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HomeRadiologyVol. 245, No. 2 PreviousNext Reviews and CommentaryEditorialsManagement of Suspected Acute Pulmonary Embolism in the Era of CT Angiography: A Statement from the Fleischner SocietyMartine Remy-Jardin, Massimo Pistolesi, Lawrence R. Goodman, Warren B. Gefter, Alexander Gottschalk, John R. Mayo, H. Dirk SostmanMartine Remy-Jardin, Massimo Pistolesi, Lawrence R. Goodman, Warren B. Gefter, Alexander Gottschalk, John R. Mayo, H. Dirk SostmanAuthor Affiliations1From the Department of Thoracic Imaging, Hospital Calmette, University Center of Lille, Boulevard Jules Leclerc, 59037 Lille, France (M.R.); Respiratory Unit, Department of Critical Care, University of Florence, Florence, Italy (M.P.); Department of Radiology, Froedtert Memorial Lutheran Hospital, Milwaukee, Wis (L.R.G.); Department of Radiology, Hospital of the University of Pennsylvania; Philadelphia, Pa (W.B.G.); Department of Diagnostic Radiology, Michigan State University, East Lansing, Mich (A.G.); Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada (J.R.M.); and Department of Radiology, New York Hospital–Cornell Medical Center, New York, NY (H.D.S.). Received February 28, 2007; revision requested March 28; revision received April 20; final version accepted June 6.Address correspondence to M.R. (e-mail: [email protected]).Martine Remy-JardinMassimo PistolesiLawrence R. GoodmanWarren B. GefterAlexander GottschalkJohn R. MayoH. Dirk SostmanPublished Online:Nov 1 2007https://doi.org/10.1148/radiol.2452070397MoreSectionsFull textPDF ToolsAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookXLinked In References1 Safriel Y, Zinn H. CT pulmonary angiography in the detection of pulmonary emboli: a meta-analysis of sensitivities and specificities. Clin Imaging 2002;26:101–105. Crossref, Medline, Google Scholar2 Qanadli SD, Hajjam ME, Mesurolle B, et al. Pulmonary embolism detection: prospective evaluation of dual-section helical CT versus selective pulmonary arteriography in 157 patients. Radiology 2000;217:447–455. Link, Google Scholar3 Winer-Muram HT, Rydberg J, Johnson MS, et al. Suspected acute pulmonary embolism: evaluation with multi-detector row CT versus digital subtraction pulmonary arteriography. Radiology 2004;233:806–815. Link, Google Scholar4 Stein PD, Fowler SE, Goodman LR, et al. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006;354:2317–2327. Crossref, Medline, Google Scholar5 Ghaye B, Szapiro D, Mastora I, et al. Peripheral pulmonary arteries: how far does multidetector–row spiral CT allow analysis? Radiology 2001;219:629–636. Link, Google Scholar6 Schoepf UJ, Goldhaber SZ, Costello P. Spiral computed tomography for acute pulmonary embolism. Circulation 2004;109:2160–2167. Crossref, Medline, Google Scholar7 Coche E, Verschuren F, Keyeux A, et al. Diagnosis of acute pulmonary embolism in outpatients: comparison of thin-collimation multi–detector row spiral CT and planar ventilation-perfusion scintigraphy. Radiology 2003;229:757–765. Link, Google Scholar8 Raptopoulos V, Boiselle PM. Multi–detector row spiral CT pulmonary angiography: comparison with single–detector row spiral CT. Radiology 2001;221(3):606–613. Link, Google Scholar9 Schoepf UJ, Holzknecht N, Helmberger TK, et al. Subsegmental pulmonary emboli: improved detection with thin-collimation multi–detector row spiral CT. Radiology 2002;222:483–490. Link, Google Scholar10 Patel S, Kazerooni EA, Cascade PN. Pulmonary embolism: optimization of small pulmonary artery visualization at multi–detector row CT. Radiology 2003;227:455–460. Link, Google Scholar11 Brunot S, Corneloup O, Latrabe V, Montaudon M, Laurent F. Reproducibility of multidetector spiral computed tomography in detection of subsegmental acute pulmonary embolism. Eur Radiol 2005;15:2057–2063. Crossref, Medline, Google Scholar12 Schoellnast H, Deutschmann HA, Fritz GA, Stessel U, Schaffler GJ, Tillich M. MDCT angiography of the pulmonary arteries: influence of iodine flow