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Is the lung scan alive and well? Facts and controversies in defining the role of lung scintigraphy for the diagnosis of pulmonary embolism in the era of MDCT

Bibliographic reference Reid, John H. ; Coche, Emmanuel ; Inoue, Tomio ; Kim, Edmund E. ; Dondi, Maurizio ; et. al. Is the lung scan alive and well? Facts and controversies in defining the role of lung scintigraphy for the diagnosis of pulmonary embolism in the era of MDCT. In: European Journal of Nuclear Medicine and Molecular Imaging, Vol. 36, no. 3, p. 505-21 (2009)
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  1. Schoepf UJ. Diagnosing pulmonary embolism: time to rewrite the textbooks. Int J Cardiovasc Imaging 2005;21:155–63.
  2. O’Neill JM, Wright L, Murchison JT. Helical CTPA in the investigation of pulmonary embolism: a 6-year review. Clin Radiol 2004;59:819–25.
  3. 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;58:470–83.
  4. Rémy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, et al. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 2007;245:315–29.
  5. Worsley DF, Alavi A. Radionuclide imaging of acute pulmonary embolism. Semin Nucl Med 2003;33:259–78.
  6. Soudry Gabriel, Dibos Pablo E., Gated Myocardial Perfusion Scan Leading to Diagnosis of Unsuspected Massive Pulmonary Embolism, 10.7326/0003-4819-132-10-200005160-00028
  7. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353(9162):1386–9.
  8. Douketis JD, Kearon C, Bates S, Duku EK, Ginsberg JS. Risk of fatal pulmonary embolism in patients with treated venous thromboembolism. JAMA 1998;279:458–62.
  9. Stein PD, Terrin ML, Hales CA, et al. Clinical laboratory, roentgenographic and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease. Chest 1991;100:598–603.
  10. Goldhaber SZ. Pulmonary embolism. Lancet 2004;363(9417):1295–305.
  11. Kelly J, Hunt BJ. The utility of pretest probability assessment in patients with clinically suspected venous thromboembolism. J Thromb Haemost 2003;1:1888–96.
  12. Worsley D F, Alavi A, Aronchick J M, Chen J T, Greenspan R H, Ravin C E, Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study., 10.1148/radiology.189.1.8372182
  13. Miniati M, Pistolesi M, Marini C, Di Ricco G, Formichi B, Prediletto R, Allescia G, Tonelli L, Sostman H D, Giuntini C, Value of perfusion lung scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISA-PED)., 10.1164/ajrccm.154.5.8912753
  14. Kelly J, Rudd A, Hunt BJ, Lewis RR. Plasma D-dimers in the diagnosis of venous thromboembolism. Arch Intern Med 2002;162:747–56.
  15. Ljungqvist M, Söderberg M, Moritz P, Ahlgren A, Lärfars G. Evaluation of Wells score and repeated D-dimer in diagnosing venous thromboembolism. Eur J Intern Med 2008;19:285–8.
  16. 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.
  17. Wagner HN Jr, Sabiston DC Jr, McAfee JG, Tow D, Stern HS. Diagnosis of massive pulmonary embolism in man by radioisotope scanning. N Engl J Med 1964;271:377–84.
  18. Taplin GV, Johnson DE, Dore EK, Kaplan HS. Lung photoscan with macroaggregates of human serum radioalbumin. Experimental basis and initial clinical trials. Health Phys 1964;10:1219–27.
  19. Dalen JE, Brooks HL, Johnson LW, Meister SG, Szucs MM Jr, Dexter L. Pulmonary angiography in acute pulmonary embolism: indications, techniques, and results in 367 patients. Am Heart J 1971;81:175–85.
  20. Paraskos VA, Adelstein SJ, Smith RE, et al. Late prognosis of acute pulmonary embolism. N Engl J Med 1973;289:55–8.
  21. Potchen EJ, Evens RG. The physiologic factors affecting regional ventilation and perfusion. Semin Nucl Med 1971;1:153–60.
  22. Sostman HD, Neumann RD. The respiratory system. In: Harbert JC, Eckelman WC, Neumann RD, editors. Nuclear medicine – diagnosis and therapy. New York, NY: Thieme Medical Publishers; 1996. p. 553–84.
