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Suspected Pulmonary Embolism
Variant: 1
Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US duplex Doppler lower extremity | Usually Not Appropriate | O |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Arteriography pulmonary with right heart catheterization | Usually Not Appropriate | ☢☢☢☢ |
| MRA pulmonary arteries without and with IV contrast | Usually Not Appropriate | O |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
| CT chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA chest with IV contrast with CTV lower extremities | Usually Not Appropriate | ☢☢☢ |
| CTA pulmonary arteries with IV contrast | Usually Not Appropriate | ☢☢☢ |
| V/Q scan lung | Usually Not Appropriate | ☢☢☢ |
Variant: 2
Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| CTA pulmonary arteries with IV contrast | Usually Appropriate | ☢☢☢ |
| V/Q scan lung | Usually Appropriate | ☢☢☢ |
| MRA pulmonary arteries without and with IV contrast | May Be Appropriate | O |
| CTA triple rule out | May Be Appropriate (Disagreement) | ☢☢☢ |
| US duplex Doppler lower extremity | Usually Not Appropriate | O |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Arteriography pulmonary with right heart catheterization | Usually Not Appropriate | ☢☢☢☢ |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
| CT chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA chest with IV contrast with CTV lower extremities | Usually Not Appropriate | ☢☢☢ |
Variant: 3
Suspected pulmonary embolism. High pretest probability. Initial Imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| CTA pulmonary arteries with IV contrast | Usually Appropriate | ☢☢☢ |
| V/Q scan lung | Usually Appropriate | ☢☢☢ |
| US duplex Doppler lower extremity | May Be Appropriate (Disagreement) | O |
| US echocardiography transthoracic resting | May Be Appropriate | O |
| MRA pulmonary arteries without and with IV contrast | May Be Appropriate | O |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| Arteriography pulmonary with right heart catheterization | Usually Not Appropriate | ☢☢☢☢ |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
| CT chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA chest with IV contrast with CTV lower extremities | Usually Not Appropriate | ☢☢☢ |
| CTA triple rule out | Usually Not Appropriate | ☢☢☢ |
Variant: 4
Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
| Procedure | Appropriateness Category | Relative Radiation Level |
| US duplex Doppler lower extremity | Usually Appropriate | O |
| Radiography chest | Usually Appropriate | ☢ |
| CTA pulmonary arteries with IV contrast | Usually Appropriate | ☢☢☢ |
| V/Q scan lung | Usually Appropriate | ☢☢☢ |
| US echocardiography transesophageal | Usually Not Appropriate | O |
| US echocardiography transthoracic resting | Usually Not Appropriate | O |
| Arteriography pulmonary with right heart catheterization | Usually Not Appropriate | ☢☢☢☢ |
| MRA pulmonary arteries without and with IV contrast | Usually Not Appropriate | O |
| MRA pulmonary arteries without IV contrast | Usually Not Appropriate | O |
| CT chest with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without and with IV contrast | Usually Not Appropriate | ☢☢☢ |
| CT chest without IV contrast | Usually Not Appropriate | ☢☢☢ |
| CTA chest with IV contrast with CTV lower extremities | Usually Not Appropriate | ☢☢☢ |
| CTA triple rule out | Usually Not Appropriate | ☢☢☢ |
Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition
Discussion of Procedures by Variant
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
A. CTPA
A. CTPA
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
B. CT Chest With IV Contrast
B. CT Chest With IV Contrast
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
C. CT Chest Without and With IV Contrast
C. CT Chest Without and With IV Contrast
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
D. CT Chest Without IV Contrast
D. CT Chest Without IV Contrast
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
E. CTA Chest With IV Contrast with CTV Lower Extremities
E. CTA Chest With IV Contrast with CTV Lower Extremities
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
F. Arteriography Pulmonary with Right Heart Catheterization
F. Arteriography Pulmonary with Right Heart Catheterization
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
G. MRA Pulmonary Arteries Without and With IV contrast
G. MRA Pulmonary Arteries Without and With IV contrast
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
H. MRA Pulmonary Arteries Without IV contrast
H. MRA Pulmonary Arteries Without IV contrast
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
I. US Duplex Doppler Lower Extremity
I. US Duplex Doppler Lower Extremity
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
J. US Echocardiography Transesophageal
J. US Echocardiography Transesophageal
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
K. US Echocardiography Transthoracic Resting
K. US Echocardiography Transthoracic Resting
Variant 1: Suspected pulmonary embolism. Low or intermediate pretest probability with a negative D-dimer. Initial Imaging.
