OBJECTIVES: To examine the diagnostic performance of CT of the pulmonary artery (CTPA) as a potential first-choice imaging modality in patients with pulmonary arterial hypertension and suspected chronic thromboembolic pulmonary hypertension (CTEPH). METHODS: A systematic review and meta-analysis were conducted in accordance with the PRISMA reporting checklist. Six scientific databases and registers (PubMed, EMBASE, Scopus, Web of Science, Cochrane, ClinicalTrials.gov ) were searched for studies evaluating the diagnostic performance of CTPA in suspected CTEPH in adult patients. Results were pooled separately for studies based on the evaluation of the pulmonary artery and those that relied solely on changes in parenchymal perfusion. RESULTS: Ten single-center studies with 734 patients were eligible for pooling of the diagnostic performance of CTPA by evaluation of the pulmonary artery. The pooled sensitivity, specificity, PPV, NPV, accuracy, and diagnostic odds ratio (DOR) estimates for CTPA in the detection of CTEPH were 0.98, 0.99, 0.94, 1.00, 0.96, 0.96, and 292. Evaluation of perfusion changes yielded pooled estimates for sensitivity, specificity, PPV, NPV, accuracy, and DOR of 0.99, 0.84, 0.79, 0.98, 0.89, 0.89, and 98 across four studies with 278 patients. Scintigraphy, SPECT, digital subtraction angiography, right heart catheterization, pulmonary endarterectomy, and international guidelines were used to establish the diagnosis. CONCLUSION: CTPA has high sensitivity and specificity in the detection of CTEPH when the examination is evaluated by expert radiologists. Evaluation of parenchymal perfusion alone is associated with slightly lower specificity. Further research is needed to determine the diagnostic performance of CTPA in excluding CTEPH in general radiology departments. KEY POINTS: • CT pulmonary angiography (CTPA) is recommended in the diagnostic workup of chronic thromboembolic pulmonary hypertension (CTEPH). • CTPA has high sensitivity and specificity in the detection of CTEPH when evaluated by an expert radiologist. • Evaluation of changes in parenchymal perfusion alone is associated with slightly lower specificity. • Little is known about the diagnostic performance of CTPA in the detection of CTEPH in general radiology departments.

Department of Anaesthesiology Resuscitation and Intensive Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague U Nemocnice 2 128 08 Prague 2 Czech Republic

Department of Radiology 1st Faculty of Medicine Charles University and General University Hospital Prague U Nemocnice 2 128 08 Prague 2 Czech Republic

Zobrazit více v PubMed

Sahay S (2019) Evaluation and classification of pulmonary arterial hypertension. J Thorac Dis 11:S1789–S1799 DOI

Gopalan D, Delcroix M, Held M (2017) Diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir Rev 26:160108 DOI

Klok FA, Couturaud F, Delcroix M, Humbert M (2020) Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Eur Respir J 55:2000189 DOI

Delcroix M, Torbicki A, Gopalan D et al (2021) ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 57:2002828 DOI

Goerne H, Batra K, Rajiah P (2018) Imaging of pulmonary hypertension: an update. Cardiovasc Diagn Ther 8:279–296 DOI

Lau EMT, Tamura Y, McGoon MD, Sitbon O (2015) The 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: a practical chronicle of progress. Eur Respir J 46:879–882 DOI

Remy-Jardin M, Ryerson CJ, Schiebler ML et al (2021) Imaging of pulmonary hypertension in adults: a position paper from the Fleischner Society. Eur Respir J 57:2004455 DOI

Tunariu N, Gibbs SJR, Win Z et al (2007) Ventilation–Perfusion Scintigraphy Is More Sensitive than Multidetector CTPA in Detecting Chronic Thromboembolic Pulmonary Disease as a Treatable Cause of Pulmonary Hypertension. J Nucl Med 48:680–684 DOI

Dong C, Zhou M, Liu D et al (2015) Diagnostic accuracy of computed tomography for chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis. PLoS One 10:e0126985

Lysdahlgaard S, Hess S, Gerke O, Weber Kusk M (2020) A systematic literature review and meta-analysis of spectral CT compared to scintigraphy in the diagnosis of acute and chronic pulmonary embolisms. Eur Radiol 30:3624–3633 DOI

Wang M, Wu D, Ma R et al (2020) Comparison of V/Q SPECT and CT angiography for the diagnosis of chronic thromboembolic pulmonary hypertension. Radiology 296:420–429 DOI

Page MJ, McKenzie JE, Bossuyt PM et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Syst Rev 10:89 DOI

Bartalena T, Oboldi D, Guidalotti PL et al (2008) Lung perfusion in patients with pulmonary hypertension: comparison between MDCT pulmonary angiography with minIP reconstructions and 99mTc-MAA perfusion scan. Invest Radiol 43:368–373 DOI