  23. Lowe VJ, Sostman HD. Pulmonary embolism. In: Ell PJ, Gambhir SS, editors. Nuclear medicine in clinical diagnosis and treatment. 3rd ed. New York, NY: Churchill Livingstone; 2004. p. 29–46.
  24. Wolfe WG, Sabiston DC Jr. Radioactive ventilation scanning in the diagnosis of pulmonary embolism. J Thorac Cardiovasc Surg 1968;55:149–59.
  25. Austin JHM, Sagel SS. Alterations of airway caliber after pulmonary embolization in the dog. Invest Radiol 1972;7:135–9.
  26. Levy SE, Simmons DH. Redistribution of alveolar ventilation following pulmonary thromboembolism in the dog. J Appl Physiol 1974;36:60–8.
  27. Dantzker D. R., Wagner P. D., Tornabene V. W., Alazraki N. P., West J. B., Gas exchange after pulmonary thromboemoblization in dogs, 10.1161/01.res.42.1.92
  28. Santolicandro A, Prediletto R, Fornai E, Formichi B, Begliomini E, Giannella-Neto A, Giuntini C, Mechanisms of hypoxemia and hypocapnia in pulmonary embolism., 10.1164/ajrccm.152.1.7599843
  29. COMROE J. H., The Main Functions of the Pulmonary Circulation, 10.1161/01.cir.33.1.146
  30. Severinghaus JW, Swenson EW, Finley TN, et al. Unilateral hypoventilation produced in dogs by occluding one pulmonary artery. J Appl Physiol 1961;16:53–60.
  31. Swenson EW, Finley TN, Guzman SV. Unilateral hypoventilation in man during temporary occlusion of one pulmonary artery. J Clin Invest 1961;40:828–35.
  32. Allgood RJ, Wolfe WG, Ebert PA, Sabiston DC Jr. Effects of carbon dioxide on bronchoconstriction after pulmonary artery occlusion. Am J Physiol 1968;214:772–5.
  33. D’Angelo E, Salvo Calderini T, Tavola M. The effects of CO2 on respiratory mechanics in anesthetized paralyzed humans. Anesthesiology 2001;94:604–10.
  34. Finley TN, Tooley WH, Swenson EW, Gardner RE, Clements JA. Pulmonary surface tension in experimental atelectasis. Am Rev Respir Dis 1964;89:372–7.
  35. Naimark A. Pulmonary blood flow and the incorporation of palpitate-I-C14 by dog lung in vivo. J Appl Physiol 1966;21:1292–8.
  36. Chernick V, Hodson WA, Greenfield LJ. Effect of chronic pulmonary artery ligation on pulmonary mechanics and surfactant. J Appl Physiol 1966;21:1315–20.
  37. Hampton AO, Castleman B. Correlation of postmortem chest tele-roentgenograms with autopsy findings – with special reference to pulmonary embolism and infarction. Am J Roentgenol Rad Ther 1940;43:305–26.
  38. McNeil BJ, Holman BL, Adelstein SJ. The scintigraphic definition of pulmonary embolism. JAMA 1974;227:753–6.
  39. Goldhaber SZ, Hennekens CH, Evans DA, Newton EC, Godleski JJ. Factors associated with correct antemortem diagnosis of major pulmonary embolism. Am J Med 1982;73:822–6.
  40. Hull RD, Hirsh J, Carter CJ, Raskob GE, Gill GJ, Jay RM, et al. Diagnostic value of ventilation-perfusion lung scanning in patients with suspected pulmonary embolism. Chest 1985;88:819–28.
  41. The PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 1990;263:2753–9.
  42. Bomanji JB. Confession and some lessons – The PISA-PED study (letter). Chest 1995;108:1475–6.
  43. Stein PD. Confession and some lessons – The PISA-PED study (letter). Chest 1995;108:1476.
  44. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al. Multidetector computer tomography for acute pulmonary embolism. N Engl J Med 2006;354:2317–27.
  45. Dalen JE. New PIOPED recommendations for the diagnosis of pulmonary embolism. Am J Med 2006;119:1001–2.
  46. Stein PD, Woodard PK, Weg JG, Wakefield TW, Tapson VF, Sostman HD, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators. Am J Med 2006;119:1048–55.
