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Role of Computed Tomography and Magnetic Resonance

Imaging for Deep Venous Thrombosis and


Pulmonary Embolism
Jeffrey P. Kanne, MD; Tasneem A. Lalani, MD
AbstractDuring the 1990s, computed tomography (CT) and magnetic resonance (MR) imaging underwent extensive
technological advancement and expanded clinical use in patients with venous thromboembolic disease, particularly with
regard to evaluation of the pulmonary vasculature. In many institutions, helical (spiral) CT pulmonary angiography has
become the initial imaging study of choice to evaluate patients with suspected pulmonary embolism, supplanting
ventilation/perfusion scintigraphy. In addition, CT venography of the pelvis and lower extremities is often incorporated
into the CT angiography protocol to identify or exclude concurrent deep venous thrombosis. MR pulmonary angiography and
MR venography are second-line diagnostic tools because of their higher cost, limited availability, and other logistical
constraints. As the technology improves and becomes more widely available, MR imaging may play a greater role in the
evaluation of patients with venous thromboembolic disease. (Circulation. 2004;109[suppl I]:I-15-I-21.)
Key Words: thrombosis pulmonary heart disease imaging MRI

uring the 1990s, technological advances in computed


tomography (CT) and magnetic resonance (MR) imaging made these techniques applicable to the diagnosis of
venous thromboembolic disease, particularly for the pulmonary vasculature in patients with suspected pulmonary embolism (PE). At the opening of the third millennium, in many
institutions, helical (spiral) CT pulmonary angiography
(CTPA) has become the initial imaging study of choice for
evaluating patients with suspected PE, supplanting ventilation/perfusion (V/Q) scintigraphy by reducing indeterminate
examinations.1 4 CT venography (CTV) of the pelvic and
lower extremity veins after CTPA of the pulmonary arteries
has been advocated by some as an adjunct to helical CT for
detection of concurrent deep venous thrombosis (DVT) using
a single imaging technique for detection of venous thromboembolic disease.
Although MR imaging produces high tissue contrast without ionizing radiation, currently, this technique is less popular
than CT for evaluation of acute venous thromboembolism
(VTE) because of technical limitations, higher costs, limited
availability, and other logistical considerations. As technology improves, however, MR pulmonary angiography
(MRPA) and MR venography (MRV) may play a greater role
in the evaluation of patients with venous thromboembolic
disease.
This article reviews applications of CT and MR imaging in
the clinical evaluation of patients with suspected venous
thromboembolic disease.

CT Pulmonary Angiography
CTPA has gained acceptance as a first-line imaging study in
cases of suspected acute PE, replacing traditional V/Q scintigraphy at many institutions. In general, V/Q scanning is
reserved for patients in whom motion artifact or poor right
heart function limit the quality of CT examination and those
with contraindications to intravenous radiographic contrast.
After contrast administration, CTPA provides visualization
of the pulmonary arterial system in the axial plane, and
multiplanar and three-dimensional reconstructions can be
generated from raw data to enhance diagnostic accuracy. The
cardinal sign of acute PE on CTPA is an intravascular filling
defect in a pulmonary artery that partially or completely
occludes the vessel and is often associated with increased
diameter of the affected vessel (Figures 1 through 3). The
most specific sign of acute PE is a filling defect that forms
acute angles with the vessel wall. Although the filling defect
of acute PE can produce obtuse angles or complete occlusion
of the vessel, these patterns are also seen in cases of chronic
thromboembolic disease.2,3
The sensitivity and specificity of CTPA for diagnosis of
acute PE have been reported to range from 53% to 100% and
67% to 100%, respectively, varying on the basis of patient
selection, extent of thrombus, area of the vasculature imaged,
interpretation criteria, and experience of the reader.1 Moreover, technological advances over the last 10 years have
improved spatial resolution (thinner collimation), abbreviated
image acquisition time, and enabled multislice imaging.

From the Department of Radiology, University of Washington School of Medicine, Seattle.


Correspondence to Tasneem A. Lalani, MD, Department of Radiology, University of Washington School of Medicine, Box 357115, Seattle WA 98195
to 7115. E-mail tal99@u.washington.edu
2004 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org

DOI: 10.1161/01.CIR.0000122871.86662.72

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Circulation

March 30, 2004

Figure 1. Image from CT pulmonary angiogram of a 67-year-old


man with cancer and symptoms of syncope and hypoxia. Large
clot (arrows) is present at the bifurcation of the main pulmonary
artery, extending into the left and right pulmonary arteries.