concentration on vessel attenuation and visualization. AJR Am J Roentgenol 2005;184:1935–1939. Crossref, Medline, Google Scholar13 Revel MP, Petrover D, Hernigou A, Lefort C, Meyer G, Frija G. Diagnosing pulmonary embolism with four–detector row helical CT: prospective evaluation of 216 outpatients and inpatients. Radiology 2005;234:265–273. Link, Google Scholar14 Kelly AM, Patel S, Carlos RC, Cronin P, Kazerooni EA. Multidetector-row CT pulmonary angiography and indirect venography for the diagnosis of venous thromboembolic disease in intensive care unit patients. Acad Radiol 2006;13:486–495. Crossref, Medline, Google Scholar15 Tillie-Leblond I, Marquette CH, Perez T, et al. Pulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors. Ann Intern Med 2006;144:390–396. Crossref, Medline, Google Scholar16 Quiroz R, Kucher N, Zou KH, et al. Clinical validity of a negative computed tomography scan in patients with suspected pulmonary embolism: a systematic review. JAMA 2005;293:2012–2017. Crossref, Medline, Google Scholar17 Perrier A, Roy PM, Sanchez O, et al. Multidetector-row computed tomography in suspected pulmonary embolism. N Engl J Med 2005;352:1760–1768. Crossref, Medline, Google Scholar18 van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. Christopher Study Investigators. JAMA 2006;295:172–179. Crossref, Medline, Google Scholar19 Stein PD, Woodard PK, Weg JG, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Radiology 2007;242(1):15–21. Link, Google Scholar20 Eyer BA, Goodman LR, Washington L. Clinicians' response to radiologists' reports of isolated subsegmental pulmonary embolism or inconclusive interpretation of pulmonary embolism using MDCT. AJR Am J Roentgenol 2005;184:623–628. Crossref, Medline, Google Scholar21 Stein PD, Henry JW, Gottschalk A. Reassessment of pulmonary angiography for the diagnosis of pulmonary embolism: relation of interpreter agreement to the order of the involved pulmonary arterial branch. Radiology 1999;210:689–691. Link, Google Scholar22 Diffin DC, Leyendecker JR, Johnson SP, Zucker RJ, Grebe PJ. Effect of anatomic distribution of pulmonary emboli on interobserver agreement in the interpretation of pulmonary angiography. AJR Am J Roentgenol 1998;171:1085–1089. Crossref, Medline, Google Scholar23 De Monye W, van Strijen MJ, Huisman MV, Kieft GJ, Pattynama PM. Suspected pulmonary embolism: prevalence and anatomic distribution in 487 consecutive patients: Advances in New Technologies Evaluating the Localisation of Pulmonary Embolism (ANTELOPE) group. Radiology 2000;215:184–188. Link, Google Scholar24 Goodman LR. Small pulmonary emboli: what do we know? [editorial]. Radiology 2005 (3);234:654–658. Link, Google Scholar25 Kreit JW. The impact of right ventricular dysfunction on the prognosis and therapy of normotensive patients with pulmonary embolism. Chest 2004;125:1539–1545. Crossref, Medline, Google Scholar26 Leacche M, Unic D, Godhaber SZ, et al. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 2005;129:1018–1023. Crossref, Medline, Google Scholar27 Lembcke A, Dohmen PM, Dewey M, et al. Multislice computed tomography for preoperative evaluation of right ventricular volumes and function: comparison with magnetic resonance imaging. Ann Thorac Surg 2005;79:1344–1351. Crossref, Medline, Google Scholar28 Koch K, Oellig F, Oberholzer K, et al. Assessment of right ventricular function by 16-detector-row CT: comparison with magnetic resonance imaging. Eur Radiol 2005;15:312–318. Crossref, Medline, Google Scholar29 Kim TH, Ryu YH, Hur J, et al. Evaluation of right ventricular volume and mass using retrospective ECG-gated cardiac multidetector computed tomography: comparison with first-pass radionuclide angiography. Eur Radiol 2005;15:1987–1993. Crossref, Medline, Google Scholar30 Coche E, Vlassenbroeck A, Roelants V, et al. Evaluation of biventricular ejection fraction with ECG-gated 16-slice CT: preliminary findings in acute pulmonary embolism in comparison with radionuclide ventriculography. Eur Radiol 