.cm) were as follows: brain (42, 527), sinus (25, 220), neck (14, 264), abdomen-pelvis (11, 295), routine chest (8, 247), CT pulmonary angiogram (32, 261) and chest HRCT (11, 455), respectively, slightly lower compared to other investigations. Conclusion: The proposed DRLs in this study should be considered as the local DRLs for the seven most common adult CT examinations in Yazd province so as to optimize the patient dose while maintaining acceptable image quality for the clinical task.

No abstract available. Article truncated after 150 words. Clinical History: A 51-year-old previously healthy man presented with complaints of increasing headache frequency and severity. The patient noted headaches in the past, but that the frequency of these headaches, which he referred to as “migraines,” had been increasing in recent months. The patient does note some auras with the headaches. The patient reported a history of pneumonia in the past, but denied recurrent pneumonias. The only medication the patient takes was ibuprofen, for his headaches; he denied allergies. The patient’s past surgical history was remarkable only for a right inguinal hernia repair, a right Achilles tendon injury repair, and surgical removal of a palpable left thigh mass, ultimately shown to represent scar tissue. The patient smoked 1-8 cigarettes / day for 35 years, quitting one year earlier. The patient’s physical examination was remarkable for obesity (BMI= 30.4). His vital signs were within the normal range. A few reddish rounded …

OBJECTIVE The purpose of this case series is to evaluate the diagnostic potential of contrast-enhanced ultrasound (CEUS) in patients with clinically suspected pulmonary embolism (PE), suspicious pleural lesions, and negative computed tomography pulmonary angiogram (CTPA). PATIENTS/METHODS Between January 2017 and January 2018, we examined patients with an intermediate or a high-risk Wells score and a negative CTPA with lung B-mode ultrasound (LUS). In a total of six patients, pleural defects were identified and further examined by CEUS. Nonenhancing lesions or those with inhomogeneous enhancement were considered to be suspicious for an embolic event and biopsied for histological validation. The data analysis was retrospective. RESULTS In LUS, the lesions had an average size of 2.4 cm (range 2-3 cm). Five were hypoechoic and one was complex. The shape was wedge shaped (n = 5) or round (n = 1), and the number was solitary (n = 4) or multiple (n = 2) with dorsobasal localization (n = 6). Three lesions were nonenhancing, and three had an inhomogeneous enhancement with areas with complete absence of enhancement. The histological examination showed pulmonary infarction in all six cases, and in one patient also cells of a lung carcinoma. CONCLUSION Our case series demonstrates the diagnostic potential of CEUS for detecting peripheral pulmonary infarction in patients with clinically suspected PE and negative CTPA scan regarding PE. A histological validation or a narrow follow-up might be warranted in some cases.

No abstract available. Article truncated after the first page. History of Present Illness A 59-year-old woman from Kingman, Arizona had a one-year history of fatigue with some shortness of breath. For this reason, she saw her primary care physician. Past Medical History, Social History and Family History She has no significant past medical history. She does not smoke. Family history is noncontributory. Physical Examination Physical examination was unremarkable. Which of the following should be done? 1. Chest x-ray 2. Complete blood count 3. Electrolytes, blood urea nitrogen and creatinine 4. Liver panel 5. All of the above …

