Xavier Cortez, Tristan Raniga

Dr. Manns
BME 330 Section S
11 October 2011
Computed Tomographic Pulmonary Angiography as the main modality for diagnosing
Pulmonary Embolism
Pulmonary embolism (PE) is a serious medical condition in which a lung artery
experiences a sudden blockage. This blockage can be attributed to several causes, but most
commonly the blockage is a blood clot that originates from another part of the body. Every year,
250,000 people are hospitalized and/or die in the United States because of pulmonary embolism.
It is estimated that PE causes 5% to 10% of all deaths in hospitals and it is the third leading cause
of cardiovascular mortality1. Although PE is a very serious condition, with a prompt diagnosis it
can be successfully treated. The challenge that clinicians face is that PE remains one of the most
difficult conditions to diagnose accurately.
Over the past thirty years, ventilation-perfusion (V/Q) lung scanning has been the
preferred diagnostic choice of doctors for pulmonary embolisms (PE) 1. This method measures
the circulation of air and blood in a patients lungs. The ventilation portion calculates the airs
ability to reach all parts of the lungs, and the perfusion portion determines how well blood is able
to circulate within the lungs. The V/Q method has been used to test patients for pulmonary
embolisms, but it does not give a definite positive or negative diagnosis, but rather a percent of
being positive for PE. For example, a normal V/Q scan excludes the diagnosis of PE. A high
probability V/Q scan has an 85% to 90% predictive value, with an incidence of PE in only 25%
to 30% of patients. Most patients with suspected PE have low or intermediate V/Q scans and the
incidence of PE ranges from 10% to 40% in these patients. This diagnostic uncertainty is a major
limitation of ventilation-perfusion lung scanning1.
Within the past decade, the use of computed tomographic pulmonary angiography
(CTPA) has been used as a form of diagnosis for PE because it can give doctors a positive or
negative diagnosis for pulmonary embolism1. CTPA helps give doctors a definitive answer of
whether or not a patient is positive for PE, unlike V/Q scanning, which gives a probability of
being positive. The use of CTPA is becoming more widespread because it gives clinicians a
definitive result and it can also detect other non-thrombotic causes of patient symptoms 1. One of
the limitations of CTPA is that it exposes the patient to radiation from X-rays, whereas
ventilation-perfusion scanning does not use any form of radiation. Another limitation of CTPA is
its accuracy in diagnosing small peripheral emboli 3. As a result, CTPA has not gained unanimous
acceptance as the reference standard for imaging PE.
It is difficult to say whether CTPA is better than V/Q scanning. In recent studies, it has
been shown that CTPA is at least as effective as V/Q scans in ruling out PE and actually
diagnoses more pulmonary embolisms than V/Q scanning. Despite this, V/Q scanning should
still play a role in the investigation of PE. A normal V/Q scan essentially excludes the diagnosis
of PE. A nondiagnostic V/Q scan in combination with negative venous ultrasonographic results
also excludes PE. Because of exposure to radiation and other adverse effects, the use of CTPA
should be limited only to patients who have a nondiagnostic V/Q scan result and a high clinical
likelihood for pulmonary embolism.

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References
Anderson, David R., Susan R. Kahn, et al. "Tomographic Pulmonary Angiography vs
Ventilation-Perfusion Lung Scanning in Patients With Suspected Pulmonary Embolism."
The Journal of the American Medical Association 298.23 (2007): 2743-753. Web.
<http://jama.ama-assn.org/content/298/23/2743.full.pdf+html>.
Donato, Anthony A., Swapnil Khoche, Joseph Santora, and Brent Wagner. "Clinical
Outcomes in Patients with Isolated Subsegmental Pulmonary Emboli Diagnosed by
Multidetector CT Pulmonary Angiography." Thrombosis Research 126.4 (2010): E266270. Print.
Schoepf, U. J., and P. Costello. "CT Angiography for Diagnosis of Pulmonary Embolism:
State of the Art." Radiology 230.2 (2004): 329-37. Print.
Venkatesh, S. K. (2011), CT pulmonary angiography for pulmonary embolism: role
beyond diagnosis?. International Journal of Clinical Practice, 65: iiiv. doi:
10.1111/j.1742-1241.2011.02660.x