2005;15:1432–1440. Crossref, Medline, Google Scholar31 Delhaye D, Remy-Jardin M, Teisseire A, et al. Estimation of right ventricular ejection fraction by multidetector row CT. I. Comparison with equilibrium radionuclide ventriculography. AJR Am J Roentgenol 2006;187:1597–1604. Google Scholar32 Dogan H, Kroft LJ, Bax JJ, et al. MDCT assessment of right ventricular systolic function. AJR Am J Roentgenol 2006;186(suppl 2):S366–S370. Crossref, Medline, Google Scholar33 White CS, Kuo D, Kelemen M, et al. Chest pain evaluation in the emergency department: can MDCT provide a comprehensive evaluation? AJR Am J Roentgenol 2005;185:533–540. Google Scholar34 Delhaye D, Remy-Jardin M, Salem R, et al. Coronary imaging quality in routine ECG-gated multidetector CT examinations of the entire thorax: preliminary experience with a 64-slice CT system in 133 patients. Eur Radiol 2007;17:902–910. Crossref, Medline, Google Scholar35 Salem R, Remy-Jardin M, Delhaye D, et al. Integrated cardio-thoracic imaging with ECG-gated 64-slice multidetector-row CT: initial findings in 133 patients. Eur Radiol 2006;16:1973–1981. Crossref, Medline, Google Scholar36 d'Agostino AG, Remy-Jardin M, Khalil C, et al. Low-dose ECG-gated multislice helical CT angiography of the chest: evaluation of image quality in 105 patients. Eur Radiol 2006;16:2137–2146. Crossref, Medline, Google Scholar37 Reittner P, Coxson HO, Nakano Y, et al. Pulmonary embolism: comparison of gadolinium-enhanced MR angiography with contrast-enhanced spiral CT in a porcine model. Acad Radiol 2001;8:343–350. Crossref, Medline, Google Scholar38 Coche EE, Muller NL, Kim W, et al. Acute pulmonary embolism: ancillary findings at spiral CT. Radiology 1998;207:753–758. Link, Google Scholar39 Shah AA, Davis SD, Gamsu G, Intriere L. Parenchymal and pleural findings in patients with and patients without acute pulmonary embolism detected at spiral CT. Radiology 1999;211:147–153. Link, Google Scholar40 Wildberger JE, Niethammer MU, Klotz E, et al. Multislice CT for visualization of pulmonary embolism using perfusion weighted color maps. Rofo 2001;173:289–294. Crossref, Medline, Google Scholar41 Screaton NJ, Coxson HO, Kalloger SE, et al. Detection of lung perfusion abnormalities using computed tomography in a porcine model of pulmonary embolism. J Thorac Imaging 2003;18:14–20. Crossref, Medline, Google Scholar42 Wildberger JE, Klotz E, Ditt H, Spüntrup E, Mahnken AH, Günther RW. Multislice computed tomography perfusion imaging for visualization of acute pulmonary embolism: animal experience. Eur Radiol 2005;15:1378–1386. Crossref, Medline, Google Scholar43 Bruzzi JF, Remy-Jardin M, Kirsch J, et al. Sixteen-slice multidetector computed tomography pulmonary angiography: evaluation of cardiogenic motion artifacts and influence of rotation time on image quality. J Comput Assist Tomogr 2005; 29(6):805–814. Crossref, Medline, Google Scholar44 Remy-Jardin M, Teisseire A, Kirsh J, Bruzzi J, Khalil C, Remy J. Cardiogenic artefacts on multidetector CT angiograms of the pulmonary circulation: comparison with ECG-gated and nongated acquisitions [abstr]. In: Radiological Society of North America Scientific Assembly and Annual Meeting Program. Oak Brook, Ill: Radiological Society of North America, 2005; 327. Google Scholar45 Qanadli SD, El Hajjam M, Vieillard-Baron A, et al. New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography. AJR Am J Roentgenol 2001;176:1415–1420. Crossref, Medline, Google Scholar46 Mastora I, Remy-Jardin M, Masson P, et al. Severity of acute pulmonary embolism: evaluation of a new spiral CT angiographic score in correlation with echocardiographic data. Eur Radiol 2003;13:29–35. Crossref, Medline, Google Scholar47 Wu AS, Pezzullo JA, Cronan JJ, Hou DD, Mayo-Smith WW. CT pulmonary angiography: quantification of pulmonary embolus as a predictor of patient outcome—initial experience. Radiology 2004;230:831–835. Link, Google Scholar48 Engelke C, Rummeny E, Marten K. Acute pulmonary embolism: prediction