  47. Sostman HD, Stein PD, Gottschalk A, Matta F, Hull R, Goodman L. Acute pulmonary embolism: sensitivity and specificity of ventilation-perfusion scintigraphy in PIOPED II study. Radiology 2008;246:941–6.
  48. MINIATI MASSIMO, PREDILETTO RENATO, FORMICHI BRUNO, MARINI CARLO, Di RICCO GIORGIO, TONELLI LUCIA, ALLESCIA GERMANA, PISTOLESI MASSIMO, Accuracy of Clinical Assessment in the Diagnosis of Pulmonary Embolism, 10.1164/ajrccm.159.3.9806130
  49. Stein PD, Terrin ML, Gottschalk A, Alavi A, Henry JV. Value of ventilation/perfusion scans compared to perfusion scans alone in acute pulmonary embolism. Am J Cardiol 1992;69:1239–41.
  50. Giuntini C. Ventilation/perfusion scan and the dead space in pulmonary embolism: are they useful for diagnosis. Q J Nucl Med 2001;45:281–6.
  51. Miniati M, Sostman HD, Gottschalk A, Monti S, Pistolesi M. Perfusion lung scintigraphy for the diagnosis of pulmonary embolism: A reappraisal and review of the prospective investigative study of pulmonary embolism diagnosis methods. Semin Nucl Med 2008;(in press).
  52. Sostman HD, Miniati M, Gottschalk A, Matta F, Stein PD, Pistolesi M. Sensitivity and specificity of perfusion scintigraphy combined with chest radiography for acute pulmonary embolism in PIOPED II. J Nucl Med 2008;49:1741–8.
  53. Gottschalk A, Sostman HD, Coleman RE, Juni JE, Thrall J, McKusick KA, et al. Ventilation-perfusion scintigraphy in the PIOPED study. Part II. Evaluation of the scintigraphic criteria and interpretation. J Nucl Med 1993;34:1119–26.
  54. Reinartz P, Wildberger JE, Schaefer W, Nowak B, Mahnken AH, Buell U. Tomographic imaging in the diagnosis of pulmonary embolism: a comparison between V/Q lung scintigraphy in SPECT technique and multislice spiral CT. J Nucl Med 2004;45:1501–8.
  55. Harris B, Bailey D, Miles S, Bailey E, Rogers K, Roach P, et al. Objective analysis of tomographic ventilation-perfusion scintigraphy in pulmonary embolism. Am J Respir Crit Care Med 2007;175:1173–80.
  56. Harris B, Bailey D, Roach P, Bailey E, King G. Fusion imaging of computed tomographic pulmonary angiography and SPECT ventilation/perfusion scintigraphy: initial experience and potential benefits. Eur J Nucl Med Mol Imaging 2006;34:135–42.
  57. Hata T, Ikeda M, Nakamori S, et al. Single-photon emission computed tomography in the screening for postoperative pulmonary embolism. Dig Dis Sci 2006;51:2073–80.
  58. Harris B, Bailey DL, Roach PJ, et al. A clinical comparison between traditional planar V/Q images and planar images generated from SPECT V/Q scintigraphy. Nucl Med Commun 2008;29:323–30.
  59. Reinartz P, Kaiser H-J, Wildberger JE, et al. SPECT imaging in the diagnosis of pulmonary embolism: automated detection of match and mismatch defects by means of image processing techniques. J Nucl Med 2006;47:968–73.
  60. White Charles S., Kuo Dick, Kelemen Mark, Jain Vineet, Musk Amy, Zaidi Eram, Read Katrina, Sliker Clint, Prasad Rajnish, Chest Pain Evaluation in the Emergency Department: Can MDCT Provide a Comprehensive Evaluation?, 10.2214/ajr.185.2.01850533
  61. White CS, Kuo D. Chest pain in the emergency department: role of multidetector CT. Radiology 2007;245:672–81.
  62. Rubinsthein R, Halon DA, Gaspar T, et al. Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation 2007;115:1762–8.
  63. Coche E, Vlassenbroek 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;15:1432–40.
  64. Dogan H, Kroft LJM, Huisman MV, van der Geest RJ, de Roos A. Right ventricular function in patients with acute pulmonary embolism: analysis with electrocardiography-synchronized multi-detector row CT. Radiology 2006;242:78–84.