The purpose of this study was to assess the diagnostic accuracy of computed tomography pulmonary angiogram (CTPA) including dual energy and reconstruction of iodine maps for diagnosing CTEPH. This method for detecting embolisms and perfusion failures was compared with V/Q-SPECT. An additional purpose was to compare the applied radiation dose of both techniques. 71 patients (49 women) with suspected CTEPH were included in this prospective study. The patients received a V/Q-SPECT and a dual-energy CTPA. Iodine maps were reconstructed from the data set. CTPA and the iodine maps were read by an experienced radiologist unaware of the clinical information as well as the results of the V/Q-SPECT. Results were compared to the V/Q-SPECT. DLP and the applied amount of radionuclides (MAA, Technegas) were obtained for comparison of radiation dose. For the diagnosis of CTEPH, the sensitivity of DECT was 1.000, specificity 0.966, PPV 0.867 and NPV 1.000, respectively. There was not a considerable difference in the x-ray exposure between the DECT examination and the V/Q-SPECT (1.892 mSv vs. 1.911 mSv; p = 0.6115). Both examination modalities were highly consistent regarding the classification of pathological segments (1177/1278 segments, 92,09 %, κ = 0,5938). This study presents the DECT, in combination with reconstructed iodine maps, as a potential alternative to the current imaging technique of first choice, V/Q-SPECT. For creating future prospective diagnostic algorithms, the implementation of DECT screening with iodine maps should be considered.· DECT correctly identified all CTEPH patients.. · There is substantial agreement between DECT and V/Q-SPECT in the classification of pathological segments.. · There is no significant difference in radiation exposure during DECT examination and V/Q-SPECT examination.. · Reduced radiation dose does not negatively impact image quality..· Schüßler A, Richter M, Tello K et al. Evaluation der diagnostischen Genauigkeit und der Strahlendosis der Dual-Energy-Computertomografie (DECT) bei chronisch thromboembolischer pulmonaler Hypertonie (CTEPH). Fortschr Röntgenstr 2021; 193: 1318 - 1326.ZIEL: Ziel der Studie war es herauszufinden, wie exakt die diagnostische Genauigkeit der computertomografischen Pulmonalisangiografie (CTPA) unter Hinzunahme von Dual-Energy und Rekonstruktionen von Jodkarten bei der Diagnosestellung einer CTEPH ist. Zudem wurde die Übereinstimmung der CTPA mit der Ventilations-/Perfusionsszintigrafie (V/Q-SPECT) bei der Detektion von Embolien und Perfusionsausfällen untersucht. Ein weiteres Ziel war es, die applizierte Strahlenexposition beider Techniken miteinander zu vergleichen. 71 Patienten (49 Frauen) mit dem Verdacht auf eine CTEPH wurden in diese prospektive Studie eingeschlossen. Die Patienten erhielten eine V/Q-SPECT und eine Dual-Energy-CTPA und hieraus rekonstruierte Jodkarten. Die Analyse der CTPA und der Jodkarten erfolgte durch einen erfahrenen Radiologen, verblindet zu den klinischen Angaben und in Unkenntnis des V/Q-SPECT-Befundes. Die Ergebnisse wurden mit dem Befund der V/Q-SPECT verglichen. DLP und die applizierten Radionuklidmengen (MAA, Technegas) wurden zur Ermittlung der Strahlenexposition erfasst. Die DECT erzielte eine Sensitivität von 1,000, eine Spezifität von 0,966, einen PPV von 0,867 und einen NPV von 1,000. Zwischen den beiden Untersuchungsmodalitäten gab es, in Bezug auf die Strahlenexposition, nahezu keinen Unterschied (1,911 mSv vs. 1,892 mSv). Die Untersuchungsmodalitäten zeigten im Hinblick auf Perfusionsdefizite eine hohe Übereinstimmung (1177/1278 Segmente, 92,09 %; κ = 0,5938). Die DECT präsentierte sich, in Kombination mit den Jodkarten, als potenzielle Alternative zum gegenwärtigen bildgebenden Verfahren der ersten Wahl, der V/Q-SPECT. Bei der Erstellung zukünftiger diagnostischer CTEPH-Untersuchungsalgorithmen sollte die Implementierung der DECT erwogen werden. · Die DECT stufte alle CTEPH-Patienten als richtig positiv ein.. · Hohe Übereinstimmung zwischen DECT und V/Q-SPECT bei der Einteilung pathologischer Segmente.. · Strahlenexposition DECT-Untersuchung und V/Q SPECT kein signifikanter Unterschied.. · Trotz eingesparter Strahlendosis keine Einbußen der Bildqualität..· Schüßler A, Richter M, Tello K et al. Evaluation of Diagnostic Accuracy and X-Ray Exposure of Dual-Energy Computed Tomography (DECT) in the Course of Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Fortschr Röntgenstr 2021; 193: 1318 – 1326.

