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Combined CT Venography and Pulmonary Angiography in Suspected Thromboembolic Disease

Diagnostic Accuracy for Deep Venous Evaluation

¹ Department of Radiology, Roswell Park Cancer Institute, Elm and Carlton Sts., Buffalo, NY 14263.
² Department of Radiology, Winthrop University Hospital, 259 First St., Mineola, NY 11501.

Received March 11, 1999; accepted after revision May 20, 1999.

 
Address correspondence to P.A. Loud.

Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
OBJECTIVE. Combined CT venography and pulmonary angiography is a new diagnostic test that evaluates both pulmonary embolism and deep venous thrombosis (DVT) in a single study. Our purpose was to compare the CT venous findings with lower extremity venous sonography.

SUBJECTS AND METHODS. Seventy-one consecutive patients with suspected pulmonary embolism underwent helical CT pulmonary angiography during rapid IV infusion of contrast medium. Axial scans at 5-cm intervals from the patient's upper calves to the diaphragm were generated 3.5 min after the beginning of contrast medium injection. CT venous phase images were interpreted prospectively and compared with subsequent bilateral lower extremity venous sonography performed within 12 hr.

RESULTS. DVT was revealed by CT venous phase images in 19 patients, 12 of whom also had pulmonary embolism. CT and sonographic findings correlated exactly in the femoropopliteal deep venous system, where most pulmonary emboli originate. CT venous phase images also revealed pelvic extension of DVT in six patients and isolated vena cava thrombus in one patient.

CONCLUSION. CT venous phase imaging at the time of CT pulmonary angiography is comparable with venous sonography in the evaluation of femoropopliteal DVT. The iliac veins and vena cava, vessels poorly shown on sonography but sometimes the source of significant pulmonary emboli, are also depicted by CT venography.

Introduction

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Pulmonary embolism is not an isolated disease of the chest but a complication of preexisting venous thrombosis. All clinically applicable imaging tests for thromboembolic disease examine the pulmonary arterial system separately from the major lower body veins, so a comprehensive evaluation of both pulmonary embolism and deep venous thrombosis (DVT) requires two separate examinations (e.g., ventilation—perfusion scan, CT pulmonary angiography, or conventional pulmonary angiography for pulmonary embolism and venous sonography, venography, MR imaging, or impedance plethysmography for DVT).

We recently reported the use of combined CT venography and pulmonary angiography, a modified CT pulmonary angiography study that allows concurrent screening for subdiaphragmatic DVT [1]. Because CT pulmonary angiography is performed after a rapid antecubital IV injection of contrast medium, we reasoned that sufficient opacification of the venous system would remain after the CT pulmonary angiogram was completed to evaluate the veins of the legs, pelvis, and abdomen for DVT, without additional venipuncture or contrast medium. Such an examination is a continuous study, adding approximately 5-7 min to conventional CT pulmonary angiography, with the added expense of only one or two sheets of film. In this paper we report the findings of combined CT venography and pulmonary angiography in 71 patients and compare CT venography results with those from lower extremity venous sonography.

Subjects and Methods

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Between June 1997 and November 1998, 71 consecutive patients (37 women and 34 men; range, 28-82 years; mean age, 60 years) underwent combined CT venography and pulmonary angiography. All patients were referred for CT evaluation of clinically suspected pulmonary embolism. Patients were not screened with ventilation—perfusion scanning or venous sonography, except for two patients who were being treated for DVT diagnosed by venous sonography 4 and 19 days before CT. Exclusion criteria for the CT study included inability to achieve venous access or contraindications to iodinated contrast medium (allergy or renal insufficiency).

Patients underwent CT pulmonary angiography after antecubital IV infusion of 120 ml of iohexol (Omnipaque 350; Nycomed, Princeton, NJ) in 65 patients or iopromide (Ultravist 370; Berlex, Wayne, NJ) in six patients at a rate of 3 ml/sec. Patients were positioned supine with a folded blanket under the heels to avoid compression of the calf veins, and the feet were taped together to limit motion artifacts. The arm with the IV catheter was placed at the patient's side. A nonmetallic table extender or head holder supported the lower legs. Helical CT of the pulmonary arteries was performed on a HiSpeed Advantage system (General Electric Medical Systems, Milwaukee, WI), 20 sec after the beginning of contrast medium infusion. Three-millimeter-thick images were generated from the diaphragm to the aortic arch, during a single breath-hold, with a pitch of 1.8-2.0.

Five-millimeter-thick axial images 5 cm apart were generated from the upper calves to the diaphragm 3.5 min after the infusion began, to screen for DVT. The first 20 patients were scanned with 10-mm-thick images. No additional contrast medium was given for the venous images. Depending on the patient's height, 17-20 images were typically acquired. The total additional time compared with conventional CT pulmonary angiography (including patient positioning, scanner programming, and image acquisition) was 5-7 min. The delay of 3.5 min until venous phase imaging allowed uniform venous opacification [1].

