acute pulmonary embolism

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  1. 1. Int Case presentation
  2. 2. Present Illness #25773451 61 y/o female Shotness of breath for 1 week Lung cancer with brain metastasis Cough with sputum, Dyspnea on exertion Bilateral lower limbs swelling No chest pain, no cold sweating, no fever
  3. 3. Physical Examination T/P/R 36.5/129/22 BP 101/56 BW 47 Kg Conjunctive: Pale Breath sound: Bibasilar crackles Heart rhythm: Irregularly irregular
  4. 4. Lab data
  5. 5. Lab data
  6. 6. Lab data
  7. 7. EKG 2014/09/18
  8. 8. Vascular echo 2014/09/18 There is some thrombosis over bilateral fem-popliteal vein, which causes partial occlusion. Duplex scanning of arteries: Site Right Left Femoral vein (V) (V) Calf vein (V) (V)
  9. 9. CXR
  10. 10. Ventilation scan
  11. 11. Perfusion scan
  12. 12. CT
  13. 13. Diagnosis Pulmonary thromboembolism with bilateral Deep vein thrombosis SVC thrombosis Lung ca with left pleural and Pericardial effusion Leukocytosis, etiology unspecified, to exclude concomitant infection
  14. 14. Discussion: Acute pulmonary embolism Int
  15. 15. Purpose To use Prospective Investigation of Pulmonary Embolism Diagnosis(PIOPED) II data to retrospectively determine 1)sensitivity 2)specificity of V/Q scintigraphic studies
  16. 16. Background PIOPED II reported (v.s. PIOPED I) CT angiography in PA to diagnose APE: sensitivity=83%,specificity=96% Venous phase CT venography: sensitivity=90%,specificity=95% Wells score helped yield positive/negative predictive values greater than 90% in 89% of patients V/Q scintigrams make predictive values higher than 90% in 22% of patients
  17. 17. Background CT has replaced V/Q scanning since 2001, while it has limitations: Cost Radiation dose Contraindications: reduced renal function, iodine allergy Use PIOPED II data to determine the sensitivity and specificity of V/Q scintigraphic studies
  18. 18. Materials and Methods Multicenter study Two blinded PIOPED II central readers for CT angiography Pulmonary DSA V/Q scanning Experienced physicians determine the Wells scores
  19. 19. Patients (a) a diagnosis recorded at V/Q scanning and either (b) a Wells score recorded prospectively and a diagnosis of PE present or PE absent at CT angiography or (c) a diagnosis of PE present or PE absent at DSA.
  20. 20. Statistic Analysis Compare PIOPED II V/Q scan with DSA results if DSA not performed or no definitive result: Compare V/Q scan with CT angiographic results which concordant with Wells score if + CT result: Wells score 2 if - CT result: Wells score 6
  21. 21. Patients and Readings
  22. 22. Patients and Readings
  23. 23. Positive predictive value in PIOPED II Probability Portion % High 89/102 87.2% Intermediate 47/152 30.9% Low 6/89 6.7% Very low 24/415 5.8% Normal 2/132 1.3%
  24. 24. Categorization of V/Q Scan Central Readings
  25. 25. Exclusion of intermediate and low probability Sensitivity of PE present= 77.4% (89/115) Specificity of PE absent= 97.7% (541/554) 26.5 % (241/910) was nondiagnostic 73.5% (669/910) was high or very low probability or normal scan
  26. 26. Categorization of V/Q Scan Central Readings PE present (high probability) and PE absent (very low probability or normal) categories showed for acute PE: sensitivity=77.4% specificity=97.7% V/Q scintigram was categorized as PE present or PE absent in 73.5% of patients
  27. 27. Discussion DSA is the most widely accepted imaging reference standard If no DSA result- CT angiography concorcant with the Wells score due to: CTA and Wells score concordance associated with high PPV and NPV The sensitivity/ specificity of V/Q scan without DSA with only CTA and Wells score concordance= 85.1% / 98.2%
  28. 28. Discussion In PIOPED II, fewer patients was low probabilities or normal, due to: Criteria for interpreting V/Q scans have improved considerably since PIOPED I Difference from V/Q scan reading depends on the patient (population, ex. pt in ICU) PIOPED I: inpatients and critically ill PIOPED II: outpatients
  29. 29. Discussion Combine low proobability and very low probability due to similarity: Sensitivity= 73.6%, Specificity=98.0% Nondiagnostic= 16.7% of population Combine Wells score with V/Q categories: PPV or NPV 90%
  30. 30. Comparion of CTA and V/Q scan in PIOPED II More nondiagnostic results with V/Q scanning (26.5% of pt) than CT (6.2% of pt) Remove nondiagnostic studies- V/Q and CTA have similar sensitivity and specificity (77% and 98%) (83% and 96%)
  31. 31. Discussion DSA was not performed in all patients due to less use of invasive pulmonary angiography PIOPED II supported CTA with Wells score as an alternative diagnostic reference to DSA
  32. 32. Conclusion V/Q scintigraphy yields diagnostically definitive results an appropriate pulmonary imaging procedure in patients for whom CTA may be disadvantageous
  33. 33. Thanks for your attention

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