Background COVID-19 is still a global challenge in regard for management and therapy. Pulmonary embolism (PE) seems to have a higher prevalence in COVID-19 instead of non-COVID patients. Clinical and laboratory parameters related with PE are still unknown. Methods We conducted a retrospective unicentre study in Alto Vicentino Hospital between March 1st, 2020, and January 31st, 2021 in patients admitted for COVID-19 tested with a RT-PCR nasal swab. Data about patients studied with computed tomography pulmonary angiogram (CTPA) because of PE suspicion were collected, as their clinical and laboratory parameters too. Results 2621 patients were admitted for COVID-19 in Alto Vicentino Hospital between March 1st, 2020, and January 31st, 2021 and in 267 of them a CTPA was performed finding 50 PE (18.7%). Only non-Caucasian race (OR = 5.44; 95% CI 1.22–24.35; p = 0.027) and previous VTE (OR = 5.3; 95% CI 1.09–26.17; p = 0.039) were found to be independently associated with PE. Conclusion PE is a frequent complication of COVID-19 and clinician need high degree of suspicion because clinical and laboratoristic parameters cannot drive diagnosis.

Introduction: Covid-19 (CV19) infection is associated with pulmonary embolism (PE). We sought to detail the presence of PE, clinical, laboratory features, and outcomes of those with PE and CV19 compared to CV19 and no PE. Methods: Retrospective analysis of all computed tomography pulmonary angiogram (CTPA) studies undertaken at our hospital during the peak of the pandemic between 29/2-3/5/2020. We included all inpatients with positive CV19 swab or classical or probable features of CV19 on CTPA. All CTPAs were reviewed by certified radiologists. The patient's electronic health records were reviewed for clinical data. Results: Total 132 (45.9%) of CTPAs met inclusion criteria. Presence of PE was 31 (23.5%), with 13 (41.9%) being central, and 18 (58.1%) peripheral. Men (70.4%, P0.04) and white ethnicity (58.1%, P0.03) were significantly associated with PE. No association was seen between CTPA radiographic severity of CV19 and presence of PE. Thromboprophylaxis was administered to 73.2% of the cohort prior to CTPA, no association (P0.29) between administration and diagnosed PE. No difference in vital observations in the 24hrs prior to CTPA as detected. Median Ddimer and Troponin T were significantly elevated (P

IntroductionSARS-CoV-2 infected patients present thrombotic complications caused by direct endothelial cells injury of the microvessels. Pulmonary thromboembolism (PE) has been reported by Computed Tomography pulmonary angiogram (CTPA) in patients with COVID-19 pneumonia with high D-dimer levels.ObjectivesWe present the characteristics of SARS-CoV-2 infected patients diagnosed of PE by CTPA in our hospital. We also present the comparison of these findings with non-infected patients with PE data.MethodsPatients 18 years of age or older with SARS-CoV2 virus infection, and patients with suspected infection at beginning of admission but with negative PCR, were studied with CTPA for suspicion of VTE, during their hospitalization.ResultsDuring the study period, 52 CTPA were performed in our hospital, sixteen in SARS-CoV-2 infected patients. No significant differences in age (p=0.43) and sex (p=0.31) were found between the two groups, infected and non-infected patients. In the infected group, the patients who had PE had a much lower median age (47.8 years) than those without PE (73.3 years). No differences between infected and non-infected patients were detected in the diagnosis of PE with CTPA, 28.6% versus 27.8% (p=1.00). Overall patient mortality was 1.9%; one patient died (6.3%) in the infected group, and none in the non-infected group (p=0.31).ConclusionA considerable incidence of PE diagnosed by CTPA in SARS-CoV-2 infected patients has been observed, despite thrombo-prophylaxis.