  65. Bogot NR, Shaham D, Nissenbaum I, Amin-Spector S, Libson E, Sosna J. Single-source dual energy MDCT: impact on attenuation in pulmonary CT angiography (abstract). RSNA Meeting 25–30 November 2007, Chicago. SSG21-06.
  66. Fink C, Johnson TRC, Nikolaou K, Krauss B, Reiser M, Becker C, et al. Dual-energy CTA of pulmonary embolism: a pilot study (abstract). RSNA Meeting 25–30 November 2007, Chicago. SSG21-07.
  67. Fontana F, Faivre J, Remy-Jardin M, Flohr TG, Pansini V, Remy J. Lung perfusion with dual-energy multidetector-row CT (MDCT): application to the management of acute pulmonary embolism (abstract). RSNA Meeting 25–30 November 2007, Chicago. SSG21-08.
  68. Chan HP, Hadjiiski L, Zhou C, Sahiner B. Computer-aided diagnosis of lung cancer and pulmonary embolism in computed tomography – a review. Acad Radiol 2008;15:535–55.
  69. Oudkerk M, van Beek EJ, Wielopolski 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;359:1643–7.
  70. 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;187:7–14.
  71. Broder J, Warshauer DM. Increasing utilization of computed tomography in the adult emergency department. Emerg Radiol 2006;13:25–30.
  72. Wells Philip S., Use of a Clinical Model for Safe Management of Patients with Suspected Pulmonary Embolism, 10.7326/0003-4819-129-12-199812150-00002
  73. Wicki J, Perneger TV, Junod AF, Bounameaux H, Perrier A. Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score. Arch Intern Med 2001;161:92–7.
  74. Eisner MD. Before diagnostic testing for pulmonary embolism: estimating the prior probability of disease. Am J Med 2003;114:232–4.
  75. Miniati M, Monti S, Bottai M. A structured clinical model for predicting the probability of pulmonary embolism. Am J Med 2003;114:173–9.
  76. McLean RG, Carolan M, Bui C, et al. Comparison of new clinical and scintigraphic algorithms for the diagnosis of pulmonary embolism. Br J Radiol 2004;77:372–6.
  77. Rosen MP, Rose K, Davis RB. Work-up of patients with malignancy after an intermediate-probability ventilation-perfusion scan: why don’t physicians pursue a definitive diagnosis. Acad Radiol 1997;4:806–11.
  78. Rosen MP, Sands DZ, Kuntz KM. Physicians’ attitudes toward misdiagnosis of pulmonary emboli: a utility analysis. Acad Radiol 2000;7:14–20.
  79. Khorasani R, Gudas T F, Nikpoor N, Polak J F, Treatment of patients with suspected pulmonary embolism and intermediate-probability lung scans: is diagnostic imaging underused?, 10.2214/ajr.169.5.9353458
  80. Landefeld CS, McGuire E, Rosenblatt MW. A bleeding risk index for estimating the probability of major bleeding in hospitalized patients starting anticoagulant therapy. Am J Med 1990;89:569–78.
  81. Redelmeier DA. Cognitive psychology and medical judgement: some downfalls of studying pitfalls. Med Decis Making 1991;11:169–70.
  82. Tversky A, Kahneman D. The framing of decisions and the psychology of choice. Science 1981;211:453–8.
  83. Anderson DR, Kahn SR, Rodger MA, Kovacs MJ, et al. Computed tomographic pulmonary angiography vs ventilation-perfusion lung scanning in patients with suspected pulmonary emboli. JAMA 2007;298:2743–53.
  84. Schoepf UJ, Holzknecht N, Helmberger TK, et al. Subsegmental pulmonary emboli: improved detection with thin-collimation multi-detector row spiral CT. Radiology 2002;222:483–90.
  85. Ghaye Benoit, Szapiro David, Mastora Ioana, Delannoy Valérie, Duhamel Alain, Remy Jacques, Remy-Jardin Martine, Peripheral Pulmonary Arteries: How Far in the Lung Does Multi-Detector Row Spiral CT Allow Analysis?, 10.1148/radiology.219.3.r01jn32629
  86. Coche E, Pawlak S, Dechambre S, Maldague B. Peripheral pulmonary arteries: identification at multi-slice spiral CT with 3D reconstruction. Eur Radiol 2003;13:815–22.
