Diagnostic management of pulmonary emboli s m us ing clini cal ass ess ment , pl as maD-dimer ass a y ,complet e lo w er limb v enous ul tr as ound and heli cal comput ed t omogr a ph y of pulmonary art er ies A multicentre clinicaloutcome study Antoine Elias 1 ,Alain Cazanave 1 , Marie Elias 1 , Valérie Chabbert 2 ,Henri Juchet 3 ,Hélène Paradis 7 ,Philippe Carrière 8 , Françoise Nguyen 4 ,Alain Didier 5 ,Michel Galinier 6 ,Cyrille Colin 9 ,Dominique Lauque 3 ,Francis Joffre 2 ,Hervé Rousseau 2 Departments of 1 Vascular Medicine, 2 Radiology , 3 Emergency , 4 Haemostasis, 5 Pulmonology ,and 6 Cardiology , Rangueil University Hospital Centre,T oulouse,France 7 Department of Cardiology and Vascular Medicine,General Hospital Centre,Auch,France 8 Department of Cardiology and Vascular Medicine,General Hospital Centre,Rodez,France 9 Department of Medical Information of the Hospices Civils de Lyon,Lyons,France Summary The objective of the studywasto assess the clinical validity of a non-invasive diagnostic strategy for acutepulmonary embolism using clinical assessment combined with both ELISA D-dimer and complete lower limb ultrasound (US)examination of proxi- mal and distal veins,before single-detector helical computed to- mography (CT) of pulmonary arteries. Weexpected the strat- egytohave a high diagnostic exclusion power and to safely de- crease the number of CT scans. This prospective, multicenter outcome study included 274 consecutiveoutpatients. All under - went a priori clinicalprobability ,D-dimer and bilateral complete lower limb US assessments. Only patients with a high clinical probability and both tests negative, or positive D-dimer and negative US assessments, underwent CT . Thiswas deemed Keywords Pulmonary embolism,D-dimer , ultrasound / diagnosis, helical computed tomography ,clinical / epidemiological studies necessary in 114 patients (42%). At baseline, venous throm- boembolism(VTE) was detected in 110 patients (40%), either by US showing proximal (n=65) or distal (n=36) thrombosis, or by CT (n=9). Anticoagulantwaswithheld in the remaining patients with negative results in both D-dimer and US but a non-high clinicalprobability (n=59), or in both US and CT (n=90), orwith negative US (n=6) and inadequate CT (n=9). All patients under - went a three-month clinical follow-up.VTE occurred in one pa- tientwith inadequate CT, yielding an incidence of 0.6% [95% confidence interval: 0.1–3.4]. Nopatient died from VTE or had major bleeding. Using clinicalprobability , ELISA D-dimer and complete US before helical CT is a safe strategyresulting in a substantial reduction in CT scans. Thromb Haemost 2005; 93: 982-8 New T echnologies and Diagnostic Tool s Correspondence to: Antoine Elias, MD, PhD Service de Médecine Vasculaire Hôpital de Rangueil-Larrey 1 Avenue Jean Poulhès CHU de T oulouse– TSA 50032 31059 T oulouse Cedex 9,France T el.: +33 5 61 32 30 38, Fax: +33 5 61 32 26 34 E-mail: elias.a@chu-toulouse.fr Received November 13, 2004 Accepted afterrevision February 7, 2005 Financial support: The studywas supported by a grant from Laboratoires BioMérieux, Marcy l’Etoile, France. The studywassponsored bythe University Hospital of T oulouse forregulatory and ethic submission. Prepublished online April 14, 2005 DOI: 10.1160/TH04–11–0734 © 2005 Schattauer GmbH, Stuttgart 982 I ntr oduction In patients with clinically suspected acute pulmonary embolism (PE),a rapid and accurate diagnosis isrequired in orderto initi- ateorwithhold anticoagulant treatment. Inorderto confirmor exclude PE, objective testing is mandatory . Various diagnostic methods such as plasmaD-dimer assay , lower limb venous ultra- sound assessment (US) and helical computed tomography (CT) of the pulmonary arteries are now being used instead of conven- tional methods like ventilation-perfusion scan and pulmonary angiography (1). For personal or educational use only. No other uses without permission. All rights reserved. Downloaded from www.thrombosis-online.com on 2018-03-18 | ID: 1001066444 | IP: 54.70.40.11