Aim: To investigate the diagnostic value of pulmonary embolism severity index (PESI), Simplified PESI (sPESI), Shock Index (SI), Modified SI (MSI), and Age SI (ASI) scores in predicting 30-day mortality in patients diagnosed with pulmonary thromboembolism (PTE) in the emergency department. Materials and Methods: The retrospective study included 257 patients that presented to the emergency department and underwent contrast-enhanced computed tomography pulmonary angiogram (CTPA) due to the suspicion of PTE and were interpreted as PTE by an experienced radiologist between January 1, 2015 and September 20, 2018.The PESI, sPESI, SI, MSI, and ASI scores were calculated for each patient. Results: On univariate logistic regression analysis, 30-day mortality was found to be significantly associated with age, mode of presentation, SBP, DBP, MAP, heart rate, respiratory rate, O2 saturation, temperature, D-dimer, troponin I, high-sensitivity cardiac troponin (hs-cTn), lactate, and SI, MSI, ASI, PESI, and sPESI scores (p

Introduction A Virtual Covid-19 Follow-up Clinic was designed in response to the need to review a large number of in-patients, at a large hospital trust, recovering from Covid-19 but without any significant increase in resources. Methods Patients complete a structured online/telephone symptom and psychological health questionnaire and have a chest x-ray 12 weeks after their illness. These results, and their medical records, are reviewed asynchronously by the medical team in a virtual clinic. Patients are then triaged to further virtual review, telephone review, face to face review, or are discharged. All patients receive comprehensive written information to aid their recovery. Results During the first 8 weeks of the service, 388 patients have completed the questionnaire (63% online) and been reviewed. Current symptoms are shown in figure 1. The questionnaire has identified the holistic needs of patients and allowed triaged follow-up with 122 discharged and 53 urgent face-to-face review appointments completed. 25 CT pulmonary angiogram scans were arranged for patients with typical symptoms of pulmonary emboli; no thromboembolic disease was identified. Conclusion This early experience of a new service has highlighted 5 learning points: Virtual review is not necessarily quicker than clinic review in person, with holistic review taking 15 minutes per patient (excluding phone calls). Patients appreciate clinical contact and this is particularly relevant in the post-Covid era of restricted healthcare attendance. All patients who attend for face to face review are extremely grateful. A multidisciplinary team is necessary bringing together respiratory, cardiology, rheumatology, radiology, psychology and immunology in one holistic review. Patients benefit from therapy input, with 13 of 49 patients assessed by the physiotherapist in clinic diagnosed with breathing pattern disorders. Medical staff redeployment during the pandemic, and the extreme pressures at that time, meant aspects of planned care were not arranged at discharge. Virtual review of medical records has addressed this, for example, re-arranging a referral for a pacemaker and arranging haematological review of a patient newly diagnosed with chronic lymphocytic leukaemia. Regular multi-disciplinary strategy meetings have allowed guidelines to be revised weekly, based on increasing evidence, and experience disseminated.

Introduction Cancer is a strong provoking factor for pulmonary embolism (PE). D-dimer levels are frequently elevated in cancer patients and its specificity decrease with age, hence resulting in frequent unwarranted CT pulmonary angiogram (CTPA). There is growing evidence on the utility of age adjusted d-dimer (AADD) in patients >50 years of age. The objective of this study is to test the efficacy of AADD in ruling out PE in cancer patients when compared to conventional d-dimer cut-off. Methods Retrospective analysis of consecutive patients undergoing CTPA within 48 hours of admission at our institution from 01/04/18 – 30/09/18. Patients Results 807 CTPAs were performed over the 6-month period. 247 patients with cancer were included in further analysis of which 69 (28%) had PE. 60/178 patients (33%) with negative CTPAs had d-dimers positive and AADD negative, whilst only 3/63 CTPAs had positive d-dimers with negative AADD. In essence, 60 patients could have avoided an unnecessary CTPA by using AADD in place of conventional d-dimer, at the expense of missing 3 sub-segmental PE. Conclusion AADD has comparable performance in cancer patients and improves the specificity while retaining sensitivity of d-dimer. It can prevent significant number of inappropriate CTPAs but can potentially miss a few sub-segmental PEs. Further studies are needed to validate its utility before its universal application. Reference Wilts, et al.Thrombosis Research 2017 Apr;152:49–51