Using thin (2 mm) collimation, sensitivities of 94% to 96%


and specificities of 94% to 100% have been achieved.5,6
Although normal V/Q scintigraphy essentially excludes
PE, a high-probability V/Q scan has a sensitivity of 88% for
PE compared with pulmonary angiography. In the prospective investigation of pulmonary embolism diagnosis (PIOPED) study, only 41% of patients with PE had a highprobability scan,7 and 57% of patients had nondiagnostic
(indeterminate or low-probability) V/Q scans. In other studies, CTPA demonstrated acute PE in 14% to 44% of patients
with nondiagnostic V/Q scans, including several in whom
lower extremity ultrasound imaging did not find DVT.8 11
CTPA gave the correct diagnosis in 92% of cases with
discordant V/Q and CTPA12 and, when used as the initial
diagnostic examination in cases of suspected PE, reader
confidence was significantly higher with CTPA than with
V/Q scanning (90% versus 54%, respectively).13
For PE in the main, lobar, or segmental pulmonary arteries,
the diagnostic accuracy of CTPA compares favorably with
that of pulmonary angiography,14 16 but how best to evaluate
the subsegmental pulmonary arteries remains controversial.
The subsegmental pulmonary arteries are more difficult to
evaluate because of their smaller size, limited contrast enhancement in relation to the finite spatial resolution of CT,
and the orientation of these vessels in space.17 The true
incidence of isolated subsegmental PE is unknown, and
reported incidences vary widely (4% to 17%), depending on
patient population and other factors. However, in large series,
isolated subsegmental emboli were identified in 4% to 6% of
patients with clinically suspected PE.7,18 20 The clinical
significance of isolated subsegmental pulmonary emboli also
is unclear, especially in patients without evidence of DVT or
cardiopulmonary dysfunction. Although many clinicians still
hold pulmonary angiography as the gold standard, balloon
occlusion studies have shown that even pulmonary angiogra-

Figure 2. A, Image from a CT pulmonary angiogram of a


90-year-old woman with dyspnea and hypoxia showing a large
clot (arrow) in the left lower lobe pulmonary artery. B, More caudal image shows multiple clots (short arrows) in the lower lobe
segmental arteries. Patchy right lower lobe subsegmental (long
arrows) atelectasis is present.

phy can miss subsegmental PE21,22 and interobserver agreement is poor (13% to 66%).18,23,24 One study comparing thin
collimation (1 mm) CTPA and pulmonary angiography in a
cast porcine model showed no statistical difference in sensitivity between the two modalities at the subsegmental levels
(each 87%).25
It has been suggested that clinical outcome (rather than
pulmonary angiography) serve as the standard against which

Figure 3. Single image from CT venography of a 45-year-old


man with burns and hypoxia showing a filling defect (arrow) in
the right popliteal vein, consistent with deep venous thrombosis.
CT pulmonary angiography showed acute pulmonary embolism.

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Kanne and Lalani


to evaluate the diagnostic accuracy of the various imaging
modalities for acute PE.26 The majority of subsequent PEs
occur within the first few weeks after an index event, with
50% of recurrences and 90% of PE-related deaths occurring
within the first 2 weeks.27,28 In patients with chronic underlying risk factors such as malignancy, however, the occurrence of a thromboembolic event after a negative diagnostic
examination for VTE does not mean that the original examination was necessarily a false-negative result. In several
outcome studies limited by a relatively high proportion of
patients lost to follow-up and relatively sparse autopsy data,
patients with negative CTPA were monitored without anticoagulation with negative predictive values ranging from 93%
to 100%;1,6,9,29 38 these results are comparable to those
obtained with pulmonary angiography.39 46
Detailed delineation of the pulmonary parenchyma and
extrapulmonary structures by CTPA offers additional information about the lungs and pleura not provided by V/Q
scintigraphy or pulmonary angiography. In one study, CTPA
identified pleural or parenchymal abnormalities that explained indeterminate defects on V/Q scans in 57% of
patients;11 in other studies, alternative intrathoracic findings
were identified in 11% to 85% of patients undergoing
CTPA;6,8,9,13,32,4751 these additional findings were nonspecific, occurring both in patients with and without PE.52
Although other such intrathoracic abnormalities may not
imply a need for further evaluation, their identification may
affect patient management.
Identification of PE on CTPA is a clear indication for
initiating appropriate therapy, but uncertainty about subsegmental thromboemboli contributes to ongoing uncertainty
about the diagnostic accuracy of both CTPA and pulmonary
angiography. As multislice CT technology becomes more
commonplace, future studies employing thinner collimation,
faster scan times, and cardiac gating are expected to result in
better visualization of the smaller pulmonary arteries, and
these enhancements may ultimately determine whether a
negative CTPA is sufficient evidence to withhold therapy
from a patient with signs or symptoms suggestive of PE.