of cor-pulmonale and short-term patient survival from morphologic embolus burden. AJR Am J Roentgenol 2006;186:1265–1271. Crossref, Medline, Google Scholar49 Oliver TB, Reid JH, Murchison JT. Interventricular shift due to massive pulmonary embolism shown by CT pulmonary angiography: an old sign revisited. Thorax 1998;53:1092–1094. Crossref, Medline, Google Scholar50 Ghaye B, Ghuysen A, Willems V, et al. Severe pulmonary embolism: pulmonary artery clot load scores and cardiovascular parameters as predictors of mortality. Radiology 2006;239(3):884–891. Link, Google Scholar51 Lewis BD, James EM, Welch TJ, Joyce JW, Hallett JW, Weaver AL. Diagnosis of acute deep venous thrombosis of the lower extremities: prospective evaluation of color Doppler flow imaging versus venography. Radiology 1994;192:651–655. Link, Google Scholar52 Ghaye B, Dondelinger RF. Non-traumatic thoracic emergencies: CT venography in an integrated diagnostic strategy of acute pulmonary embolism and venous thrombosis. Eur Radiol 2002;12:1906–1921. Crossref, Medline, Google Scholar53 Loud PA, Grossman ZD, Klippenstein DL, Ray CE. Combined CT venography and pulmonary angiography: a new diagnostic technique for suspected thromboembolic disease. AJR Am J Roentgenol 1998;170:951–954. Crossref, Medline, Google Scholar54 Katz DS, Loud PA, Bruce D, et al. Combined CT venography and pulmonary angiography: a comprehensive review. RadioGraphics 2002;22(Spec Issue):S3–S19. Medline, Google Scholar55 Wildberger JE, Mahnken AH, Sinha AM, et al. A differentiated approach to the diagnosis of pulmonary embolism and deep venous thrombosis using multi-slice CT [in German]. Rofo 2002;174:301–307. Crossref, Medline, Google Scholar56 Garg K, Kemp JL, Russ PD, Baron AE. Thromboembolic disease: variability of interobserver agreement in the interpretation of CT venography with CT pulmonary angiography. AJR Am J Roentgenol 2001;176:1043–1047. Crossref, Medline, Google Scholar57 Loud PA, Katz DS, Bruce D, Klippenstein DL, Grossman ZD. Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography. Radiology 2001;219:498–501. Link, Google Scholar58 Cham MD, Yankelevitz DF, Henschke CI. Thromboembolic disease detection at indirect CT venography versus CT pulmonary angiography. Radiology 2005;234:591–594. Link, Google Scholar59 Taffoni MJ, Ravenel JG, Ackerman SJ. Prospective comparison of indirect CT venography versus venous sonography in ICU patients. AJR Am J Roentgenol 2005;185:457–462. Crossref, Medline, Google Scholar60 Coche EE, Hamoir XL, Hammer FD, Hainaut P, Goffette PP. Using dual-detector helical CT angiography to detect deep venous thrombosis in patients with suspicion of pulmonary embolism: diagnostic value and additional findings. AJR Am J Roentgenol 2001;176:1035–1038. Crossref, Medline, Google Scholar61 Richman PB, Wood J, Kasper DM, et al. Contribution of indirect computed tomography venography to computed tomography angiography of the chest for the diagnosis of thromboembolic disease in two United States emergency departments. J Thromb Haemost 2003;1:652–657. Crossref, Medline, Google Scholar62 Walsh G, Redmond S. Does addition of CT pelvic venography to CT pulmonary angiography protocols contribute to the diagnosis of thromboembolic disease? Clin Radiol 2002;57:462–465. Crossref, Medline, Google Scholar63 Jonetz-Mentzel L, Eger C, Basche S. CT venography and CT angiography of the pulmonary arteries in acute pulmonary embolism [in German]. Zentralbl Chir 2002;127:755–759. Crossref, Medline, Google Scholar64 Ghaye B, Nchimi A, Noukoua CT, Dondelinger RF. Does multi–detector row CT pulmonary angiography reduce the incremental value of indirect CT venography compared with single–detector row CT pulmonary angiography? Radiology 2006;240:256–262. Link, Google Scholar65 Weiss CR, Scatarige JC, Diette GB, Haponik EF, Merriman B, Fishman EK. CT pulmonary angiography is the first-line imaging test for acute pulmonary embolism: a survey of US clinicians. Acad Radiol 2006;13:434–446. Crossref, Medline, Google