  87. Storto Maria Luigia, Di Credico Angela, Guido Francesca, Larici Anna Rita, Bonomo Lorenzo, Incidental Detection of Pulmonary Emboli on Routine MDCT of the Chest, 10.2214/ajr.184.1.01840264
  88. Ritchie G, McGurk S, Graham C, Murchison GT. Prospective evaluation of unsuspected pulmonary embolism on contrast enhanced multidetector CT (MDCT). Thorax 2007;62:536–40.
  89. Engelke C, Manstein P, Rummeny EJ, Marten K. Suspected and incidental pulmonary embolism on multidetector-row CT: analysis of technical and morphological factors influencing the diagnosis in a cross-sectional cancer centre patient cohort. Clin Radiol 2006;61:71–80.
  90. Gurney J W, No fooling around: direct visualization of pulmonary embolism., 10.1148/radiology.188.3.8351321
  91. Moser Kenneth M., Venous Thromboembolism, 10.1164/ajrccm/141.1.235
  92. Tillie-Leblond Isabelle, Marquette Charles-Hugo, Perez Thierry, Scherpereel Arnaud, Zanetti Christophe, Tonnel André-Bernard, Remy-Jardin Martine, Pulmonary Embolism in Patients with Unexplained Exacerbation of Chronic Obstructive Pulmonary Disease: Prevalence and Risk Factors, 10.7326/0003-4819-144-6-200603210-00005
  93. Tetalman Marc R., Hoffer Paul B., Heck Larry L., Kunzmann Axel, Gottschalk Alexander, Perfusion Lung Scan in Normal Volunteers, 10.1148/106.3.593
  94. Novelline Robert A., Baltarowich Oksana H., Athanasoulis Christos A., Waltman Arthur C., Greenfield Alan J., McKusick Kenneth A., The Clinical Course of Patients with Suspected Pulmonary Embolism and a Negative Pulmonary Arteriogram, 10.1148/126.3.561
  95. Goodman L. Small pulmonary emboli: what do we know. Radiology 2005;234:654–8.
  96. Desai SR. Unsuspected pulmonary embolism on CT scanning: yet another headache for clinicians. Thorax 2007;62:470–2.
  97. Hull R, Raskob GE, Ginsberg JS, et al. A noninvasive strategy for the treatment of patients with suspected pulmonary embolism. Arch Intern Med 1994;154:289–97.
  98. Patriquin L, Khorasani R, Polak J F, Correlation of diagnostic imaging and subsequent autopsy findings in patients with pulmonary embolism., 10.2214/ajr.171.2.9694449
  99. Oser R F, Zuckerman D A, Gutierrez F R, Brink J A, Anatomic distribution of pulmonary emboli at pulmonary angiography: implications for cross-sectional imaging., 10.1148/radiology.199.1.8633168
  100. Nielsen HK, Husted SE, Krusell LR, Fasting H, Charles P, Hansen HH. Silent pulmonary embolism in patients with deep venous thrombosis: incidence and fate in a randomised, controlled trial of anticoagulation versus no anticoagulation. J Intern Med 1994;235:457–61.
  101. Eyer Benjamin A., Goodman Lawrence R., Washington Lacey, Clinicians' Response to Radiologists' Reports of Isolated Subsegmental Pulmonary Embolism or Inconclusive Interpretation of Pulmonary Embolism Using MDCT, 10.2214/ajr.184.2.01840623
  102. Gleeson Tadhg G., Bulugahapitiya Sudi, Contrast-Induced Nephropathy, 10.2214/ajr.183.6.01831673
  103. Scarsbrook AF, Gleeson FV. Investigating suspected pulmonary embolism in pregnancy. BMJ 2007;334(7590):418–9.
  104. Parker MS, Hui FK, Camacho MA, Chung JK, Broga BW, Sethi NN. Female breast radiation exposure during CT pulmonary angiography. AJR Am J Roentgenol 2005;185:1228–33.