Multislice CT
In the past several years, multislice CT has become commonplace in major U.S. medical centers. Most university medical
centers and other tertiary care centers have at least one
multislice scanner. Sixteen-slice scanners, now offered by
most vendors, are currently appearing in many radiology
departments and offer even faster scan times, result in lower
radiation doses than 4- and 8-slice scanners, and provide
isotropic imaging (z-axis spatial resolution equal to x- and
y-axis spatial resolution). As availability of these newer
multislice scanners increases, updated studies of the diagnostic accuracy of CTPA using newer techniques can be
expected.

CT Venography for Diagnosis of DVT


Duplex ultrasound, including both gray-scale and Doppler
imaging examination of the lower extremity venous system,
has replaced conventional venography as the first-line diagnostic test for DVT, with reported sensitivity and specificity

CT and MRI to Diagnose DVT and PE

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Advantages and Disadvantages of CTV


Advantages
One exam for both DVT and PE
High diagnostic accuracy similar to colorflow duplex and CTPA
Detects other nonthromboembolic pathology (eg, cancer)
After-hours availability (unlike duplex in many locations)
Drawbacks
Iodinate contrast nephrotoxicity
Radiation exposure
Cannot be performed at bedside (risk of transporting critically ill)
Higher cost
Accuracy in diagnosis of calf vein thrombosis
Streak artifact

above 90% in symptomatic patients.53 Ultrasound imaging


can be performed at the bedside, does not involve ionizing
radiation, is noninvasive, and is relatively inexpensive. The
technical quality of the examination depends on operator
skill, however, and evaluation of the pelvic and calf veins is
limited.54 56 In many institutions, ultrasound may not be as
readily available after hours as CTV.
CTV provides direct imaging of the inferior vena cava,
pelvic, and lower extremity veins immediately after CTPA
without injection of additional contrast material, adding only
a few minutes to the examination. Because DVT is the most
important factor predisposing to PE,56 a single examination
capable of evaluating both the pulmonary arterial system and
the pelvic and lower extremity venous system offers distinct
advantages over other tests directed at either diagnosis alone.
Combined CTPA/CTV fills this role, and the results of one
component can be used to guide therapy when the complementary component is not diagnostic, increasing the overall
cost-effectiveness.57,58
Like CTPA, CTV is occasionally plagued by technical
limitations such as streak artifact from orthopedic hardware
or poor venous enhancement. Table 1 summarizes the advantages and disadvantages of CTV. Additionally, errors in
interpretation related to anomalous vessels, adjacent pathology, and reader inexperience may result in inaccurate interpretation. The reported sensitivity and specificity of CTV has
been reported between 89% to 100% and 94% to 100%,
respectively.60 62 In one of the largest series, CTV was 97%
sensitive and 100% specific for femoropopliteal DVT.63 A
more recent study using multislice CT showed a sensitivity of
100% and specificity of 97% and positive and negative
predictive values of 92% and 100%, respectively.64
There are several drawbacks to combining CTV with
CTPA as a single comprehensive imaging modality for VTE.
In a number of published studies of combined CTPA and
CTV, 150 mL of iodinated contrast was required to produce
adequate opacification of the pulmonary arteries and pelvic
and lower extremity veins,61,63 68 more than the amount
usually required for adequate opacification of the pulmonary
arteries alone. Given that the nephrotoxicity of iodinated
radiocontrast is dose related,69 minimizing the dose is important, especially in critically ill patients with underlying renal

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Figure 4. Coronal image from MR pulmonary angiogram shows


focus of low signal (arrow) in the left main pulmonary artery
consistent with pulmonary embolism. The mural-based morphology suggests this clot is chronic (Courtesy of Michael B. Gotway, MD; San Francisco, Calif).

insufficiency or in those who require multiple imaging


procedures over a short period of time.
Exposure to ionizing radiation is also greater with combined CTRA/CTV over either test alone, and this is particularly pertinent to radiosensitive tissues such as the ovaries and
testes. Protocols using spaced sections rather than helical
acquisition help reduce radiation doses but risk missing
smaller venous thrombi.63 Although concern about exposure
need not preclude clinically indicated examinations, physicians should be aware of the deleterious effects, particularly
in younger patients, and remember that CT imaging contributes to the bulk of medical radiation exposure. In part because
of these issues, the value of combining CTV with CTPA is
still debated, and in many institutions, including our own,
CTV is not routinely included in the CTPA protocol.

