Chronic thromboembolic pulmonary hypertension: Evaluation with 64-detector row CT versus digital substraction angiography

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Abstract

The aim of the study was to evaluate the role of 64-row CT in the diagnostic workup of patients with chronic thromboembolic pulmonary hypertension (CTEPH) using digital substraction angiography (DSA) as the method of diagnostic reference. CT and DSA studies of 27 patients (54 main, 162 lobar and 540 segmental arteries) with a clinical suspicion of CTEPH were included in this retrospective and blinded analysis. Axial images and multiplanar thin maximum intensity projections (MIPs) (3 mm) were consequently used for exact image interpretation whereas additional reconstructed thick MIPs gave an overview of the entire vascular tree comparable to DSA. Sensitivity and specificity of CT regarding CTEPH-related pathological changes in general were 98.3% and 94.8% at main/lobar level and 94.1% and 92.9% at segmental level, respectively. Sensitivity and specificity of CT regarding the different pathological criteria of CTEPH (complete obstruction, intimal irregularities, bands and webs, indirect signs) were 88.9–100% and 96.1–100% at main/lobar level and 84.3–90.5% and 92–98.7% at segmental level, respectively. Our results show that CT is an accurate and reliable non-invasive alternative to conventional DSA in the diagnostic workup in patients with CTEPH.

Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but serious consequence of recurrent pulmonary embolism which can often be treated by pulmonary endarterectomy (PEA) [1], [2]. High-quality imaging is essential for correct diagnosis, to distinguish CTEPH from other forms of pulmonary hypertension and to identify candidates for surgery. To date, invasive pulmonary digital substraction arteriography (DSA) is regarded to be the diagnostic “gold standard” for the evaluation of CTEPH and for assessment of surgical resectability [3], [4]. On the other hand helical computed tomography (CT) with 16- or 64-row scanners is considered a non-invasive substitute for vascular imaging, in general [5], [6], [7], [8], [9]. In case of acute pulmonary embolism the extremely high accuracy of CT has already been determined [10], [11], [12]. Few studies have also proposed CT as a reliable method in the evaluation of CTEPH that may have the potential to replace more invasive DSA [5], [13], [14]. Pitton et al. analyzed the diagnostic impact of helical CT in CTEPH using a synopsis of CT and DSA as reference standard [15], but the accuracy of 64-row CT has never been evaluated against DSA as gold standard.

In order to further determine the role of helical CT in the diagnostic workup of patients with CTEPH, we conducted the present study directly comparing the results of CT and DSA imaging.

Section snippets

Material and methods

From September 2005 to September 2006, 27 consecutive patients (14 women, 13 men; mean age 59 years; age range, 18–76 years) with high clinical suspicion of CTEPH were examined with DSA and 64-row CT. The shortest interval between CT and DSA was two days, the longest two weeks. In our institution, DSA is performed routinely as part of the diagnostic workup of patients with suspected CTEPH. CT is also routinely used because surgeons and pneumologists require detailed knowledge on mediastinal

Results

The examined 756 vessel segments comprise 54 main arteries, 162 lobar arteries and 540 segmental arteries. Except for 14 of 756 arteries (1.9% corresponding to the left lung of one patient) image quality was considered appropriate for analysis. The inconclusive images were excluded from analysis so that 742 vessel segments were included for statistical analysis.

All 27 patients had clear signs of pulmonary hypertension as revealed by the hemodynamic data in Table 1. Among the latter, both DSA

Discussion

Pitton et al. already demonstrated the diagnostic accuracy of a 4-row CT at the segmental and the subsegmental levels in 14 patients with CTEPH [15]. In our study subsegmental arteries were not included in the analysis. This decision was based on two different facts: First, there is no reliable reference standard for assessment of subsegmental alterations. Results from previous clinical studies have shown that interobserver agreement of DSA at the level of subsegmental arteries was clearly

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