Scholar66 Tillie-Leblond I, Mastora I, Radenne F, et al. Risk of pulmonary embolism after a negative spiral CT angiogram in patients with pulmonary disease: 1-year clinical follow-up study. Radiology 2002;223(2):461–467. Link, Google Scholar67 Henry JW, Relyea B, Stein PD. Continuing risk of thromboemboli among patients with normal pulmonary angiograms. Chest 1995;107:1375–1378. Crossref, Medline, Google Scholar68 Kavanagh EC, O'Hare A, Hargaden G, Murray JG. Risk of pulmonary embolism after negative MDCT pulmonary angiography findings. AJR Am J Roentgenol 2004;182:499–504. Crossref, Medline, Google Scholar69 Perrier A, Bounameaux H. Accuracy or outcome in suspected pulmonary embolism. N Engl J Med 2006;354:2383–2385. Crossref, Medline, Google Scholar70 Rademaker J, Griesshaber V, Hidajat N, Oestmann JW, Felix R. Combined CT pulmonary angiography and venography for diagnosis of pulmonary embolism and deep vein thrombosis: radiation dose. J Thorac Imaging 2001;16:297–299. Crossref, Medline, Google Scholar71 Goodman LR, Stein PD, Beemath A, et al. CT venography: continuous helical images versus reformatted discontinuous images using PIOPED II data. AJR Am J Roentgenol (in press). Google Scholar72 Mayo JR, Aldrich JE, Müller NL. Radiation exposure at chest CT: a statement of the Fleischner Society. Radiology 2003;228:15–21. Link, Google Scholar73 Golding SJ, Shrimpton PC. Radiation dose in CT: are we meeting the challenge? [editorial]. Br J Radiol 2002;75:1–4. Crossref, Medline, Google Scholar74 Rogers LF. Radiation exposure in CT: why so high? [editorial]. AJR Am J Roentgenol 2001;177:277. Crossref, Medline, Google Scholar75 Brenner DJ. Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative. Pediatr Radiol 2002;32:228–231. Crossref, Medline, Google Scholar76 Brenner DJ, Elliston CD. Estimated radiation risks potentially associated with full-body CT screening. Radiology 2004;232:735–738. Link, Google Scholar77 Aldrich JE, Williams J. Change in patient dose from radiological procedures over 11 years. Presented at the World Congress on Medical Physics and Biomedical Engineering, Sydney, Australia, October 24–29, 2003. Google Scholar78 International Commission on Radiological Protection and Measurements. Radiological protection and safety. International Commission on Radiological Protection Measurements publication no. 60. Oxford, England: Pergamon, 1991. Google Scholar79 Parker MS, Hui FK, Camacho MA. Female breast radiation exposure during CT pulmonary angiography. AJR Am J Roentgenol 2005;185:1228–1233. Crossref, Medline, Google Scholar80 Cook JV, Kyriou J. Radiation from CT and perfusion scanning in pregnancy. BMJ 2005;331:350. [Published correction appears in BMJ 2005;331:613.] Crossref, Medline, Google Scholar81 Task Group on Control of Radiation Dose in Computed Tomography. Managing patient dose in computed tomography: a report of the International Commission on Radiological Protection and Measurements. Ann ICRP 2000;30:7–45. Medline, Google Scholar82 Milne EN. Female breast radiation exposure [letter]. AJR Am J Roentgenol 2006;186:E24. Crossref, Medline, Google Scholar83 Hurwitz LM, Yoshizumi TT, Reiman RE, et al. Radiation dose to the female breast from 16-MDCT body protocols. AJR Am J Roentgenol 2006;186:1718–1722. Crossref, Medline, Google Scholar84 Fink C, Sebastian L, Kroeker R, Martin R, Kauczor H, Bock M. Time-resolved contrast-enhanced three-dimensional magnetic resonance angiography of the chest. Invest Radiol 2005;40:40–48. Medline, Google Scholar85 Kluge A, Luboldt W, Bachmann G. Acute pulmonary embolism to the subsegmental level: diagnostic accuracy of three MRI techniques compared with 16-MDCT. AJR Am J Roentgenol 2006;187(1):W7–W14. Crossref, Medline, Google Scholar86 Ohno Y, Higashino T, Takenaka D, et al. MR angiography with sensitivity encoding (SENSE) for suspected pulmonary embolism: comparison with MDCT and ventilation-perfusion scintigraphy. AJR Am J Roentgenol 2004;183:91–98. Crossref, Medline, Google