MR Pulmonary Angiography
In the 1990s, MRPA involved mainly two-dimensional timeof-flight (TOF) techniques with limited anatomic coverage.
Breath-holding capability, registration artifacts, and poor
differentiation of slow blood flow from thrombus also compromised image quality.70,71 The advent of faster gradients
and better reconstruction algorithms has made threedimensional contrast MR angiography feasible. These scans
can be completed in 10 to 30 seconds during a single
breath-holdwith increased signal-to-noise ratio and improved image quality through administration of intravenous
gadolinium (Figure 4). Despite these advances, limitations on
spatial resolution and breath-holding71,72 make evaluation of
the segmental and subsegmental pulmonary arteries difficult.
Increasing the image matrix size can improve spatial resolution at the cost of longer imaging time and, therefore, require
breath-holding for longer intervals. Additionally, because the
acquisition time for MR exceeds that for CT or conventional
angiography, selective pulmonary arterial phase enhancement

cannot be achieved,71 making it difficult to distinguish arterial


from venous structures.
In an animal model, 81% and 61% of fifth-order (subsegmental) vessels were visualized using 192192 and
160160 matrices, respectively, on a single breath-hold scan.
Without breath-holding, the same matrices yielded definition
of only 26% (192192) and 20% (160160) of subsegmental pulmonary arteries.73 In another study, the sensitivity and
specificity for detection of lobar and segmental emboli was
87% and 97%, respectively.74 In a subsequent study, sensitivity for detection of subsegmental emboli was only 68%,75
making this technique inferior to CTPA or angiography.
Newer techniques using navigator pulses that allow free
breathing are promising for dyspneic patients undergoing
MR, as tracking of diaphragmatic excursions facilitate cumulative data acquisition at the same phase of the respiratory
cycle. Additionally, improved gating reduces the cardiac
pulsation artifact that affects MR more than CT imaging.
Improvements in the speed of data acquisition, faster gradients, and radial acquisition of raw data rather than current
Cartesian acquisition methods promise to further improve the
future diagnostic accuracy of MRPA.76,77

MR Venography
MRV may be used to evaluate central venous pathology,
anatomic variants, and DVT of the extremities (Figure 5).
The technique is less stringent than most MR angiography
techniques because venous flow profiles are relatively uniform, vessel size is greater, and flow is slower. Additionally,
venous pathology is usually more extensive than arterial
pathology, requiring lower image resolution. MRV can be
performed without intravenous contrast using TOF and
phase-contrast (PC) techniques. Alternatively, intravenous
gadolinium can be administered to enhance the venous signal.
Contrast-enhanced MRV has several advantages over both
TOF and PC techniques, including faster acquisition, better
signal-to-noise ratio, and greater accuracy in states of slow
flow or tortuous venous anatomy.78
MRV shares with CTV the advantage of better delineating
the inferior vena cava and pelvic veins than does sonography,
and does not require venous compression, which is pertinent
to examination of limbs in plaster casts or other impediments
to compression sonography. Studies comparing MRV with
sonography have found MRV superior for diagnosis of DVT
in the thigh.79 84 One study of 25 patients undergoing both
MRV and sonography of the pelvic and common femoral
veins found the sensitivity and specificity of MRV to be
100% and 98%, respectively, whereas sonography had a
sensitivity of 91% and a specificity of 97%.83

Conclusions
Even with modern technology, VTE is an elusive clinical
entity and no perfect diagnostic test has been developed.
Helical CTPA will likely continue to serve as the initial
diagnostic imaging examination of choice for patients with
clinically suspected acute PE in the absence of contraindications to radiograph contrast material, especially as multislice
technology proliferates. Should future studies find multislice
CTPA technology superior to pulmonary angiography at the

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Kanne and Lalani

CT and MRI to Diagnose DVT and PE

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sure, it may prove more cost-effective and result in appropriate anticoagulation therapy for a higher proportion of patients
with DVT, thereby reducing the risk of a life-threatening PE.
MRV and MRPA remain second-line diagnostic tools
because of higher cost, technical limitations, limited availability, and logistical constraints. As MR technology improves and becomes more readily available, the role of MRV
and MRPA in evaluating venous thromboembolic disease
may expand. Pulmonary angiography is generally reserved
for patients in whom the clinical suspicion of PE remains
high despite negative CTPA and bilateral lower extremity
venous evaluations (by CTV or ultrasound), or for those with
contraindications to CTPA and an indeterminate V/Q scan.

