Role of Computed Tomography and Magnetic Resonance

Imaging for Deep Venous Thrombosis and

Pulmonary Embolism
Jeffrey P. Kanne, MD; Tasneem A. Lalani, MD
AbstractDuring the 1990s, computed tomography (CT) and magnetic resonance (MR) imaging underwent extensive
technological advancement and expanded clinical use in patients with venous thromboembolic disease, particularly with
regard to evaluation of the pulmonary vasculature. In many institutions, helical (spiral) CT pulmonary angiography has
become the initial imaging study of choice to evaluate patients with suspected pulmonary embolism, supplanting
ventilation/perfusion scintigraphy. In addition, CT venography of the pelvis and lower extremities is often incorporated
into the CT angiography protocol to identify or exclude concurrent deep venous thrombosis. MR pulmonary angiography and
MR venography are second-line diagnostic tools because of their higher cost, limited availability, and other logistical
constraints. As the technology improves and becomes more widely available, MR imaging may play a greater role in the
evaluation of patients with venous thromboembolic disease. (Circulation. 2004;109[suppl I]:I-15-I-21.)
Key Words: thrombosis pulmonary heart disease imaging MRI

uring the 1990s, technological advances in computed

tomography (CT) and magnetic resonance (MR) imaging made these techniques applicable to the diagnosis of
venous thromboembolic disease, particularly for the pulmonary vasculature in patients with suspected pulmonary embolism (PE). At the opening of the third millennium, in many
institutions, helical (spiral) CT pulmonary angiography
(CTPA) has become the initial imaging study of choice for
evaluating patients with suspected PE, supplanting ventilation/perfusion (V/Q) scintigraphy by reducing indeterminate
examinations.1 4 CT venography (CTV) of the pelvic and
lower extremity veins after CTPA of the pulmonary arteries
has been advocated by some as an adjunct to helical CT for
detection of concurrent deep venous thrombosis (DVT) using
a single imaging technique for detection of venous thromboembolic disease.
Although MR imaging produces high tissue contrast without ionizing radiation, currently, this technique is less popular
than CT for evaluation of acute venous thromboembolism
(VTE) because of technical limitations, higher costs, limited
availability, and other logistical considerations. As technology improves, however, MR pulmonary angiography
(MRPA) and MR venography (MRV) may play a greater role
in the evaluation of patients with venous thromboembolic
disease.
This article reviews applications of CT and MR imaging in
the clinical evaluation of patients with suspected venous
thromboembolic disease.

CT Pulmonary Angiography
CTPA has gained acceptance as a first-line imaging study in
cases of suspected acute PE, replacing traditional V/Q scintigraphy at many institutions. In general, V/Q scanning is
reserved for patients in whom motion artifact or poor right
heart function limit the quality of CT examination and those
with contraindications to intravenous radiographic contrast.
After contrast administration, CTPA provides visualization
of the pulmonary arterial system in the axial plane, and
multiplanar and three-dimensional reconstructions can be
generated from raw data to enhance diagnostic accuracy. The
cardinal sign of acute PE on CTPA is an intravascular filling
defect in a pulmonary artery that partially or completely
occludes the vessel and is often associated with increased
diameter of the affected vessel (Figures 1 through 3). The
most specific sign of acute PE is a filling defect that forms
acute angles with the vessel wall. Although the filling defect
of acute PE can produce obtuse angles or complete occlusion
of the vessel, these patterns are also seen in cases of chronic
thromboembolic disease.2,3
The sensitivity and specificity of CTPA for diagnosis of
acute PE have been reported to range from 53% to 100% and
67% to 100%, respectively, varying on the basis of patient
selection, extent of thrombus, area of the vasculature imaged,
interpretation criteria, and experience of the reader.1 Moreover, technological advances over the last 10 years have
improved spatial resolution (thinner collimation), abbreviated
image acquisition time, and enabled multislice imaging.

From the Department of Radiology, University of Washington School of Medicine, Seattle.

Correspondence to Tasneem A. Lalani, MD, Department of Radiology, University of Washington School of Medicine, Box 357115, Seattle WA 98195
to 7115. E-mail tal99@u.washington.edu
2004 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org

DOI: 10.1161/01.CIR.0000122871.86662.72

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Circulation

March 30, 2004

Figure 1. Image from CT pulmonary angiogram of a 67-year-old

man with cancer and symptoms of syncope and hypoxia. Large
clot (arrows) is present at the bifurcation of the main pulmonary
artery, extending into the left and right pulmonary arteries.

