Michiels J J, Schroyens W, De Backer W, van der Planken M, Hoogsteden H, Pattynama P M T
Hemostasis Thrombosis Research, Department of Hematology, University Hospital, Antwerp, Belgium.
Int Angiol. 2003 Mar;22(1):1-14.
Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but no longer for its subsegmental PE, because the inter-observer agreement for angiographically documented subsegmental PE is only 60%. Two non-invasive tools exclude PE with a negative predictive value of > 99%: a normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test. The positive predictive value of a high probability ventilation-perfusion lung scan (VP-scan) is only 85% to 87%. The combination of a low clinical score and a non-diagnostic VP-scan safely exclude PE without the need of angiography. The prevalence of PE and that of an alternative diagnosis in symptomatic patients with a non-diagnostic VP-scan are 10% to 20% and 30% to 45%, respectively. Helical spiral computed tomography (CT) detects all clinically relevant PE and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic or high probability VP-scan. The positive predictive value of the spiral CT is > 95%. Single-slice helical CT as the primary diagnostic test in patients with suspected PE in retrospective outcome studies and in prospective multicenter management studies indicate that the negative predictive value of a negative spiral CT preceded or followed by a negative compression ultrasonography (CUS) is > 99%. Therefore, a helical spiral CT can replace both the VP-scan and pulmonary angiography to safely rule in and out PE. A negative rapid ELISA VIDAS D-dimer test result will reduce the need for helical spiral CT by 25% to 35%.
肺血管造影术是诊断节段性肺栓塞（PE）的金标准，但不再是亚段性肺栓塞的金标准，因为血管造影记录的亚段性肺栓塞的观察者间一致性仅为60%。两种非侵入性检查手段可排除PE，其阴性预测值>99%：灌注肺扫描正常和快速酶联免疫吸附测定法（ELISA）VIDAS D - 二聚体检测结果正常。高概率通气 - 灌注肺扫描（VP扫描）的阳性预测值仅为85%至87%。临床评分低且VP扫描结果未明确诊断的患者联合使用可安全地排除PE，无需进行血管造影。在VP扫描结果未明确诊断的有症状患者中，PE的患病率和可替代诊断的患病率分别为10%至20%和30%至45%。螺旋计算机断层扫描（CT）可检测出所有临床相关的PE以及大量VP扫描结果未明确诊断或高概率的有症状患者的可替代诊断。螺旋CT的阳性预测值>95%。在回顾性结局研究和前瞻性多中心管理研究中，将单层螺旋CT作为疑似PE患者的主要诊断检查表明，在螺旋CT阴性之前或之后进行的加压超声检查（CUS）阴性的阴性预测值>99%。因此，螺旋CT可替代VP扫描和肺血管造影术来安全地确诊或排除PE。快速ELISA VIDAS D - 二聚体检测结果为阴性将使螺旋CT的需求减少25%至35%。