CT studies were evaluated prospectively by one of two radiologists. Diagnostic criteria for DVT were an intravascular filling defect or localized nonenhancement of a vascular segment. Additional ancillary findings of DVT including venous expansion, wall enhancement, and perivenous edema were noticed, but they did not influence the diagnosis in any of our cases. The criterion used to exclude DVT was the absence of intraluminal venous filling defects. CT density measurements were obtained in the popliteal vein, common femoral vein, and mid inferior vena cava of each patient by centering a circular region-of-interest cursor (approximately half the diameter of the vein) within each vessel. The density within areas of venous thrombosis was also measured.

All patients underwent bilateral lower extremity venous sonography from the inguinal level to the popliteal trifurcation within 12 hr of CT venography and pulmonary angiography using standard compression and Doppler techniques [2]. Ninety percent of patients were scanned within 1 hr of the CT study. One of four radiologists experienced in venous sonography interpreted the study. The radiologist was aware of the patient's clinical status (suspicion of pulmonary embolism) but was unaware of the results of CT venography and pulmonary angiography. Sonography was considered to yield positive findings if intraluminal thrombus prevented complete collapse of a vessel during compression. Standard Doppler evaluation was also used but in no patient was a diagnosis of DVT made by Doppler examination alone.

Results of CT venous imaging were compared with bilateral lower extremity venous sonography. Sensitivity and specificity of CT venous phase imaging for DVT evaluation, compared with venous sonography, were determined.

Results

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CT venous phase imaging showed no evidence of DVT in 52 patients. Within nonthrombosed vessels we observed venous blood densities of 96 ± 21 H (mean ± SD) in the popliteal vein, 94 ± 19 H in the common femoral vein, and 99 ± 19 H in the mid inferior vena cava. No DVT was revealed by venous sonography in the femoropopliteal deep veins of patients with a negative CT venous phase (Fig. 1A, Fig. 1B, Fig. 1C). The lowest venous density in a CT venous study without evidence of DVT was 45-55 H bilaterally. This patient had a 25-cm abdominal sarcoma that compressed the inferior vena cava and presumably impaired venous return.

View larger version (0K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —31-year-old woman with chest pain and suspected pulmonary embolism. CT pulmonary angiography (not shown) failed to show abnormalities of pulmonary arteries. A, CT venous phase scan at knee level shows uniform opacification of normal popliteal veins (arrows).

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —31-year-old woman with chest pain and suspected pulmonary embolism. CT pulmonary angiography (not shown) failed to show abnormalities of pulmonary arteries. B, CT scan at inguinal level shows normal common femoral veins (arrows).

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   C, CT scan at upper abdominal level shows normal inferior vena cava (arrow).

DVT was diagnosed in 19 patients, 12 of whom also had pulmonary embolism (Fig. 2A, Fig. 2B, Fig. 2C). The mean density of venous thrombi was 31 ± 10 H. All femoropopliteal DVT imaged by CT venography was confirmed sonographically. In no patient was thrombus shown by sonography but missed by CT venous phase imaging. Sensitivity and specificity of the CT venous phase imaging for femoropopliteal DVT, as compared with venous sonography, were both 100%.

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —70-year-old woman with pulmonary embolism and bilateral deep venous thrombosis. A, Helical CT scan at mid chest shows acute emboli as filling defects in right upper lobe and left lower lobe pulmonary arteries (arrows).

View larger version (60K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —70-year-old woman with pulmonary embolism and bilateral deep venous thrombosis. B, CT scan at knee level shows deep vein thrombosis as nonenhancing areas in both popliteal veins (arrows).

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —70-year-old woman with pulmonary embolism and bilateral deep venous thrombosis. C, CT scan at inguinal level shows thrombi within both common femoral veins (arrows).

In six patients, CT venous phase images showed thrombosis involving the inferior vena cava or iliac veins. One case of isolated inferior vena cava thrombosis was shown by CT (Fig. 3A, Fig. 3B). This finding was confirmed by venacavography at the time of caval filter placement. Superior extension of femoral DVT into the pelvis and abdomen in five patients could be clearly seen on CT (Fig. 4A, Fig. 4B, Fig. 4C); thrombus extended to the external iliac vein in two patients, to the common iliac vein in two patients, and to the vena cava—above the level of a caval filter—in one patient.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3. —53-year-old woman with pulmonary embolism and isolated inferior vena cava thrombosis. CT pulmonary angiography (not shown) showed bilateral pulmonary emboli. CT venography and venous sonography (not shown) failed to show abnormalities of leg veins. A, CT scan at renal vein level shows large thrombus within inferior vena cava (arrow).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3. —53-year-old woman with pulmonary embolism and isolated inferior vena cava thrombosis. CT pulmonary angiography (not shown) showed bilateral pulmonary emboli. CT venography and venous sonography (not shown) failed to show abnormalities of leg veins. B, Inferior venacavogram performed before suprarenal caval filter placement confirms presence of caval thrombus (arrows). (Reprinted from [1])

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —69-year-old man with deep venous thrombosis extending into pelvis. CT pulmonary angiography (not shown) failed to show abnormalities. C, CT scan at lower pelvic level shows thrombus in right external iliac vein (arrow).