References

Figure 5. Ovarian vein thrombophlebitis in a 44-year-old


woman. A, Axial post-gadolinium T1 SPGR image shows thrombus (arrow) in and inflammation of the left ovarian vein. B-C,
Coronal post-gadolinium T1 SPGR images confirm ovarian vein
thrombophlebitis (arrows).

subsegmental arterial level with better interobserver agreement, CTPA would become the first and only imaging study
needed for diagnosis of acute PE in most patients.
Several authors advocate including CTV in the CTPA
protocol for more complete evaluation of VTE and to
increase the overall sensitivity of the examination. This
technique seems comparable to ultrasound in the femoropopliteal region and superior in the pelvis. Although involving a
larger iodinated contrast load and additional radiation expo-

1. Ghaye B, Remy J, Remy-Jardin M. Non-traumatic thoracic emergencies:


CT diagnosis of acute pulmonary embolism: the first 10 years. Eur
Radiol. 2002;12:1886 1905.
2. Remy-Jardin M, Mastora I, Remy J. Pulmonary embolus imaging with
multislice CT. Radiol Clin North Am. 2003;41:507519.
3. Powell T, Mu ller NL. Imaging of acute pulmonary thromboembolism:
should spiral computed tomography replace the ventilation-perfusion
scan? Clin Chest Med. 2003;24:29 38.
4. Johnson MS. Current strategies for the diagnosis of pulmonary embolus.
J Vasc Interv Radiol. 2002;13:1323.
5. Blachere H, Latrabe V, Montaudon M, et al. Pulmonary embolism
revealed on helical CT angiography: comparison with ventilationperfusion radionuclide lung scanning. Am J Roentgenol. 2000;174:
10411047.
6. Remy-Jardin M, Remy J, Baghaie F, et al. Clinical value of thin collimation in the diagnostic workup of pulmonary embolism. Am J
Roentgenol. 2000;175:407 411.
7. The PIOPED Investigators. Value of the ventilation/perfusion scan in
acute pulmonary embolism. Results of the prospective investigation of
pulmonary embolism diagnosis (PIOPED). JAMA. 1990;263:27532759.
8. Garg K, Welsh CH, Feyerabend AJ, et al. Pulmonary embolism:
diagnosis with spiral CT and ventilation-perfusion scanning correlation
with pulmonary angiographic results or clinical outcome. Radiology.
1998;208:201208.
9. Ferretti GR, Bosson JL, Buffaz PD, et al. Acute pulmonary embolism:
role of helical CT in 164 patients with intermediate probability at
ventilation-perfusion scintigraphy and normal results at duplex US of the
legs. Radiology. 1997;205:453 458.
10. Remy-Jardin M, Remy J, Deschildre F, et al. Diagnosis of pulmonary
embolism with spiral CT: comparison with pulmonary angiography and
scintigraphy. Radiology. 1996;200:699 706.
11. van Rossum AB, Treurniet FE, Kieft GJ, et al. Role of spiral volumetric
computed tomographic scanning in the assessment of patients with
clinical suspicion of pulmonary embolism and an abnormal ventilation/
perfusion lung scan. Thorax. 1996;51:2328.
12. Mayo JR, Remy-Jardin M, Mu ller NL, et al. Pulmonary embolism:
prospective comparison of spiral CT with ventilation-perfusion scintigraphy. Radiology. 1997;205:447 452.
13. Cross JJ, Kemp PM, Walsh CG, et al. A randomized trial of spiral CT and
ventilation perfusion scintigraphy for the diagnosis of pulmonary
embolism. Clin Radiol. 1998;53:177182.
14. Blum AG, Delfau F, Grignon B, et al. Spiral-computed tomography
versus pulmonary angiography in the diagnosis of acute massive pulmonary embolism. Am J Cardiol. 1994;74:96 98.
15. Goodman LR, Curtin JJ, Mewissen MW, et al. Detection of pulmonary
embolism in patients with unresolved clinical and scintigraphic diagnosis:
helical CT versus angiography. Am J Roentgenol. 1995;164:1369 1374.
16. Qanadli SD, El Hajjam M, Vieillard-Baron A, et al. New CT index to
quantify arterial obstruction in pulmonary embolism: comparison with
angiographic index and echocardiography. Am J Roentgenol. 2001;176:
14151420.
17. Kauczor HU, Heussel CP, Thelen M. Update on diagnostic strategies of
pulmonary embolism. Eur Radiol. 1999;9:262275.
18. Stein PD, Henry JW, Gottschalk A. Reassessment of pulmonary
angiography for the diagnosis of pulmonary embolism: relation of inter-

Downloaded from http://circ.ahajournals.org/ by guest on April 16, 2015

I-20

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.
29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

Circulation

March 30, 2004

preter agreement to the order of the involved pulmonary arterial branch.


