Helical CT has replaced the ventilation/perfusion scan ([V with dot above]/[Q with dot above] scan) as the study of choice in many hospitals for PE evaluation
4 because of the speed of the study and the ability to concurrently evaluate potential embolic sources in the legs or pelvis. The results of studies that have evaluated the helical CT have shown sensitivities up to 90% with single detector CT scans.
8 Multidetector row CT scans have an increased sensitivity for subsegmental PE
9 but, in postoperative patients, should still be used in conjunction with pretest probability and ultrasonography of the lower extremities.
10
The PIOPED II investigators have recently investigated the use of clinical pretest probability in conjunction with either CT angiogram or combined CT angiogram and CT venography.
11 These investigators concluded that the CT angiogram combined with CT venography has a higher sensitivity for venous thromboembolism (VTE). In addition, the pretest probability should still be used in the diagnostic algorithm for PE. The PIOPED II investigators did note that a negative CT angiogram does not rule out a subsegmental PE; studies suggest that it is safe to withhold anticoagulation in patients with low or intermediate pretest probability.
9,
12 The PIOPED pretest probability is based on the Wells criteria, which uses a scoring system based on signs and symptoms that include DVT, tachycardia, immobilization, and recent surgery among others.
7 All postsurgical patients would then, by definition, be considered at least intermediate pretest probability, and thus a physician’s global judgement should be used in the postsurgical patient. For diagnosing a PE with a CT scan (see
Fig. 13.1), a pretest probability is assessed, and only patients with a high pretest probability and a negative CT scan should have compression ultrasonography of the lower extremities to rule out VTE.