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —69-year-old man with deep venous thrombosis extending into pelvis. CT pulmonary angiography (not shown) failed to show abnormalities. B, CT scan at inguinal level shows thrombus in right common femoral vein (arrow).

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —69-year-old man with deep venous thrombosis extending into pelvis. CT pulmonary angiography (not shown) failed to show abnormalities. A, CT venous image at mid thigh level shows nonenhancing thrombi within duplicated right femoral veins (straight arrows) and right greater saphenous vein (curved arrow). Duplicated left femoral veins enhance normally (arrowheads).

Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
In the United States alone, pulmonary embolism and DVT account for 300,000-600,000 hospitalizations, and pulmonary embolism kills approximately 50,000 people annually [3]. Early diagnosis and treatment significantly improve survival with thromboembolism [4]. CT pulmonary angiography is being used with increasing frequency in the evaluation of suspected pulmonary thromboembolism, because it accurately shows central and segmental pulmonary emboli [5, 6, 7, 8] while providing detailed images of the chest to elucidate other causes of a patient's thoracic symptoms [9].

More than 90% of pulmonary emboli are known to arise from lower extremity DVT [10], and the primary prognostic factor for recurrent thromboembolism is residual DVT in the proximal veins [11]. Although most algorithms for work-up of pulmonary embolism begin with the pulmonary circulation (ventilation-perfusion scans or CT pulmonary angiography), a study of the leg veins frequently follows if noninvasive studies do not show pulmonary embolism [12, 13, 14]. A comprehensive screening test that evaluates the total thrombus burden may obviate additional imaging in most cases. To that end, CT venography and pulmonary angiography address thromboembolism as one disease, bundling an examination of the source (veins) and the target (pulmonary arterial tree) into a single, rapid study.

In our patient population, evaluation of the femoropopliteal veins using CT venous phase images was comparable with that of venous sonography. Although small isolated areas of thrombosis could be missed by screening CT venous images that are acquired at 5-cm intervals, no such cases were seen in our study. The abdominal and pelvic CT images screen the iliac veins and vena cava for thrombosis, an important advantage over sonography, particularly when interventions like caval filter placement are considered. If the accuracy of venous imaging after CT pulmonary angiography is confirmed in larger studies, its use could be considered whenever CT pulmonary angiography is indicated. Omission of venous phase imaging may be considered in patients who have had other recent venous studies.

The exclusion of DVT by CT venous phase imaging relies on uniformly enhanced blood filling the venous lumen. Unlike conventional venography, this technique uses the patient's circulation to deliver contrast medium to the veins of the legs. Lower levels of enhancement may be expected in patients with arterial disease that decreases blood flow to the legs or with venous obstruction that impairs blood return from the legs. Although detection of DVT relies primarily on outlining thrombus with enhanced venous blood, completely thrombosed veins generally show a thin rim of peripheral enhancement. Other investigators have postulated that this reflects increased blood flow to the vessel wall as a part of the body's normal inflammatory response to venous thrombosis [15].

CT pulmonary arterial images are not always of ideal quality. Problems with breath-holding and vascular opacification can lead to technical failures in approximately 4% of CT pulmonary angiography studies [6]. The addition of venous phase imaging allows the radiologist to obtain an excellent venous study despite a suboptimal pulmonary study. Detection of DVT will usually lead to initiation of anticoagulation therapy, and additional pulmonary arterial imaging in such cases will generally be unnecessary.

Because our study was performed at Roswell Park Cancer Institute, nearly all patients were cancer patients, a group at increased risk for both DVT and pulmonary embolism. CT venography results were not compared with those of conventional venography, the accepted gold standard for lower extremity DVT diagnosis. Venous sonography was used because it is the accepted clinical standard, with approximately 95% sensitivity and 98% specificity for the diagnosis of DVT in the femoropopliteal veins, where most pulmonary emboli originate [16]. Only one of six cases of iliac vein-vena cava thrombosis detected by CT was confirmed with another imaging study (venacavography). The other cases clearly represented contiguous superior extension of sonographically confirmed femoral vein thrombosis. The CT findings of pelvic DVT are well known, having been first described by Zerhouni et al. [15] in 1980.

In conclusion, our findings indicate that CT venous phase imaging at the time of CT pulmonary angiography can be used to effectively screen the femoropopliteal deep venous system for DVT. CT venous phase images also show the iliac veins and vena cava, vessels that are not well shown on sonography but that can be the source of significant pulmonary emboli. This combination of CT venography and pulmonary angiography creates a unique, comprehensive baseline study for thromboembolism, because the patient's overall thrombus burden is defined in a single, rapid examination. If further studies confirm our results, this combined imaging approach may play an important role in diagnostic evaluation of suspected thromboembolic disease.

References

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