Scholar87 Stein PD, Woodard PK, Hull RD, et al. Gadolinium-enhanced magnetic resonance angiography for detection of acute pulmonary embolism. Chest 2003;124:2324–2328. Crossref, Medline, Google Scholar88 Oudkerk M, van Beek EJ, Weilopolski P, et al. Comparison of contrast-enhanced magnetic resonance angiography and conventional pulmonary angiography for the diagnosis of pulmonary embolism: a prospective study. Lancet 2002;359:1643–1647. Crossref, Medline, Google Scholar89 Evans AJ, Sostman HD, Witty LA, et al. Detection of deep venous thrombosis: prospective comparison of MR imaging and sonography. J Magn Reson Imaging 1996;6:44–51. Crossref, Medline, Google Scholar90 Laissy JP, Cinqualbre A, Loshkajian A, et al. Assessment of deep venous thrombosis in the lower limbs and pelvis: MR venography versus duplex Doppler sonography. AJR Am J Roentgenol 1996;167:971–975. Crossref, Medline, Google Scholar91 Fraser DG, Moody AR, Morgan PS, et al. Diagnosis of lower-limb deep venous thrombosis: a prospective blinded study of magnetic resonance direct thrombus imaging. Ann Intern Med 2002;136:89–98. Crossref, Medline, Google Scholar92 Stern JB, Abehsera M, Grenet D, et al. Detection of pelvic vein thrombosis by magnetic resonance angiography in patients with acute pulmonary embolism and normal lower limb compression ultrasonography. Chest 2002;122:115–121. Crossref, Medline, Google Scholar93 Fraser DG, Moody AR, Davidson IR, et al. Deep venous thrombosis: diagnosis by using venous enhanced subtracted peak arterial MR venography versus conventional venography. Radiology 2003;226:812–820. Link, Google Scholar94 Catalano C, Pavone P, Laghi A, et al. Role of MR venography in the evaluation of deep venous thrombosis. Acta Radiol 1997;38:907–912. Crossref, Medline, Google Scholar95 Spritzer CE, Arata MA, Freed KS. Isolated pelvic deep venous thrombosis: relative frequency as detected with MR imaging. Radiology 2001;219:521–525. Link, Google Scholar96 Dupas B, el Kouri D, Curtet C, et al. Angiomagnetic resonance imaging of iliofemorocaval venous thrombosis. Lancet 1995;346:17–19. Crossref, Medline, Google Scholar97 Kluge A, Mueller C, Strunk J, Lange U, Bachmann G. Experience in 207 combined MRI examinations for acute pulmonary embolism and deep vein thrombosis. AJR Am J Roentgenol 2006;186:1686–1696. Crossref, Medline, Google Scholar98 Larsson EM, Sunden P, Olsson CG, et al. MR venography using an intravascular contrast agent: results from a multicenter phase 2 study of dosage. AJR Am J Roentgenol 2003;180:227–232. Crossref, Medline, Google Scholar99 Ruehm SG, Wiesner W, Debain JF. Pelvic and lower extremity veins: contrast-enhanced three-dimensional MR venography with a dedicated vascular coil—initial experience. Radiology 2000;215:421–427. Link, Google Scholar100 Kluge A, Rominger M, Schonburg M, Bachmann G. Indirect MR venography: contrast media protocols, post processing and combination with MRI diagnostics for pulmonary embolism [in German]. Rofo 2004;176:976–984. Crossref, Medline, Google Scholar101 Obernosterer A, Aschauer M, Portugaller H, Koppel H, Lipp RW. Three-dimensional gadolinium-enhanced magnetic resonance angiography used as a “one-stop shop” imaging procedure for venous thromboembolism: a pilot study. Angiology 2005;56:423–430. Crossref, Medline, Google Scholar102 Department of Health and Human Services. Medicare national coverage determinations manual. Chapter 1, part 4 (sections 200–310.1): coverage determinations (rev 62, 12-15-06). Department of Health and Human Services. http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf. Accessed October 2005. Updated February 23, 2007. Google Scholar103 Thomsen HS. Nephrogenic systemic fibrosis: a serious late adverse reaction to gadodiamide [editorial]. Eur Radiol 2006;16:2619–2621. Crossref, Medline, Google Scholar104 Marckmann P, Skov L, Rossen K, et al. Nephrogenic systemic fibrosis: suspected etiological role of gadodiamide used for contrast-enhanced magnetic resonance