  105. Scarsbrook A, Bradley K, Gleeson F. Perfusion scintigraphy still has important role in evaluation of majority of pregnant patients with suspicion of pulmonary embolism. Radiology 2007;244:623–5.
  106. Groves AM, Yates SJ, Win T, et al. CT pulmonary angiography versus ventilation-perfusion scintigraphy in pregnancy implications from a UK survey of doctors’ knowledge of radiation exposure. Radiology 2006;240:765–70.
  107. Palla A, Formichi B, Santolicandro A, Di Ricco G, Giuntini C. From not detected pulmonary embolism to diagnosis of thromboembolic pulmonary hypertension: a retrospective study. Respiration 1993;60:9–14.
  108. Konstantinides S, Geibel A, Heusel G, Heinrich F, Kasper W; Management Strategies and Prognosis of Pulmonary Embolism-3 Trial Investigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002;347:1143–50.
  109. Pengo V, Lensing AW, Prins MH, Marchiori A, Davidson BL, Tiozzo F, et al.; Thromboembolic Pulmonary Hypertension Study Group. Incidence of chronic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004;350:2257–64.
  110. Miniati M, Monti S, Bottai M, Scoscia E, Bauleo C, Tonelli L, et al. Survival and restoration of pulmonary perfusion in a long-term follow-up of patients after acute pulmonary embolism. Medicine (Baltimore) 2006;85:253–62.
  111. Donnamaria V, Palla A, Petruzzelli S, Carrozzi L, Pugliesi O, Giuntini C. Early and late follow-up of pulmonary embolism. Respiration 1993;60:15–20.
  112. Palla A, Donnamaria V, Petruzzelli S, Giuntini C. Follow-up of pulmonary perfusion recovery after embolism. J Nucl Med Allied Sci 1986;30:23–8.
  113. Parker J A, Markis J E, Palla A, Goldhaber S Z, Royal H D, Tumeh S, Kim D, Rustgi A K, Holman B L, Kolodny G M, Pulmonary perfusion after rt-PA therapy for acute embolism: early improvement assessed with segmental perfusion scanning., 10.1148/radiology.166.2.3122266
  114. Prediletto R, Paoletti P, Fornai E, Perissinotto A, Petruzzelli S, Formichi B, et al. Natural course of treated pulmonary embolism. Evaluation by perfusion lung scintigraphy, gas exchange, and chest roentgenogram. Chest 1990;97:554–61.
  115. Menéndez R, Martínez E, Nauffal D, Gil Suay V, Marco V. Influence of cardiopulmonary disease on resolution of pulmonary embolism. A mathematical model to predict remaining defects at six months. Respiration 1996;63:267–71.
  116. Palla A, Pazzagli M, Manganelli D, De Nitto P, Marini C, Rossi G, et al. Resolution of pulmonary embolism: effect of therapy and putative age of emboli. Respiration 1997;64:50–3.
  117. Wartski M, Collignon MA. Incomplete recovery of lung perfusion after 3 months in patients with acute pulmonary embolism treated with antithrombotic agents. THESEE Study Group. Tinzaparin ou Heparin Standard: Evaluation dans l’Embolie Pulmonaire Study. J Nucl Med 2000;41:1043–8.
  118. Becattini C, Agnelli G, Pesavento L, Silingardi M, Poggio R, Taliani MR, Ageno W. Incidence of chronic thromboembolic pulmonary hypertension after a first episode of pulmonary embolism. Chest 2006;130:172–5.
  119. Lang IM. Chronic thromboembolic pulmonary hypertension: not so rare after all. N Engl J Med 2004;350:2236–8.
  120. Tunariu N, Gibbs SJR, Win Z, Gin-Sing W, Graham A, Gishen P, et al. 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 2007;48:680–4.
  121. Munechika H, Hiramatsu Y, Kudo S, Sugimura K, Hamada C, Yamaguchi K, et al. A prospective survey of delayed adverse reactions to iohexol in urography and computed tomography. Eur Radiol 2003;13:185–94.
  122. Tramer MR, von Elm E, Loubeyre P, Hauser C. Pharmacological prevention of serious anaphylactic reactions due to iodinated contrast media: systematic review. BMJ 2006;333:675.