Radiologie up2date 2016; 16(03): 211-227
DOI: 10.1055/s-0042-112445
Pulmonale und kardiovaskuläre Radiologie
© Georg Thieme Verlag KG Stuttgart · New York

Lungenarterienembolie

Pulmonary embolism
S. Sudarski
,
T. Henzler
Further Information

Publication History

Publication Date:
14 September 2016 (online)

Zusammenfassung

Eine Lungenarterienembolie (LE) erfordert einen schnellen Diagnosealgorithmus, da sie unbehandelt mit einer hohen Morbidität und Mortalität einhergeht. Für das diagnostische Vorgehen sind die initiale klinische Wahrscheinlichkeit einer LE und das individuelle Risikoprofil des Patienten entscheidend. Ziel ist es, so schnell wie möglich eine Therapie einzuleiten oder eine LE zuverlässig auszuschließen. Die Computertomografie der Pulmonalarterien (CTPA) mit Mehrzeilen-CT-Systemen ist der Goldstandard im diagnostischen Vorgehen. Darüber hinaus kann die CTPA weitere relevante Informationen liefern, z. B., ob eine Rechtsherzbelastung vorliegt. Es gibt eine ganze Reihe von Scan- und Kontrastmittelprotokollen, mit denen das Ziel einer diagnostischen CTPA mit suffizientem Kontrastmittelenhancement in den Pulmonalarterien unter Vermeidung von Artefakten erreicht werden kann. Dieser Übersichtsartikel stellt eine praktische Handlungshilfe dar, um einen Patienten mit Verdacht auf LE leitliniengerecht radiologisch zu untersuchen.

Abstract

Pulmonary embolism (PE) requires a quick diagnostic algorithm, as the untreated disease has a high mortality and morbidity. Crucial for the diagnostic assessment chosen is the initial clinical likelihood of PE and the individual risk profile of the patient. The overall goal is to diagnose or rule out PE as quickly and safely as possible or to initiate timely treatment if necessary. CT angiography of the pulmonary arteries (CTPA) with multi-slice CT scanner systems presents the actual diagnostic reference standard. With CTPA further important diagnoses can be made, like presence of right ventricular dysfunction. There are different scan and contrast application protocols that can be applied in order to gain diagnostic examinations with sufficient contrast material enhancement in the pulmonary arteries while avoiding all kinds of artifacts. This review article is meant to be a practical guide to examine patients with suspected PE according to the actual guidelines.

Kernaussagen
  • Die CTPA ist der Goldstandard der nicht invasiven Diagnostik der LE und liefert wichtige Zusatzinformationen wie das Vorliegen einer Rechtsherzbelastung.

  • Die Revisionen der ESC-Leitlinien stärken im Vergleich von 2008 zu 2014 die Position der CTPA im Diagnosealgorithmus weiter.

  • Niedrigere kV-Werte sind bei der CTPA im Hinblick auf eine geringere Strahlenbelastung und ein stärkeres Kontrastmittelenhancement zu bevorzugen, falls dies scannertechnisch umsetzbar ist.

  • Neue technische Möglichkeiten wie z. B. die Dual-Energy-Technik oder das Ultra-High-Pitch-Verfahren können die Bildqualität und somit die Diagnostik weiter verbessern – sind jedoch noch nicht weit verbreitet.

  • Kontrastmittelprotokolle und Atemkommandos sind die 2 Hauptfehlerquellen bei nicht diagnostischen CTPAs.

  • Bei Schwangeren mit Verdacht auf eine LE sollte bei initial erfolglosem Ausschluss einer TVT mittels Ultraschall frühzeitig die weitere Bildgebung mittels CTPA (oder zentrenabhängig auch Szintigrafie) zum Einsatz kommen.