L. V/Q Scan Lung
L. V/Q Scan Lung
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
A. CTPA
A. CTPA
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
B. CT Chest With IV Contrast
B. CT Chest With IV Contrast
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
C. CT Chest Without and With IV Contrast
C. CT Chest Without and With IV Contrast
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
D. CT Chest Without IV Contrast
D. CT Chest Without IV Contrast
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
E. CTA Chest With IV Contrast With CTV Lower Extremities
E. CTA Chest With IV Contrast With CTV Lower Extremities
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
F. CTA Triple Rule Out
F. CTA Triple Rule Out
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
G. Arteriography Pulmonary with Right Heart Catheterization
G. Arteriography Pulmonary with Right Heart Catheterization
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
H. MRA Pulmonary Arteries Without and With IV Contrast
H. MRA Pulmonary Arteries Without and With IV Contrast
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
I. MRA Pulmonary Arteries Without IV Contrast
I. MRA Pulmonary Arteries Without IV Contrast
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
J. US Duplex Doppler Lower Extremity
J. US Duplex Doppler Lower Extremity
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
K. US Echocardiography Transesophageal
K. US Echocardiography Transesophageal
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
L. US Echocardiography Transthoracic Resting
L. US Echocardiography Transthoracic Resting
Variant 2: Suspected pulmonary embolism. Low or intermediate pretest probability with a positive D-dimer. Initial imaging.
M. V/Q Scan Lung
M. V/Q Scan Lung
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
A. CTPA
A. CTPA
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
B. CT Chest With IV Contrast
B. CT Chest With IV Contrast
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
C. CT Chest Without and With IV Contrast
C. CT Chest Without and With IV Contrast
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
D. CT Chest Without IV Contrast
D. CT Chest Without IV Contrast
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
E. CTA Chest With IV Contrast With CTV Lower Extremities
E. CTA Chest With IV Contrast With CTV Lower Extremities
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
F. CTA Triple Rule Out
F. CTA Triple Rule Out
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
G. Arteriography Pulmonary with Right Heart Catheterization
G. Arteriography Pulmonary with Right Heart Catheterization
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
H. MRA Pulmonary Arteries Without and With IV Contrast
H. MRA Pulmonary Arteries Without and With IV Contrast
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
I. MRA Pulmonary Arteries Without IV Contrast
I. MRA Pulmonary Arteries Without IV Contrast
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
J. US Duplex Doppler Lower Extremity
J. US Duplex Doppler Lower Extremity
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
K. US Echocardiography Transesophageal
K. US Echocardiography Transesophageal
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
L. US Echocardiography Transthoracic Resting
L. US Echocardiography Transthoracic Resting
Variant 3: Suspected pulmonary embolism. High pretest probability. Initial Imaging.
M. V/Q Scan Lung
M. V/Q Scan Lung
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
A. Radiography Chest
A. Radiography Chest
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
B. CTPA
B. CTPA
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
C. CT Chest With IV Contrast
C. CT Chest With IV Contrast
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
D. CT Chest Without and With IV Contrast
D. CT Chest Without and With IV Contrast
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
E. CT Chest Without IV Contrast
E. CT Chest Without IV Contrast
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
F. CTA Chest With IV Contrast with CTV Lower Extremities
F. CTA Chest With IV Contrast with CTV Lower Extremities
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
G. CTA Triple Rule Out
G. CTA Triple Rule Out
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
H. Arteriography Pulmonary with Right Heart Catheterization
H. Arteriography Pulmonary with Right Heart Catheterization
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
I. MRA Pulmonary Arteries Without and With IV Contrast
I. MRA Pulmonary Arteries Without and With IV Contrast
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
J. MRA Pulmonary Arteries Without IV Contrast
J. MRA Pulmonary Arteries Without IV Contrast
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
K. US Duplex Doppler Lower Extremity
K. US Duplex Doppler Lower Extremity
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
L. US Echocardiography Transesophageal
L. US Echocardiography Transesophageal
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
M. US Echocardiography Transthoracic Resting
M. US Echocardiography Transthoracic Resting
Variant 4: Suspected pulmonary embolism. Pregnant patient. Initial Imaging.
N. V/Q Scan Lung
N. V/Q Scan Lung
Summary of Recommendations
Supporting Documents
The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.
For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.
Safety Considerations in Pregnant Patients
Appropriateness Category Names and Definitions
|
Appropriateness Category Name |
Appropriateness Rating |
Appropriateness Category Definition |
|
Usually Appropriate |
7, 8, or 9 |
The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients. |
|
May Be Appropriate |
4, 5, or 6 |
The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal. |
|
May Be Appropriate (Disagreement) |
5 |
The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned. |
|
Usually Not Appropriate |
1, 2, or 3 |
The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable. |
Relative Radiation Level Information
Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.
|
Relative Radiation Level Designations |
||
|
Relative Radiation Level* |
Adult Effective Dose Estimate Range |
Pediatric Effective Dose Estimate Range |
|
O |
0 mSv |
0 mSv |
|
☢ |
<0.1 mSv |
<0.03 mSv |
|
☢☢ |
0.1-1 mSv |
0.03-0.3 mSv |
|
☢☢☢ |
1-10 mSv |
0.3-3 mSv |
|
☢☢☢☢ |
10-30 mSv |
3-10 mSv |
|
☢☢☢☢☢ |
30-100 mSv |
10-30 mSv |
|
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.” |
||
References
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Disclaimer
The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination