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Matthew D. Cham, MD
David F. Yankelevitz, MD
Claudia I. Henschke, PhD,
Published online
Radiology 2005; 234:591–594

Thromboembolic Disease
Detection at Indirect CT
Venography versus CT
Pulmonary Angiography1

DVT deep venous thrombosis

From the Department of Radiology,
Strong Memorial Hospital–University
of Rochester School of Medicine and
Dentistry, 620 Park Ave, PMB 244,
Rochester, NY 14607 (M.D.C.); and
Department of Radiology, New York
Presbyterian Hospital–Weill Medical
College at Cornell University, New
York, NY (D.F.Y., C.I.H.). From the
2002 RSNA Annual Meeting. Received
December 9, 2002; revision requested
February 6, 2003; final revision received
April 12, 2004; accepted April 28. Address correspondence to M.D.C.
(e-mail: matthew_cham@urmc.rochester
Authors stated no financial relationship to disclose.

PURPOSE: To assess the incremental increase in thromboembolic disease detection
at indirect computed tomographic (CT) venography versus CT pulmonary angiography and to determine the importance of scan interval for indirect CT venography
on the basis of thrombus length.
MATERIALS AND METHODS: Institutional review board approval was obtained,
and informed consent was not required. The study included 1590 consecutive
patients undergoing CT pulmonary angiography for the suspicion of pulmonary
embolism. Two minutes after completion of pulmonary angiography, a contiguous
indirect CT venography was performed from the iliac crest to the popliteal fossa. The
presence of pulmonary embolism or deep venous thrombosis (DVT) was recorded
for all patients. The lengths of all deep venous thrombi found in the first 378
consecutive patients were recorded.
RESULTS: Pulmonary embolism was detected in 243 (15%) of 1590 patients at CT
pulmonary angiography, and DVT was detected in 148 (9%) patients at indirect CT
venography. Among 148 patients with DVT, pulmonary embolism was detected in
100 patients at CT pulmonary angiography. Thus, the addition of indirect CT
venography to CT pulmonary angiography resulted in a 20% incremental increase
in thromboembolic disease detection compared with that at CT pulmonary angiography alone (99% confidence interval: 17%, 23%). Among the 378 patients, DVT
was present in 33 patients at indirect CT venography. Two (6%) of 33 patients had
clots measuring 2 cm or less, six (18%) had clots measuring 3– 4 cm, and 25 (76%)
had clots measuring more than 4 cm in length.
CONCLUSION: The addition of indirect CT venography to CT pulmonary angiography incrementally increases the detection rate of thromboembolic disease by
20%. Performance of indirect CT venography by using contiguous section intervals,
with a section width of 1 cm, is recommended to accurately detect DVT.

Author contributions:
Guarantors of integrity of entire study,
D.F.Y., M.D.C., C.I.H.; study concepts
and design, D.F.Y., C.I.H.; literature
research, M.D.C., D.F.Y., C.I.H.; clinical studies, D.F.Y., M.D.C.; data acquisition, M.D.C., D.F.Y.; data analysis/
interpretation, M.D.C., D.F.Y., C.I.H.;
statistical analysis, C.I.H., M.D.C.,
D.F.Y.; manuscript preparation, definition of intellectual content, editing, revision/review, and final version approval, M.D.C., D.F.Y., C.I.H.
RSNA, 2005

RSNA, 2005

Pulmonary embolism is a life-threatening disease that affects between 40 000 and 200 000
patients annually in the United States alone (1–3). Pulmonary embolism is a well-recognized sequela of deep venous thrombosis (DVT) of the lower extremities (4,5). Findings of
studies have shown that inadequately treated DVT is associated with recurrent pulmonary
embolism (6 – 8). To accurately diagnose thromboembolic disease in patients suspected of
having pulmonary embolism, several investigators have developed helical computed tomographic (CT) protocols that depict both pulmonary embolism and lower extremity DVT
(9,10). This technique has been referred to as combined CT pulmonary angiography and
indirect CT venography.
Indirect CT venography allows examination of the pelvis and lower extremities by using
only the contrast material already in circulation from the preceding CT pulmonary
angiography, thus obviating additional contrast material, which is associated with both
traditional and direct CT venography (9,10).
The addition of indirect CT venography to the standard CT pulmonary angiographic

protocol requires only an additional

1999. wh venography on the basis of thrombus length. Patients who could not complete the study because of known allergic reactions. or renal insufficiency without hemodialysis were excluded from the study.minutes to perform. All patients were referred to the New York Presbyterian-Hospital–Weill Medical College at Cornell University because of the clinical suspicion of pulmonary embolism. The widespread use of this examination has been further supported by studies in which a moderately good interobserver agreement. 64 years.10). Patients The purpose of this study wa Our study included 1590 consecutive s to assess the incremental increase in thr patients who had undergone combined CT pulmonary angiography and indirect CT omboemvenography between June 2. like CT pulmonary angiography. Of 1590 patients (age range. 61 years) and 883 (56%) were women (median age. Authors of a doubleblinded prospective study involving 70 consecutive patients undergoing both lower extremity sonography and combined CT pulmonary angiography and indirect CT venography reported a sensitivity and specificity of 100% and 97 %. inadequate intravenous access. We previously evaluated t he former and found that the 2-minute delay following CT pulmonary angiography produced near maximum opacification in the majority of patients (11). indirect CT venography also has the potential to provide alternative nonvascular diagnoses for the patient’s clinical pre sentation (15–17). it is necessary to consider two important pa rameters: the time delay prior to initiatin g indirect CT venography and the sectio n intervals.17. A . 5-cm) section intervals would potenbolic disease detection at indirect CT tially miss small thrombi. Imaging Our imaging protocol was the standard hospital protocol used for routine clinical care. mean age. and a low radiation risk were r eported (18 –21). 62 years). increasing the section giography and to determine the importance of scan interval for indirect CT interval reduces radiation exposure. and October 31. Because no additional contrast agent was necessary to perform indirect CT venography. We also recorded whether these 378 patients and an additional 1212 consecutive patients had positive findings for pulmonary embolism or DVT at combined CT pulmonary angiography and indirect CT venography.14). Consideration o f the latter necessitates obtaining infor ma- tion about thrombi length. 18–99 years). A total of 1324 (83%) patients were from the inpatient setting. mean age. From June 2. ich is currently slightly lower than tha MATERIALS AND METHODS t of a standard pelvic CT (21). 64 years. On venography versus CT pulmonary anthe other hand. for a total of 1590 patients. All studies were ordered by physicians as clinically indicated and were not influenced by the study protocol. 2001. a consi stently high level of venous enhancement. respectively. without modifications. potentially obviating a separate lower extremity examination that can further delay the tur naround time of results (9.22). we compared indirect CT venography with lower extremity sonography in 116 patients and found a disagreemen t rate of only 3% (11). b ecause long (ie. we documented the lengths of deep venous thrombi in 378 consecutive patients. all patients with a serum creatinine level of less than 1. All patients underwent combined CT pulmonary angiography and indirect CT venography. to June 27. while 266 (17%) were from the emergency department and outpatient setting. In our prior study. Authors of several large prospecti ve multicenter studies have found that the addition of indirect CT venography to the basic CT pulmonary angiographi c protocol increased the diagnosis of thromboembolic disease by 15%–38% (11. From a technical standpoint. Authors of other nonrandomized retrospective studies have reported sensi tivities of 71%–94% and specificities o f 93%–94% for indirect CT venography (13. for indirect CT venography (12). Several investigators have also note d that. 707 (44%) were men (median age. Another consideration in the increasingly common use of combined CT pu lmonary angiography and indirect CT venography is the optimization of the indirect CT venographic portion of the examination. Informed consent was not required by our institutional review board. 1998.5 mg/dL (133 mol/L) were eligible to undergo combined CT pulmonary angiography and indirect CT venography. 1998. Institutional review board approval was obtained for the study (IRB# 0699–746). patient identifiers were deleted.