imaging. J Am Soc Nephrol 2006;17:2359–2362. Crossref, Medline, Google Scholar105 Grobner T. Gadolinium: a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis? Nephrol Dial Transplant 2006;21:1104–1108. Crossref, Medline, Google Scholar106 U.S. Food and Drug Administration. Public health advisory: update on magnetic resonance imaging (MRI) contrast agents containing gadolinium and nephrogenic fibrosing dermopathy. U.S. Food and Drug Administration. http://www.fda.gov/cder/drug/advisory/gadolinium_agents_20061222.htm. Published December 22, 2006. Accessed November 2005. Google Scholar107 Kipper MS, Moser KM, Kortman KE, Ashburn WL. Long term follow-up in patients with suspected pulmonary embolism and a normal lung scan. Chest 1982;82:411–415. Crossref, Medline, Google Scholar108 Hull RD, Raskob GE, Coates G, Panju AA. Clinical validity of a normal perfusion lung scan in patients with suspected pulmonary embolism. Chest 1990;97:23–26. Crossref, Medline, Google Scholar109 van Beek EJ, Kuyer PM, Schenk BE, Brandjes DP, ten Cate JW, Buller HR. A normal perfusion scan in patients with clinically suspected pulmonary embolism: frequency and clinical validity. Chest 1995;108:170–173. Crossref, Medline, Google Scholar110 Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). The PIOPED Investigators. JAMA 1990;263:2753–2759. Crossref, Medline, Google Scholar111 Stein PD, Alavi A, Gottschalk A, et al. Usefulness of non-invasive diagnostic tools for diagnosis of acute pulmonary embolism in patients with a normal chest radiograph. Am J Cardiol 1991;67:1117–1120. Crossref, Medline, Google Scholar112 Forbes KP, Reid JH, Murchison JT. Do preliminary chest x-ray findings define the optimum role of pulmonary scintigraphy in suspected pulmonary embolism? Clin Radiol 2001;56:397–400. Crossref, Medline, Google Scholar113 Stein PD, Terrin ML, Gottschalk A, et al. Value of ventilation/perfusion scans compared to perfusion scans alone in acute pulmonary embolism. Am J Cardiol 1992;69:1239–1241. Crossref, Medline, Google Scholar114 Miniati M, Pistolesi M, Marini C, et al. Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED). Am J Respir Crit Care Med 1996;154:1387–1393. Crossref, Medline, Google Scholar115 Miniati M, Monti S, Bottai M, et al. Survival and restoration of pulmonary perfusion in a long-term follow-up of patients after acute pulmonary embolism. Medicine 2006;85:253–262. Crossref, Medline, Google Scholar116 Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med 2001;135:98–107. Crossref, Medline, Google Scholar117 British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470–484. Crossref, Medline, Google Scholar118 Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997–1005. Crossref, Medline, Google Scholar119 Sanson BJ, Lijmer JG, Mac Gillavry MR, et al. Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group. Thromb Haemost 2000;83:199–203. Crossref, Google Scholar120 Chagnon I, Bounameaux H, Aujesky D, et al. Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med 2002;113:269–275. Crossref, Medline, Google Scholar121 Wicki J, Perneger TV, Junod AF, et al. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001;161:92–97. Crossref, Medline, Google Scholar122 Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score. Ann Intern Med 2006;144:165–171. Crossref, Medline, Google Scholar123 Miniati M, Bottai M, Monti S. Comparison of 3 clinical models for predicting the probability of pulmonary embolism. Medicine 2005;84:107–114. Crossref, Medline, Google Scholar124 Kearon C. Diagnosis of pulmonary embolism. CMAJ 2003;168:183–194. Medline, Google Scholar125 Fedullo PF, Tapson VF. Clinical practice: the evaluation of suspected pulmonary embolism. N Engl J Med 2003;349:1247–1256. Crossref, Medline, Google Scholar126 Lee AY, Ginsberg JS. Laboratory diagnosis of venous thromboembolism. Baillieres Clin Haematol 1998;11:587–604. Crossref, Medline, Google Scholar127 Meyer G, Roy PM, Sors H, Sanchez O. Laboratory tests in the diagnosis of pulmona