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CORSO DI CLINICAL COMPETENCE SULLA MALATTIA TOMBROEMBOLICA VENOSA Firenze 4-5 Novembre 2010 DALLA TROMBOSI VENOSA ALL EMBOLIA ALL IPERTENSIONE POLMONARE.

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Presentation on theme: "CORSO DI CLINICAL COMPETENCE SULLA MALATTIA TOMBROEMBOLICA VENOSA Firenze 4-5 Novembre 2010 DALLA TROMBOSI VENOSA ALL EMBOLIA ALL IPERTENSIONE POLMONARE."— Presentation transcript:

1 CORSO DI CLINICAL COMPETENCE SULLA MALATTIA TOMBROEMBOLICA VENOSA Firenze 4-5 Novembre 2010 DALLA TROMBOSI VENOSA ALL EMBOLIA ALL IPERTENSIONE POLMONARE C. Marini, Dipartimento Cardio-Toracico e Vascolare Università di Pisa, e Fondazione CNR/Regione Toscana Gabriele Monasterio, Pisa. Scintigrafia polmonare

2 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 techniques 1,2. 1.Williams JR, et al. JAMA 1963;184:473-476 2.Wagner HN Jr, et al. N Engl J Med 1964;271:377-384

3 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 PE 1. 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 techniques 2. 1. Dalen JE, et al. Am Heart J 1971;81:175-185 2. McNeal BJ, et al. JAMA 1974;227:753-756

4 Rapporto ventilazione/perfusione nella embolia 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, ODoherty 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.

5 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 diagnosis 1. In other words, the PE diagnosis was still a problem, and the use of V/Q lung scan did not increase the diagnostic capability 2. 1.Goldhaber SZ, et al. Am J Med 1982;73:822-826 2.Hull RD, et al. Chest 1985;88:819-828

6 The PIOPED study Prospective 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.

7 The PISAPED study Prospective 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.

8 1 2 3 4 5 6 9 8 7 Right lung apex 1 2 3 6 7 89 4 5 Left lung apex Normal pulmonary angiographyNormal lung scan base Anterior Right artery lateral view Left artery lateral view Left oblique posterior view apex Anterior base apex Anterior Left oblique posterior view

9 Acute pulmonary embolism Left pulmonary artery angiogram (anterior-posterior view) Left lung perfusion scan (left lateral view) 2 1 3 4 5 6 7 8 9 Anterior Base Apex

10 apex 3 6 7 8 2 3 8 7 2 1 2 3 4 5 6 9 8 7 1 2 3 6 7 89 4 5 base apex base Normal lung scan Lung scan with wedge-shaped defects [PE +] Lung scan without wedge-shaped defects [PE -] Right lung Anterior base Left lung base Anterior base Right oblique posterior Left oblique posterior Anterior 1 4 5 6 9 1 4 5

11 PIOPED versus PISA-PED V/Q scan High probability (PIOPED) Q scan suggestive of PE (PISA-PED) Sensitivity (%) 4186 Specificity (%) 9793

12 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 parenchimali in 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%), elevazione diaframma in 185/440 pz. (42%) e versamento pleurico in 198/440 pz. (45%).

13 sensitivity specificity The PIOPED study PIOPED 83% 96% PISAPED 86% 93%

14 Radiation burden for commonly used imaging techniques TechniqueDose(mSv)Equivalent no. of chest radiographs Ultrasonography00 Chest radiography0.021 Lung scintigraphy150 Spiral CTPA7350

15 Costs of imaging techniques for pulmonary embolism TechniqueCost (Euros) Ultrasonography72 Chest radiography21 Lung scintigraphy (Q)68 Lung scintigraphy (V)198 Spiral CTPA206

16 Miniati M. et al. Medicine (Baltimore) 2006;85(5):253-262 Follow-up scintigrafico ed emogasanalitico in pazienti con APE

17 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 studies 1,2 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 alone 2. 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

18 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

19 Consolidation (infarction) Consolidation (no infarction)

20 Oblique posteriori destre Oblique posteriori sinistre giugulo base giugulo base giugulo base giugulo base giugulo base giugulo base Scan NormaleScan di EPScan di non EP

21 Radiation burden for commonly used imaging techniques TechniqueDose(mSv)Equivalent no. of chest radiographs Ultrasonography00 Chest radiography0.021 Lung scintigraphy150 Spiral CTPA7350

22 Costs of imaging techniques for pulmonary embolism TechniqueCost (Euros) Ultrasonography72 Chest radiography21 Lung scintigraphy (Q)68 Lung scintigraphy (V)198 Spiral CTPA206

23 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

24 Clinical probability combined with CTA results (PIOPED, 477 patients) Clinical probabilityCTAPE/No. of pts% High+22/2396 Intermediate+93/10192 Low+22/3858 High-6/1540 Intermediate-15/13611 Low-6/1644 189/477 = 40% need further investigation to reach diagnosis

25 Pisa Model 2. AUC: 0.88 Miniati M, et al. Am J Respir Crit Care Med 2008;178:290-294

26 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

27 Angiografia polmonare con Stop Flow

28 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 studies 1,2 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 alone 2. 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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