 
  • Literatur

  • 1 Konstantinides SV, Torbicki A, Agnelli G et al. 2014 esc guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35: 3033-3069 , 69a – 69k
  • 2 Pengo V, Lensing AW, Prins MH et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350: 2257-2264
  • 3 Righini M, Van Es J, Den Exter PL et al. Age-adjusted d-dimer cutoff levels to rule out pulmonary embolism: The adjust-pe study. JAMA 2014; 311: 1117-1124
  • 4 Engelberger RP, Kucher N. Ultrasound-assisted thrombolysis for acute pulmonary embolism: A systematic review. Eur Heart J 2014; 35: 758-764
  • 5 van Belle A, Buller HR, Huisman MV et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, d-dimer testing, and computed tomography. JAMA 2006; 295: 172-179
  • 6 Anderson DR, Kahn SR, Rodger MA et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary embolism: A randomized controlled trial. JAMA 2007; 298: 2743-2753
  • 7 Righini M, Le Gal G, Aujesky D et al. Diagnosis of pulmonary embolism by multidetector ct alone or combined with venous ultrasonography of the leg: A randomised non-inferiority trial. Lancet 2008; 371: 1343-1352
  • 8 Stein PD, Fowler SE, Goodman LR et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317-2327
  • 9 Sostman HD, Stein PD, Gottschalk A et al. Acute pulmonary embolism: Sensitivity and specificity of ventilation-perfusion scintigraphy in pioped ii study. Radiology 2008; 246: 941-946
  • 10 Schembri GP, Miller AE, Smart R. Radiation dosimetry and safety issues in the investigation of pulmonary embolism. Semin Nucl Med 2010; 40: 442-454
  • 11 Schiebler ML, Nagle SK, Francois CJ et al. Effectiveness of mr angiography for the primary diagnosis of acute pulmonary embolism: Clinical outcomes at 3 months and 1 year. J Magn Reson Imaging 2013; 38: 914-925
  • 12 Adhikari NK, Fowler RA, Bhagwanjee S et al. Critical care and the global burden of critical illness in adults. Lancet 2010; 376: 1339-1346
  • 13 Araoz PA, Gotway MB, Harrington JR et al. Pulmonary embolism: Prognostic ct findings. Radiology 2007; 242: 889-897
  • 14 Henzler T, Roeger S, Meyer M et al. Pulmonary embolism: CT signs and cardiac biomarkers for predicting right ventricular dysfunction. Eur Respir J 2012; 39: 919-926
  • 15 Meinel FG, Nance Jr JW, Schoepf UJ et al. Predictive value of computed tomography in acute pulmonary embolism: Systematic review and meta-analysis. Am J Med 2015; 128: 747-59 e2
  • 16 Carrier M, Righini M, Wells PS et al. Subsegmental pulmonary embolism diagnosed by computed tomography: Incidence and clinical implications. A systematic review and meta-analysis of the management outcome studies. J Thromb Haemost 2010; 8: 1716-1722
  • 17 Stein PD, Goodman LR, Hull RD et al. Diagnosis and management of isolated subsegmental pulmonary embolism: Review and assessment of the options. Clin Appl Thromb Hemost 2012; 18: 20-26
  • 18 Szucs-Farkas Z, Christe A, Megyeri B et al. Diagnostic accuracy of computed tomography pulmonary angiography with reduced radiation and contrast material dose: A prospective randomized clinical trial. Invest Radiol 2014; 49: 201-208
  • 19 Szucs-Farkas Z, Schaller C, Bensler S et al. Detection of pulmonary emboli with ct angiography at reduced radiation exposure and contrast material volume: Comparison of 80 kvp and 120 kvp protocols in a matched cohort. Invest Radiol 2009; 44: 793-799
  • 20 Megyeri B, Christe A, Schindera ST et al. Diagnostic confidence and image quality of ct pulmonary angiography at 100 kvp in overweight and obese patients. Clin Radiol 2015; 70: 54-61
  • 21 Hansmann J, Fink C, Jost G et al. Impact of iodine delivery rate with varying flow rates on image quality in dual-energy ct of patients with suspected pulmonary embolism. Acad Radiol 2013; 20: 962-971
  • 22 Szucs-Farkas Z, Schibler F, Cullmann J et al. Diagnostic accuracy of pulmonary ct angiography at low tube voltage: Intraindividual comparison of a normal-dose protocol at 120 kvp and a low-dose protocol at 80 kvp using reduced amount of contrast medium in a simulation study. AJR Am J Roentgenol 2011; 197: W852-W859