F. Princeton. NJ) was injected at a rate of 3 mL/sec. GE Medical Systems. The 99% confidence interval for only one transverse image demonstrated this incremental increase was calculated by a filling defect. Because a A typical example of a deep venous thrombus section width of 10 mm was used for at indirect CT venography is shown in Figure indirect CT venography. Among the first 378 consecutive patients. Images were obtained from the diaphragm to the aortic arch. Among 33 patients with DVT at indirect CT venography. not be diagnosed. Indirect CT venography was evaluated by using standard 10-mmthick nonoverlapping images. 43 (3%) had DVT in the absence of pulmonary embolism.). Thrombus length was measured by counting the number of RESULTS consecutive images on which the deep venous thrombus was visible. Bar graph illu strates the relative frequency of thrombi of various lengths among 378 consecutive patients suspected of having pulmo nary embolism. Figure 1.6:1. with DVT in the absence of pulmonary embolism and the five (0.—Data are the numbers of patients. Indirect CT venogram of the left common femoral vein shows a deep venous thrombus (arrow).H. The parameter of interest was the increFor both CT pulmonary angiography and mental increase in detection of thromboindirect CT venography.Y. Nycomed-Amersham. resents 1 cm of the thrombus length.Findings of the examination were categorized as inconclusive when poor examination quality resulted in a nondiagnosEach study had been read by one of six tic impression. the 43 (3%) patients Results of CT Pulmonary Angiography and Indirect CT Venography CT Pulmonary Angiography Indirect CT Venography Positive for DVT Negative for DVT Inconclusive for DVT Total Positive for Pulmonary Embolism Negative for Pulmonary Embolism Inconclusive for Pulmonary Embolism Total 100 139 4 43 1263 24 5 12 0 148 (9) 1414 (89) 28 (2) 243 (15) 1330 (84) 17 (1) 1590 (100) Note. Helical CT scanning was performed (Hi-Speed Advantage CT/i. and C. and 139 (9%) had pulmonary embolism in the absence of DVT (Table). with a scan delay of 28 seconds. Reconstruction for the CT pulmonary angiographic portion was performed at 1-mm intervals. thrombi were defined as low-attenuating partial or embolic disease when combined CT pulmonary angiography and indirect CT complete intraluminal filling defects surrounded by a high-attenuating ring of venography was performed versus when enhanced blood and were seen on at least only CT pulmonary angiography was pertwo consecutive transverse images. Numbers in parentheses are percentages. each image rep1. Thus. 592 Radiology February 2005 Cham et al DVT. Scanning of the pelvis started from the iliac crest 120 seconds after completion of CT pulmonary angiography and continued to the popliteal fossa. 24% had maximum thrombus lengths of less th an 5 cm. attending chest radiologists (including D.3%) patients with DVT and nondiagnostic CT pulmonary anFigure 2. Milwaukee. with a section width of 3 mm and a pitch of 1. Wis). If formed. .I. with a section width of 10 mm and a pitch of 1:1. Image Interpretation Radiology 140 mL dose of iohexol (Omnipaque 300. Each attending radiolStatistical Analysis ogist had at least 10 years of experience. then a thrombus would using the standard approach.