Reichelt A, Hoeper MM, Galanski M, Keberle M (2009) Chronic thromboembolic pulmonary hypertension: evaluation with 64-detector row CT versus digital subtraction angiography. Eur J Radiol 71:49–54 DOI

Nakazawa T, Watanabe Y, Hori Y et al (2011) Lung perfused blood volume images with dual-energy computed tomography for chronic thromboembolic pulmonary hypertension: correlation to scintigraphy with single-photon emission computed tomography. J Comput Assist Tomogr 35:590–595 DOI

He J, Fang W, Lv B et al (2012) Diagnosis of chronic thromboembolic pulmonary hypertension: comparison of ventilation/perfusion scanning and multidetector computed tomography pulmonary angiography with pulmonary angiography. Nucl Med Commun 33:459–463 DOI

Dournes G, Verdier D, Montaudon M et al (2014) Dual-energy CT perfusion and angiography in chronic thromboembolic pulmonary hypertension: diagnostic accuracy and concordance with radionuclide scintigraphy. Eur Radiol 24:42–51 DOI

Masy M, Giordano J, Petyt G et al (2018) Dual-energy CT (DECT) lung perfusion in pulmonary hypertension: concordance rate with V/Q scintigraphy in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). Eur Radiol 28:5100–5110 DOI

Fathala A, Aldurabi A (2021) Frequency of computed tomography abnormalities in patients with chronic thromboembolic pulmonary hypertension: a comparative study between lung perfusion scan and computed tomography pulmonary angiography. Multidiscip Respir Med 16:753 DOI

Schüβler A, Richter M, Tello K et al (2021) Evaluation of diagnostic accuracy and radiation exposure of dual-energy computed tomography (DECT) in the course of chronic thromboembolic pulmonary hypertension (CTEPH). Rofo 193:1318–1326 DOI

Kligerman S, Hsiao A (2021) Optimizing the diagnosis and assessment of chronic thromboembolic pulmonary hypertension with advancing imaging modalities. Pulm Circ 11:20458940211007376 DOI

Memon HA, Lin CH, Guha A (2016) Chronic thromboembolic pulmonary hypertension: pearls and pitfalls of diagnosis. Methodist Debakey Cardiovasc J 12:199–204

Boon GJAM, Jairam PM, Groot GMC et al (2021) Identification of chronic thromboembolic pulmonary hypertension on CTPAs performed for diagnosing acute pulmonary embolism depending on level of expertise. Eur J Intern Med 93:64–70 DOI

Renapurkar RD, Bolen MA, Shrikanthan S et al (2018) Comparative assessment of qualitative and quantitative perfusion with dual-energy CT and planar and SPECT-CT V/Q scanning in patients with chronic thromboembolic pulmonary hypertension. Cardiovasc Diagn Ther 8:41422–41422 DOI

Tamura M, Yamada Y, Kawakami T et al (2017) Diagnostic accuracy of lung subtraction iodine mapping CT for the evaluation of pulmonary perfusion in patients with chronic thromboembolic pulmonary hypertension: Correlation with perfusion SPECT/CT. Int J Cardiol 243:538–543 DOI

Aldosari S, Sun Z (2019) A systematic review of double low-dose CT pulmonary angiography in pulmonary embolism. Curr Med Imaging Rev 15:453–460 DOI

Sauter A, Koehler T, Fingerle AA et al (2016) Ultra low dose CT pulmonary angiography with iterative reconstruction. PLoS One 11:e0162716

Schembri GP, Miller AE, Smart R (2010) Radiation dosimetry and safety issues in the investigation of pulmonary embolism. Semin Nucl Med 40:442–454 DOI

Moore AJE, Wachsmann J, Chamarthy MR et al (2018) Imaging of acute pulmonary embolism: an update. Cardiovasc Diagn Ther 8:225–243 DOI

Thieme SF, Graute V, Nikolaou K et al (2012) Dual energy CT lung perfusion imaging - correlation with SPECT/CT. Eur J Radiol 81:360–365 DOI

Giordano J, Khung S, Duhamel A et al (2017) Lung perfusion characteristics in pulmonary arterial hypertension (PAH) and peripheral forms of chronic thromboembolic pulmonary hypertension (pCTEPH): Dual-energy CT experience in 31 patients. Eur Radiol 27:1631–1639 DOI

Meysman M, Everaert H, Buls N, Nieboer K, de Mey J (2015) Comparison of ventilation-perfusion single-photon emission computed tomography (V/Q SPECT) versus dual-energy CT perfusion and angiography (DECT) after 6 months of pulmonary embolism (PE) treatment. Eur J Radiol 84:1816–1819 DOI

Fully automated Bayesian analysis for quantifying the extent and distribution of pulmonary perfusion changes on CT pulmonary angiography in CTEPH

Even non-expert radiologists report chronic thromboembolic pulmonary hypertension (CTEPH) on CT pulmonary angiography with high sensitivity and almost perfect agreement