Radiology. 1999;210:689 691.
Diffin DC, Leyendecker JR, Johnson SP, et al. Effect of anatomic distribution of pulmonary emboli on interobserver agreement in the interpretation of pulmonary angiography. Am J Roentgenol. 1998;171:
10851089.
Oser RF, Zuckerman DA, Gutierrez FR, et al. Anatomic distribution of
pulmonary emboli at pulmonary angiography: implications for crosssectional imaging. Radiology. 1996;199:3135.
Bynum LJ, Wilson JE3rd, Christensen EE et al. Radiographic techniques
for balloon-occlusion pulmonary angiography. Radiology. 1979;133:
518 520.
Ferris EJ, Holder JC, Lim WN, et al. Angiography of pulmonary emboli:
digital studies and balloon-occlusion cineangiography. Am J Roentgenol.
1984;142:369 373.
Quinn MF, Lundell CJ, Klotz TA, et al. Reliability of selective pulmonary
arteriography in the diagnosis of pulmonary embolism. Am J Roentgenol.
1987;149:469 471.
Stein PD, Athanasoulis C, Alavi A, et al. Complications and validity of
pulmonary angiography in acute pulmonary embolism. Circulation. 1992;
85:462 468.
Baile EM, King GG, Mu ller NL, et al. Spiral computed tomography is
comparable to angiography for the diagnosis of pulmonary embolism.
Am J Respir Crit Care Med. 2000;161:1010 1015.
Ryu JH, Swensen SJ, Olson EJ, et al. Diagnosis of pulmonary embolism
with use of computed tomographic angiography. Mayo Clin Proc. 2001;
76:59 65.
Hirsh J. Low-molecular-weight heparin: a review of the results of recent
studies of the treatment of venous thromboembolism and unstable angina.
Circulation. 1998;98:15751582.
Carson JL, Kelley MA, Duff A, et al. The clinical course of pulmonary
embolism. N Engl J Med. 1992;326:1240 1245.
Swensen SJ, Sheedy PF 2nd, Ryu JH et al. Outcomes after withholding
anticoagulation from patients with suspected acute pulmonary embolism
and negative computed tomographic findings: a cohort study. Mayo Clin
Proc. 2002;77:130 138.
Remy-Jardin M, Tillie-Leblond I, Szapiro D, et al. CT angiography of
pulmonary embolism in patients with underlying respiratory disease:
impact of multislice CT on image quality and negative predictive value.
Eur Radiol. 2002;12:19711978.
Krestan CR, Klein N, Kreuzer S, et al. Value of a negative spiral-CT
angiography in patients with suspected acute PE: retrospective analysis of
PE recurrence and outcom. Eur Radiol. 1999;9(suppl):200.
Garg K, Sieler H, Welsh CH, et al. Clinical validity of helical CT being
interpreted as negative for pulmonary embolism: implications for patient
treatment. Am J Roentgenol. 1999;172:16271631.
Lomis NN, Yoon HC, Moran AG, et al. Clinical outcomes of patients
after a negative spiral CT pulmonary arteriogram in the evaluation of
acute pulmonary embolism. J Vasc Interv Radiol. 1999;10:707712.
Goodman LR, Lipchik RJ, Kuzo RS, et al. Subsequent pulmonary
embolism: risk after a negative helical CT pulmonary angiogramprospective comparison with scintigraphy. Radiology. 2000;215:535542.
Gottsater A, Berg A, Centergard J, et al. Clinically suspected pulmonary
embolism: is it safe to withhold anticoagulation after a negative spiral
CT? Eur Radiol. 2001;11:6572.
Ost D, Rozenshtein A, Saffran L, et al. The negative predictive value of
spiral computed tomography for the diagnosis of pulmonary embolism in
patients with nondiagnostic ventilation-perfusion scans. Am J Med. 2001;
110:16 21.
Tillie-Leblond I, Mastora I, Radenne F, et al. Risk of pulmonary
embolism after a negative spiral CT angiogram in patients with pulmonary disease: 1-year clinical follow-up study. Radiology. 2002;223:
461 467.
Bourriot K, Couffinhal T, Bernard V, et al. Clinical outcome after a
negative spiral CT pulmonary angiographic finding in an inpatient population from cardiology and pneumology wards. Chest. 2003;123:
359 365.
van Beek EJ, Reekers JA, Batchelor DA, et al. Feasibility, safety and
clinical utility of angiography in patients with suspected pulmonary
embolism. Eur Radiol. 1996;6:415 419.
Cheely R, McCartney WH, Perry JR, et al. The role of noninvasive tests
versus pulmonary angiography in the diagnosis of pulmonary embolism.
Am J Med. 1981;70:1722.