agent. 148 (9%) had DVT.24). y ings at CT pulmonary angiography.18). DVT. In previous studies. or ICRP-60. there is great need to optimize its effectiveness (11) . this corre sponds to a 593 genetic risk of about 1:15 000 among pa tients in the reproductive age group undergoin g indirect CT venography (21). patients had poor boluses of the contrast consecutive sections. only one radiologist read each image common.22). with many institutions worldwide from the combined CT pulmonary angiograroutinely incorporating indirect CT venograDVT was detected at indirect CT venograph enteen (1%) patients had inconclusive find. guidelines (25).12. rect CT venography has become increasingly First. or both. while 126 (6%) had both pulmonary embolism and 3 (79%) patients had negative findings for bot h pulmonary embolism and DVT (Table).attributed to partial volume averaging. with 5-cm gaps between sections (9. Sev- Radiology giographic findings adds up to 48 patients. CT pulmonary angiograthromboembolic disease was increased by phy has become a commonly ordered exam18% with use of indirect CT venography in ination. the ris k of mortality and morbidity from thrombo embolic disease should be considered in the context of these risks. Such an underestimation of clot length would however only add sured 4 cm or less. such as leukemia and heri table genetic disease.parisons performed in this study. which is 20% of the 243 patients found to have pulmonary embolism at CT pulmonary angiography. As indirect CT venography becomes increasingly used at more institutions. Rademaker et al (21) measured patient gonadal doses on the order of 2.22). There are several stochastic effects that may arise from irradiation of the pelvis during indirect C T venography. where the detection rate of Over the past years. 23%).phy and indirect CT venography.(2%) patients had inconclusive findings at in. The use of discontinuous sections can reduce the in tegral dose by as much as 80% but h as the potential to decrease specificity owing t o in- . Findings of 282 (18%) had positive findings for pulmo. Our current results lend has replaced ventilation-perfusion scanning further support to the consistent diagnostic as the initial examination in the work-up of yield that can be expected from indirect CT pulmonary embolism (23. while six had lower extremity prosthe. tients.1–10.our criterion for thrombus diagnosis requires tiguous sections in 21 patients. 100 published prospective studies in which indinary embolism. and two CT venography. This genetic r isk does not exist for the majority of pa tients undergoing indirect CT venography who. this increase in gonadal dose is well below the thresholds for deterministic radia tion effects provided in the International C ommission on Radiological Protection Public ation 60.22). The addition of indirect CT venography to CT pulmonary angiography resulted in a 20% incremental increase in the detection rate of thromboembolic disease (99% confidence interval: that resulted in nondiagnostic indirect CT there is potential for small clots of less than 1 tients. otherwise. DISCUSSION 23%) compared with CT pulmonary angiography alone. which resulted in poorly opacified ing defects seen on only one section would be tient is shown in Figure 2. Given the ICRP-60 stochasti c risk estimate of 1% per sievert. there were no standard comy Of 1590 patients. Likewise. we found that combined CT pulmonary angiography and indirect CT venography increases thromboembolic disease detection by 20% (99% confidence interval: 17%. comvenography. They found that the addition of indirect CT venography increases the gonadal radiation dose by 500. Using a com bined CT pulmonary angiographic and indirect CT venographic protocol similar to ours. This result is similar to our previous findings.phy into the CT pulmonary angiographic examination (11. In many specific clinical situations. Twenty-two of the 28 that filling defects are seen on at least two tinct thrombi were seen in 12 patients each. and 28 this replicates real-world conditions. compared with the basic CT pulmonary angiographic examination (11. Volume 234 Number 2 rect CT venography was directly compar ed with sonography have confirmed our initial findings that indirect CT venography is similar to sonography in sensitivity and specific ity (11. in 33 patients. bined CT pulmonary angiography and indiThere were several limitations in our study. indirect CT venography has been shown to increase the diagnosis of thromboembolic disease by 15%–38%. Thrombus lengths veins. intervals. possible fillThe longest thrombus length for each pa. Some investigators have suggested th e use of discontinuous transverse sections. Fortunately. ranged from 2 to 81 cm. are older than 60 years. However.5 mSv for indirect CT venography. a thrombus was seen on con. especially for patients in the reproductive age group. Third.nary embolism. onl CT pulmonary angiography. In eight (24%) pa. The radiation dose to the pelvis and gonads is an important consideration when perform ing indirect CT venography. 243 (15%) had pulmo.7 mSv. the maximum thrombus lengths mea venographic studies. the risk of radi ation-related death from leukemia is on the or der of 1:8000 (21). In four of the 28 pa cm to be undiagnosed. it 541 patients (11). Given the ICRP-60 stoch astic risk estimate of 5% per sievert and a ca lculated effective dose of about 2. on average.17. In this study. Like all other forms of x-ray–based 2000-fold compared with CT Thromboembolic Disease Detection pulmonary angiography alone. Second. with variation between individuals and sex. Thus. pulmonary embolism was detected at credence to the need for contiguous section Among the 1590 patients enrolled.21.