  • 23 Delesalle MA, Pontana F, Duhamel A et al. Spectral optimization of chest ct angiography with reduced iodine load: Experience in 80 patients evaluated with dual-source, dual-energy ct. Radiology 2013; 267: 256-266
  • 24 Apfaltrer P, Bachmann V, Meyer M et al. Prognostic value of perfusion defect volume at dual energy cta in patients with pulmonary embolism: Correlation with cta obstruction scores, ct parameters of right ventricular dysfunction and adverse clinical outcome. Eur J Radiol 2012; 81: 3592-3597
  • 25 Meyer M, Haubenreisser H, Sudarski S et al. Where do we stand?. Functional imaging in acute and chronic pulmonary embolism with state-of-the-art ct. Eur J Radiol 2015; 84: 2432-2437
  • 26 Heusch P, Lanzman RS, Aissa J et al. Evaluation of a high iodine delivery rate in combination with low tube current for dose reduction in pulmonary computed tomography angiography. J Thorac Imaging 2014; 29: 293-297
  • 27 Hartmann IJ, Wittenberg R, Schaefer-Prokop C. Imaging of acute pulmonary embolism using multi-detector ct angiography: An update on imaging technique and interpretation. Eur J Radiol 2010; 74: 40-49
  • 28 Bae KT. Intravenous contrast medium administration and scan timing at ct: Considerations and approaches. Radiology 2010; 256: 32-61
  • 29 Henzler T, Meyer M, Reichert M et al. Dual-energy ct angiography of the lungs: Comparison of test bolus and bolus tracking techniques for the determination of scan delay. Eur J Radiol 2012; 81: 132-138
  • 30 Cornea AM, McCullough BJ, Mitsumori LM et al. Enhancement of the pulmonary arteries and thoracic aorta: Comparison of a biphasic contrast injection and fixed delay protocol with a monophasic injection and a timing bolus protocol. Emerg Radiol 2015; 22: 231-237
  • 31 Bolen MA, Renapurkar RD, Popovic ZB et al. High-pitch ecg-synchronized pulmonary ct angiography versus standard ct pulmonary angiography: A prospective randomized study. AJR Am J Roentgenol 2013; 201: 971-976
  • 32 Bamberg F, Marcus R, Sommer W et al. Diagnostic image quality of a comprehensive high-pitch dual-spiral cardiothoracic ct protocol in patients with undifferentiated acute chest pain. Eur J Radiol 2012; 81: 3697-3702
  • 33 Apfaltrer P, Henzler T, Meyer M et al. Correlation of ct angiographic pulmonary artery obstruction scores with right ventricular dysfunction and clinical outcome in patients with acute pulmonary embolism. Eur J Radiol 2012; 81: 2867-2871
  • 34 Furlan A, Aghayev A, Chang CC et al. Short-term mortality in acute pulmonary embolism: Clot burden and signs of right heart dysfunction at ct pulmonary angiography. Radiology 2012; 265: 283-293
  • 35 Kang DK, Thilo C, Schoepf UJ et al. Ct signs of right ventricular dysfunction: Prognostic role in acute pulmonary embolism. JACC Cardiovasc Imaging 2011; 4: 841-849
  • 36 Bach AG, Restrepo CS, Abbas J et al. Imaging of nonthrombotic pulmonary embolism: Biological materials, nonbiological materials, and foreign bodies. Eur J Radiol 2013; 82: e120-e141
  • 37 Morse M. Establishing a normal range for d-dimer levels through pregnancy to aid in the diagnosis of pulmonary embolism and deep vein thrombosis. J Thromb Haemost 2004; 2: 1202-1204
  • 38 Weisser G, Steil V, Neff KW et al. radiology and pregnancy: Part 2: Clinical recommendations. Radiologe 2013; 53: 75-82 ; quiz 3 – 4
  • 39 Bettmann MA, Baginski SG, White RD et al. Acr appropriateness criteria(r) acute chest pain – suspected pulmonary embolism. J Thorac Imaging 2012; 27: W28-W31
  • 40 Webb JA, Thomsen HS, Morcos SK. Members of Contrast Media Safety Committee of European Society of Urogenital R. The use of iodinated and gadolinium contrast media during pregnancy and lactation. Eur Radiol 2005; 15: 1234-1240
  • 41 Baert A, Knauth M, Thomsen HS et al. Contrast media: Safety issues and esur guidelines. Berlin, Heidelberg: Springer; 2009