41. Nilsson T, Turen J, Billstrom A, et al. Validity of pulmonary cine


arteriography for the diagnosis of pulmonary embolism. Eur Radiol.
1999;9:276 280.
42. Henry JW, Relyea B, Stein PD. Continuing risk of thromboemboli among
patients with normal pulmonary angiograms. Chest. 1995;107:
13751378.
43. Novelline RA, Baltarowich OH, Athanasoulis CA, et al. The clinical
course of patients with suspected pulmonary embolism and a negative
pulmonary arteriogram. Radiology. 1978;126:561567.
44. Hull RD, Hirsh J, Carter CJ, et al. Pulmonary angiography, ventilation
lung scanning, and venography for clinically suspected pulmonary
embolism with abnormal perfusion lung scan. Ann Intern Med. 1983;98:
891 899.
45. van Rooij WJ, den Heeten GJ, Sluzewski M. Pulmonary embolism:
diagnosis in 211 patients with use of selective pulmonary digital subtraction angiography with a flow-directed catheter. Radiology. 1995;195:
793797.
46. van Beek EJ, Bakker AJ, Reekers JA. Pulmonary embolism: interobserver
agreement in the interpretation of conventional angiographic and DSA
images in patients with nondiagnostic lung scan results. Radiology. 1996;
198:721724.
47. Montgomery AB, Gilkeson RC, Glauser J, et al. The role of spiral CT
using the pulmonary embolus protocol: a comparison of emergency
department and hospitalized populations. Emerg Radiol. 2000;7:2530.
48. Senac JP, Vernhet H, Bousquet C, et al. [Pulmonary embolism: contribution of spiral x-ray computed tomography]. J Radiol. 1995;76:
339 345.
49. Kim KI, Mu ller NL, Mayo JR. Clinically suspected pulmonary embolism:
utility of spiral CT. Radiology. 1999;210:693 697.
50. van Rossum AB, Pattynama PM, Mallens WM, et al. Can helical CT
replace scintigraphy in the diagnostic process in suspected pulmonary
embolism? A retrolective-prolective cohort study focusing on total diagnostic yield. Eur Radiol. 1998;8:90 96.
51. Lorut C, Ghossains M, Horellou MH, et al. A noninvasive diagnostic
strategy including spiral computed tomography in patients with suspected
pulmonary embolism. Am J Respir Crit Care Med. 2000;162:14131418.
52. Shah AA, Davis SD, Gamsu G, et al. Parenchymal and pleural findings in
patients with and patients without acute pulmonary embolism detected at
spiral CT. Radiology. 1999;211:147153.
53. White RH, McGahan JP, Daschbach MM, et al. Diagnosis of deep-vein
thrombosis using duplex ultrasound. Ann Intern Med. 1989;111:297304.
54. Wakefield TW, Greenfield LJ. Diagnostic approaches and surgical
treatment of deep venous thrombosis and pulmonary embolism. Hematol
Oncol Clin North Am. 1993;7:12511267.
55. Fraser JD, Anderson DR. Deep venous thrombosis: recent advances and
optimal investigation with US. Radiology. 1999;211:9 24.
56. Hull RD, Raskob GE, Coates G, et al. A new noninvasive management
strategy for patients with suspected pulmonary embolism. Arch Intern
Med. 1989;149:2549 2555.
57. Goodman LR. 1999 plenary session: Friday imaging symposium: CT
diagnosis of pulmonary embolism and deep venous thrombosis. Radiographics. 2000;20:12011205.
58. Fishman EK, Horton KM. CT of suspected pulmonary embolism: study
design optimization. Am J Roentgenol. 2000;175:10021003.
59. Deleted in proof.
60. Loud PA, Grossman ZD, Klippenstein DL, et al. Combined CT
venography and pulmonary angiography: a new diagnostic technique for
suspected thromboembolic disease. Am J Roentgenol. 1998;170:951954.
61. Garg K, Kemp JL, Wojcik D, et al. Thromboembolic disease: comparison
of combined CT pulmonary angiography and venography with bilateral
leg sonography in 70 patients. Am J Roentgenol. 2000;175:9971001.
62. Duwe KM, Shiau M, Budorick NE, et al. Evaluation of the lower
extremity veins in patients with suspected pulmonary embolism: a retrospective comparison of helical CT venography and sonography. 2000
ARRS Executive Council Award I. Am Roentgen Ray Society. Am J
Roentgenol. 2000;175:15251531.
63. Loud PA, Katz DS, Bruce DA, et al. Deep venous thrombosis with
suspected pulmonary embolism: detection with combined CT venography
and pulmonary angiography. Radiology. 2001;219:498 502.
64. Begemann PG, Bonacker M, Kemper J, et al. Evaluation of the deep
venous system in patients with suspected pulmonary embolism with
multi-detector CT: a prospective study in comparison to Doppler
sonography. J Comput Assist Tomogr. 2003;27:399 409.
65. Cham MD, Yankelevitz DF, Shaham D, et al. Deep venous thrombosis:
detection by using indirect CT venography. The Pulmonary Angiography-

Downloaded from http://circ.ahajournals.org/ by guest on April 16, 2015

Kanne and Lalani

66.

