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CORSO DI CLINICAL COMPETENCE SULLA MALATTIA TOMBROEMBOLICA VENOSA
Firenze 4-5 Novembre 2010
DALLA TROMBOSI VENOSA ALL’ EMBOLIAALL’ IPERTENSIONE POLMONARE
C. Marini, Dipartimento Cardio-Toracico e VascolareUniversità di Pisa, e Fondazione CNR/Regione Toscana“Gabriele Monasterio”, Pisa.
“Scintigrafia polmonare”
Background. 1
“Prior to 1960, physician diagnosed pulmonary
embolism (PE) by the identification of a
suspicious combination of symptoms, signs,
and non-specific laboratory tests.
After 1960, the diagnostic capabilities were
enriched by the development of angiographic
and radionuclide pulmonary imaging
techniques1,2.”
1. Williams JR, et al. JAMA 1963;184:473-4762. Wagner HN Jr, et al. N Engl J Med 1964;271:377-384
Background. 2“Although invasive, angiography became a “gold
standard” for a validation of any other technique in the
diagnosis of PE, even though it was reported that a
normal perfusion lung scan essentially excludes the
presence of PE1.
In the mid ‘70s, due to some limitations of pulmonary
angiography, ventilation scan (V) was added to
perfusion lung scan (Q) to increase diagnostic
capability for PE by non-invasive techniques2.”
1. Dalen JE, et al. Am Heart J 1971;81:175-1852. McNeal BJ, et al. JAMA 1974;227:753-756
Rapporto ventilazione/perfusione nellaembolia polmonare acuta (EPA)
1. De Nardo GL, Goodwin DA, Ravasini R, Dietrich PA. The ventilatory lung scan in the diagnosis of pulmonary embolism. N Engl J Med 1970; 282: 1334-6.
2. 2. McNeil BJ, Holman BL, Adelstein SJ. The scintigraphic definition of pulmonary embolism. JAMA 1974; 227: 753-6.
3. Miller RF, O’Doherty MJ. Pulmonary nuclear medicine. Eur J Nucl Med 1992;19:355-368.
La strategia diagnostica era basata sulla aspettativa (teorica) dei rapporti ventilazione/perfusione (V/Q) : -Ventilazione normale nelle zone con alterata perfusione (V/Q mismatch) 1,2 : EPA;-Ventilazione alterata nelle zone con alterata perfusione (V/Q match) 3: no EPA .
Background. 3
“Despite the availability of this new diagnostic tool
(V/Q lung scan), a retrospective clinical pathologic
correlative study published in the early ‘80s indicated
a frequency of only 10% of in vita successful PE
diagnosis1.
In other words, the PE diagnosis was still a problem,
and the use of V/Q lung scan did not increase the
diagnostic capability2.”
1. Goldhaber SZ, et al. Am J Med 1982;73:822-8262. Hull RD, et al. Chest 1985;88:819-828
The PIOPED studyProspective Investigation of Pulmonary Embolism Diagnosis( JAMA 1990;263:2753-2759)
Aim. To determine the sensitivity and specificity of ventilation-perfusion (V/Q) lung scan for acute pulmonary embolism (PE).
Methods. To evaluate, in patients with established angiographic diagnosis, the presence and % dimention of at least two or more perfusion defects with or without matching ventilation or chest radiographic abnormalities.
Results. V/Q lung scan: sensitivity 41%, specificity 97%.
Conclusion. V/Q lung scan established the diagnosis or exclusion of PE only for a minority of patients.
The PISAPED studyProspective Investigation Study of Acute Pulmonary Embolism Diagnosis.
(Miniati M, Pistolesi M, Marini C, et al. Am J Respir Crit Care Med1996;154:1387-1393)
Aim. To assess the value of perfusion lung scan (PLS) alone in the diagnosis of acute pulmonary embolism.
Methods. To detect on PLS the presence (PE+) or the absence (PE-) of at least one of wedge-shaped perfusion defect with or without matching roentgenographic lung parenchimal abnormalities in patients with established angiographic diagnosis.
Results. PLS alone: sensitivity 86%, specificity 93%.
Conclusion. Accurate diagnosis of PE is possible by PLS alone.
12
3
4
56
98
7
Right lung
apex
12
3
6
78 9
4
5
Left lung
apex
Normal pulmonary angiographyNormal lung scan
base
base
Anterior
Anterior
Right arterylateral view
Left arterylateral view
Left oblique posterior view
apex
Anterior
base
base
apex
Anterior
Left oblique posterior view
Acute pulmonary embolism
Left pulmonary artery angiogram(anterior-posterior view)
Left lung perfusion scan(left lateral view)
2
1
3
4
56
78 9
Anterior
Base
Apex
apex
apex
3
6
78
23
87
2
12
3
4
56
98
7
apex
12
3
6
78 9
4
5
apex
apex
base
apex
base
Normal lung scan Lung scan withwedge-shaped defects
[PE +]
Lung scan withoutwedge-shaped defects
[PE -] Right lung
Anterior
base base
Left lung
base
Anterior
base
Right oblique posterior
Left oblique posterior
Anterior
Anterior Anterior
1
4
56
9
1
4
5
Anterior
PIOPED versus PISA-PEDV/Q scan
High probability(PIOPED)
Q scansuggestive of PE
(PISA-PED)
Sensitivity (%) 41 86
Specificity (%) 97 93
Alterazioni radiografiche in PIOPED e PISAPED
* Worsley DF, et al. Radiology 1993;189:133-6
PIOPED: JAMA 1990;263:2753 1063 pazienti; 88% con alterazioni Rx toraciche*.Nelle embolie, atelettasie e densità parenchimaliin 99/219 pz. (45%) a dx e 93/183 pz. (51%) a sn.