et al. The lengths of deep vein thrombi among w and there are subtle differences in the atten patients suspected of having pulmonary embolism strongly favor the use of contiguous uation distribution. This approach is used routinely in th quency of isolated pelvic DVT is relativel y e interpretation of CT pulmonary angiographic uncommon. Most multi–detector row CT scanners are now equipped with dose-reducing applications that automatically modulate the tube current in the z-. N Engl J Med 1982. 11. 2. will adversely affect the detection of thromboembolic disease. In the future. this technology can reduce radiation dose by as much as 50%. Hull R. Adjusted subcutaneous heparin versus warfarin sodium in the long-term treatment of venous thrombosis. 307:1676–1681. Goldberg RJ. Landefeld CS. Different intensities of oral anticoagulant therapy in the treatment of proximal-vein thrombosis. Pulmonary embolism.Even in the absence of interpretive pitfalls. tle filling defect persists on more than o Some investigators have found that the fre ne image. et al. 9. AJR Am J Roentgenol 2000. Am Rev Respir Dis 1990. et al. Sanders GD. 155:1031–1037. r Several new technologies have the potena definitive diagnosis. Since contraf missing the thrombi that measure less than st enhancement in the legs can be relatively lo 5 cm. 10. x-. Shah A. 4. Jay R. 151:933–938. where it is often necessary to identi positive for DVT (22. Beyth RJ. et al. Garber AM.27). or y-axis. Warfarin sodium versus low-dose heparin in the longterm treatment of venous thrombosis. A population-based perspective of the hospital incidence and case fatality rates of deep veno us thrombosis and pulmonary embolism: the Worcester DVT study. 141:235–249. Ray CE. Thus. Yankelevitz DF. Arch Intern Med 1995. N Engl J Med 1982. 306:189–194.28). at the expense of a slightly increased noise. Hull R. Delmore T. Shaham D. et al. 3. Ann Intern Med 1999. Gould MK. clinical studies will be needed to determine whether a small reduction in radiation dose. Goldhaber SZ. verse plane and are thus prone to partial volour current data suggest that use of a 5-cm scan interval would result in a 40% chance o ume artifacts that mimic a clot. Dembitzer AD. Loud PA. 301:855–858.26. Genton E. 170:951–954. 174:67–69. Moser KM. N Engl J Med 1979. 6. Arch Intern Med 1991. Noncontiguous section intervals can adversely affect the interpretation of images along the iliac an d popliteal veins that run oblique to the trans. Anderson FA Jr. it is useful to see if a sub indirect CT venography for the pelvis and lower extremities. Indirect CT venography in the detection of . 5. Depending on patient’s body habitus. Cohen AM. AJR Am J Roentgenol 1998. comprising 1%–4% of all cases studies. another possible imaging option would be to scan only fy a clot on two or more consecutive images fo the legs in patients who are in the reproductive age group. tial to decrease the radiation dose during combined CT pulmonary angiography and indirect CT venography. 130:789–799. 7. N Engl J Med 1998. Optimization of combined pulmonary CT angiography with lower extremity CT venography. 8. Gamsu G. Hirsh J. while hopefully maintaining diagnostic effectiveness. Cham MD. Grossman ZD. Carter C. Hull R. 339:93–104. Long-term outcomes of deep vein thrombosis. Wheeler B. Yankelevitz DF. Klippenstein DL. Venous thromboembolism. Low-molecular-weight heparin compared with unfractionated heparin for the treatment of acute deep venous thrombosis. Combined CT venography and pulmonary angiography: a new diagnostic technique for suspected thromboembolic disease. et al.terpretive pitfalls (16. Delmore T. References 1.

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