67.

68.
69.

70.
71.
72.

73.

74.

75.

Indirect CT Venography Cooperative Group. Radiology. 2000;216:


744 751.
Loud PA, Katz DS, Klippenstein DL, et al. Combined CT venography
and pulmonary angiography in suspected thromboembolic disease: diagnostic accuracy for deep venous evaluation. Am J Roentgenol. 2000;174:
61 65.
Bruce D, Loud PA, Klippenstein DL, et al. Combined CT venography and
pulmonary angiography: how much venous enhancement is routinely
obtained? Am J Roentgenol. 2001;176:12811285.
Ghaye B, Szapiro D, Willems V, et al. Pitfalls in CT venography of lower
limbs and abdominal veins. Am J Roentgenol. 2002;178:14651471.
Cigarroa RG, Lange RA, Williams RH, et al. Dosing of contrast material
to prevent contrast nephropathy in patients with renal disease. Am J Med.
1989;86:649 652.
Meaney JF, Johansson LO, Ahlstrom H, et al. Pulmonary magnetic
resonance angiography. J Magn Reson Imaging. 1999;10:326 338.
Meaney JF, Prince MR. Pulmonary MR angiography. Magn Reson
Imaging Clin N Am. 1999;7:393 409.
Vrachliotis TG, Bis KG, Shetty AN, et al. Contrast-enhanced threedimensional MR angiography of the pulmonary vascular tree. Int J Cardiovasc Imaging. 2002;18:283293.
Huynh TV, Bergin CJ, Hauschildt J, et al. Magnetic resonance detection
of acute pulmonary emboli in a canine model with pathologic correlation.
Acad Radiol. 1996;3:1019 1024.
Meaney JF, Weg JG, Chenevert TL, et al. Diagnosis of pulmonary
embolism with magnetic resonance angiography. N Engl J Med. 1997;
336:14221427.
Gupta A, Frazer CK, Ferguson JM, et al. Acute pulmonary embolism:
diagnosis with MR angiography. Radiology. 1999;210:353359.

CT and MRI to Diagnose DVT and PE

I-21

76. Haage P, Piroth W, Krombach G, et al. Pulmonary embolism: comparison


of angiography with spiral computed tomography, magnetic resonance
angiography, and real-time magnetic resonance imaging. Am J Respir
Crit Care Med. 2003;167:729 734.
77. Oudkerk M, van Beek EJ, Wielopolski P, et al. Comparison of contrastenhanced magnetic resonance angiography and conventional pulmonary
angiography for the diagnosis of pulmonary embolism: a prospective
study. Lancet. 2002;359:16431647.
78. Prince MR, Grist TM, Debatin JF, et al. 3D Contrast MR Angiography,
3rd ed. New York, NY: Springer-Verlag, 2003.
79. Evans AJ, Sostman HD, Knelson MH, et al. 1992 ARRS Executive
Council Award. Detection of deep venous thrombosis: prospective comparison of MR imaging with contrast venography. Am J Roentenol.
1993;161:131139.
80. Carpenter JP, Holland GA, Baum RA, et al. Magnetic resonance
venography for detection of deep venous thrombosis: comparison with
contrast venography and duplex Doppler ultrasonography. J Vasc Surg.
1993;18:734 741.
81. Laissy JP, Cinqualbre A, Loshkajian A, et al. Assessment of deep venous
thrombosis in the lower limbs and pelvis: MR venography versus duplex
Doppler sonography. Am J Roentgenol. 1996;167:971975.
82. Polak JF, Fox LA. MR assessment of the extremity veins. Semin
Ultrasound CT MR. 1999;20:36 46.
83. Dupas B, el Kouri D, Curtet C, et al. Angiomagnetic resonance imaging
of iliofemorocaval venous thrombosis. Lancet. 1995;346:1719.
84. Evans AJ, Sostman HD, Witty LA, et al. Detection of deep venous
thrombosis: prospective comparison of MR imaging and sonography. J
Magn Reson Imaging. 1996;6:44 51.

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Role of Computed Tomography and Magnetic Resonance Imaging for Deep Venous
Thrombosis and Pulmonary Embolism
Jeffrey P. Kanne and Tasneem A. Lalani
Circulation. 2004;109:I-15-I-21
doi: 10.1161/01.CIR.0000122871.86662.72
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