PISA-PED: Am J Respir Crit Care Med 1996;154:1387 1100 pazienti; nelle embolie, infarti in 74/440 pz. (17%), atelettasie in 123/440 pz. (28%), elevazionediaframma in 185/440 pz. (42%) e versamento pleurico in 198/440 pz. (45%).
sensitivity
specificity
The PIOPED study
PIOPED
83%
96%
PISAPED
86%
93%
Radiation burden for commonly used imaging
techniques
Technique Dose(mSv) Equivalent no. of chest radiographs
Ultrasonography 0 0
Chest radiography 0.02 1
Lung scintigraphy 1 50
Spiral CTPA 7 350
Costs of imaging techniques for pulmonary
embolismTechnique Cost (Euros)
Ultrasonography 72
Chest radiography 21
Lung scintigraphy (Q) 68
Lung scintigraphy (V) 198
Spiral CTPA 206
Miniati M. et al. Medicine (Baltimore) 2006;85(5):253-262
Follow-up scintigrafico ed emogasanalitico in pazienti con APE
Management of suspected acute pulmonary embolism in the era of CTAngiography: A statement from the Fleischner Society.
Remy-Jardin M, et al. Radiology 2007;245:315-329
“If scintigraphy is used, elimination of the ventilation scan can reduce
cost and radiation. Although this is not common practice in most
centers, there is evidence from two studies1,2 that ventilation scan
can be eliminated without compromising diagnostic accuracy……
In addition, better sensitivity was achieved when the scans of the
PIOPED I study were reread by a blinder observer using the
perfusion images alone2.
Accordingly, scintigraphy can be considered as a preferred altenative
chest imaging technique for patients who cannot undergo
CTAngiography.”
1. Stein PD, et al. Am J Cardiol 1992;69:1239-1241
2. Miniati M, et al. Am J Respir Crit Care Med 1996;154:1387-1393
CONCLUSIONE
La scintigrafia polmonare da perfusione da sola nella diagnosi di embolia polmonare acuta:
VANTAGGI:- alta accuratezza diagnostica;- bassa esposizione radiante;- basso costo;- facile da ottenere;- facile da leggere;- innocua per il paziente;- utile per il monitoraggio del paziente .
LIMITI:- Nessuno
Consolidation(infarction)
Consolidation(no infarction)
Oblique posteriori destre
Oblique posteriori sinistre
giugulo
base
giugulo
base
giugulo
base
giugulo
base
giugulo
base
giugulo
base
Scan Normale Scan di EP Scan di non EP
Radiation burden for commonly used imaging techniques
Technique Dose(mSv) Equivalent no. of chest radiographs
Ultrasonography 0 0
Chest radiography 0.02 1
Lung scintigraphy 1 50
Spiral CTPA 7 350
Costs of imaging techniques for pulmonary embolism
Technique Cost (Euros)
Ultrasonography 72
Chest radiography 21
Lung scintigraphy (Q) 68
Lung scintigraphy (V) 198
Spiral CTPA 206
Expected versus observed PE (583 patients)
12/1872PE-Low
108/8113PE-Intermediate
7115/2158PE-High
5910/1758PE+Low
9259/6493PE+Intermediate
99212/21399PE+High
(%)PE /no. ptsExpected PE (%)ScanClinical probability
Miniati et al: Am J Respir Crit Care Med 1999
119/583 = 20% need further investigation to reach diagnosis
Clinical probability combined with CTA results (PIOPED , 477 patients)
Clinical probability CTA PE/No. of pts %
High + 22/23 96
Intermediate + 93/101 92
Low + 22/38 58
High - 6/15 40
Intermediate - 15/136 11
Low - 6/164 4
189/477 = 40% need further investigation to reach diagnosis
Predictors of pulmonary embolism
-2
-1,5
-1
-0,5
0
0,5
1
1,5
2
Ag
e 5
7-6
7 y
Ag
e 6
8-7
4 y
Ag
e 7
5-9
4 y
Ma
le s
ex
His
tory
of
DV
T
Imm
ob
iliza
tio
n
Prio
r ca
rdia
c d
ise
ase
Prio
r p
ulm
on
ary
dis
ea
se
Su
dd
en
dys
pn
ea
Ort
ho
pn
ea
Ch
est
pa
in
He
mo
pty
sis
Syn
cop
e
Leg
sw
elli
ng
(u
nila
tera
l)
Hig
h f
eve
r
Cra
ckle
s
Wh
ee
zes
Acu
te c
or
pu
lmo
na
le
Coeffi
cient
Pisa Model 2. AUC: 0.88
Miniati M, et al. Am J Respir Crit Care Med 2008;178:290-294
Le Gal, et al. Ann Intern Med 2006;144:165
Wells PS, et al.Thromb Haemost 2000;83:413
Clinical models: predictors of PE
AUC: 0.78 AUC: 0.74
Angiografia polmonare con “Stop Flow”
Management of suspected acute pulmonary embolism in the era of CTAngiography: A statement from the Fleischner Society.
Remy-Jardin M, et al. Radiology 2007;245:315-329
“If scintigraphy is used, elimination of the ventilation scan can reduce
cost and radiation. Although this is not common practice in most
centers, there is evidence from two studies1,2 that ventilation scan
can be eliminated without compromising diagnostic accuracy……
In addition, better sensitivity was achieved when the scans of the
PIOPED I study were reread by a blinder observer using the
perfusion images alone2.
Accordingly, scintigraphy can be considered as a preferred altenative
chest imaging technique for patients who cannot undergo
CTAngiography.”
1. Stein PD, et al. Am J Cardiol 1992;69:1239-1241
2. Miniati M, et al. Am J Respir Crit Care Med 1996;154:1387-1393
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