J Korean Soc Radiol.  2016 Dec;75(6):455-465. 10.3348/jksr.2016.75.6.455.

Pulmonary Embolism Overlooked on Chest CT Under the Application of the American College of Radiology Appropriateness Criteria

Affiliations
  • 1Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
  • 2Department of Radiology, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea. leebae@catholic.ac.kr

Abstract

PURPOSE
We retrospectively estimated the frequency and clinical significance of pulmonary embolism (PE) that would have been missed on chest CT scans if the American College of Radiology (ACR) appropriateness criteria were applied and contrast enhanced CT scans were not performed.
MATERIALS AND METHODS
From 2007 to 2014, a total of 696 patients with acute PE were reviewed. The ACR appropriateness criteria relevant to performing a chest CT scan were reorganized into 37 clinical topics (reasons for performing CT). Furthermore, based on the strength of recommendation for CT contrast usage, topics were divided into Group A (appropriate), Group B (not appropriate), Group C (may be appropriate), and Group D (no CT). The patients were assigned into groups and compared for the clinical characteristics and prognostic CT findings.
RESULTS
Four hundred ninety-one patients were assigned into Group A (70.5%), 104 patients were assigned into Group B (14.9%), 101 patients were assigned into Group C (14.5%), and none of the patients were assigned into Group D. Patients in Group C (69.3 ± 14.6 years) were significantly older (p < 0.001) than those in the other groups. The most common reason for performing CT in Group B was screening of pulmonary metastasis (72%).
CONCLUSION
Under circumstances of many pulmonary emboli without clinical suspicion, PE could be overlooked under the application of contrast usage criteria, especially in patients in old age and with underlying malignancy. Such a recommendation can be useful to determine the usage of CT contrast in patients with a complex medical background.


MeSH Terms

Contrast Media
Diagnostic Imaging
Humans
Mass Screening
Multidetector Computed Tomography
Neoplasm Metastasis
Pulmonary Embolism*
Retrospective Studies
Thorax*
Tomography, X-Ray Computed*
Contrast Media

Figure

  • Fig. 1 Schematic illustration of application of the simplified ACR appropriateness criteria. All the ACR appropriateness criteria related to performing chest CT were selected and summarized into 37 topics. Based on the 1–9 rating scale of the ACR appropriateness criteria, all 37 topics were classified into 4 groups. If the topic had a 7–9 rating scale for chest CT with contrast, or chest CT without and with contrast, or CTA or CT venography chest with contrast, it fell into Group A. Group B had topics with a maximal 7–9 rating scale for chest CT without contrast and it was strongly recommended to perform chest CT without contrast. Among the remaining topics, if a topic had a 1–3 rating scale for all three; chest CT without contrast, chest CT with contrast, and chest CT without/with contrast, it was classified into Group D. The remaining topics, uncertainity of contrast usage for performing chest CT, belonged to Group C. ACR = American College of Radiology, CTA = CT angiography

  • Fig. 2 A representative case of group B (strongly recommended to perform chest CT without contrast) with pulmonary thromboembolism. A. A 69-year-old female was admitted for chemotherapy. The patient had a history of rectal cancer with pulmonary metastasis. She did not present with acute respiratory symptoms. There are nodular opacities in the left upper lung field on chest plain radiograph. B. She underwent chest CT for screening of pulmonary metastasis, which is the simplified ACR appropriateness criteria topic number 30 and belongs to Group B. There is a small pulmonary embolus in the right lower lobar pulmonary artery with an embolic burden score of 5 on contrast–enhanced chest CT (Group B, C). PE might have been missed if she had undergone chest CT without contrast according to the simplified ACR appropriateness criteria. ACR = American College of Radiology


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