Using thin (2 mm) collimation, sensitivities of 94% to 96%

and specificities of 94% to 100% have been achieved.5,6
Although normal V/Q scintigraphy essentially excludes
PE, a high-probability V/Q scan has a sensitivity of 88% for
PE compared with pulmonary angiography. In the prospective investigation of pulmonary embolism diagnosis (PIOPED) study, only 41% of patients with PE had a highprobability scan,7 and 57% of patients had nondiagnostic
(indeterminate or low-probability) V/Q scans. In other studies, CTPA demonstrated acute PE in 14% to 44% of patients
with nondiagnostic V/Q scans, including several in whom
lower extremity ultrasound imaging did not find DVT.8 11
CTPA gave the correct diagnosis in 92% of cases with
discordant V/Q and CTPA12 and, when used as the initial
diagnostic examination in cases of suspected PE, reader
confidence was significantly higher with CTPA than with
V/Q scanning (90% versus 54%, respectively).13
For PE in the main, lobar, or segmental pulmonary arteries,
the diagnostic accuracy of CTPA compares favorably with
that of pulmonary angiography,14 16 but how best to evaluate
the subsegmental pulmonary arteries remains controversial.
The subsegmental pulmonary arteries are more difficult to
evaluate because of their smaller size, limited contrast enhancement in relation to the finite spatial resolution of CT,
and the orientation of these vessels in space.17 The true
incidence of isolated subsegmental PE is unknown, and
reported incidences vary widely (4% to 17%), depending on
patient population and other factors. However, in large series,
isolated subsegmental emboli were identified in 4% to 6% of
patients with clinically suspected PE.7,18 20 The clinical
significance of isolated subsegmental pulmonary emboli also
is unclear, especially in patients without evidence of DVT or
cardiopulmonary dysfunction. Although many clinicians still
hold pulmonary angiography as the gold standard, balloon
occlusion studies have shown that even pulmonary angiogra-

Figure 2. A, Image from a CT pulmonary angiogram of a

90-year-old woman with dyspnea and hypoxia showing a large
clot (arrow) in the left lower lobe pulmonary artery. B, More caudal image shows multiple clots (short arrows) in the lower lobe
segmental arteries. Patchy right lower lobe subsegmental (long
arrows) atelectasis is present.

phy can miss subsegmental PE21,22 and interobserver agreement is poor (13% to 66%).18,23,24 One study comparing thin
collimation (1 mm) CTPA and pulmonary angiography in a
cast porcine model showed no statistical difference in sensitivity between the two modalities at the subsegmental levels
(each 87%).25
It has been suggested that clinical outcome (rather than
pulmonary angiography) serve as the standard against which

Figure 3. Single image from CT venography of a 45-year-old

man with burns and hypoxia showing a filling defect (arrow) in
the right popliteal vein, consistent with deep venous thrombosis.
CT pulmonary angiography showed acute pulmonary embolism.

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Kanne and Lalani

to evaluate the diagnostic accuracy of the various imaging
modalities for acute PE.26 The majority of subsequent PEs
occur within the first few weeks after an index event, with
50% of recurrences and 90% of PE-related deaths occurring
within the first 2 weeks.27,28 In patients with chronic underlying risk factors such as malignancy, however, the occurrence of a thromboembolic event after a negative diagnostic
examination for VTE does not mean that the original examination was necessarily a false-negative result. In several
outcome studies limited by a relatively high proportion of
patients lost to follow-up and relatively sparse autopsy data,
patients with negative CTPA were monitored without anticoagulation with negative predictive values ranging from 93%
to 100%;1,6,9,29 38 these results are comparable to those
obtained with pulmonary angiography.39 46
Detailed delineation of the pulmonary parenchyma and
extrapulmonary structures by CTPA offers additional information about the lungs and pleura not provided by V/Q
scintigraphy or pulmonary angiography. In one study, CTPA
identified pleural or parenchymal abnormalities that explained indeterminate defects on V/Q scans in 57% of
patients;11 in other studies, alternative intrathoracic findings
were identified in 11% to 85% of patients undergoing
CTPA;6,8,9,13,32,4751 these additional findings were nonspecific, occurring both in patients with and without PE.52
Although other such intrathoracic abnormalities may not
imply a need for further evaluation, their identification may
affect patient management.
Identification of PE on CTPA is a clear indication for
initiating appropriate therapy, but uncertainty about subsegmental thromboemboli contributes to ongoing uncertainty
about the diagnostic accuracy of both CTPA and pulmonary
angiography. As multislice CT technology becomes more
commonplace, future studies employing thinner collimation,
faster scan times, and cardiac gating are expected to result in
better visualization of the smaller pulmonary arteries, and
these enhancements may ultimately determine whether a
negative CTPA is sufficient evidence to withhold therapy
from a patient with signs or symptoms suggestive of PE.

Multislice CT
In the past several years, multislice CT has become commonplace in major U.S. medical centers. Most university medical
centers and other tertiary care centers have at least one
multislice scanner. Sixteen-slice scanners, now offered by
most vendors, are currently appearing in many radiology
departments and offer even faster scan times, result in lower
radiation doses than 4- and 8-slice scanners, and provide
isotropic imaging (z-axis spatial resolution equal to x- and
y-axis spatial resolution). As availability of these newer
multislice scanners increases, updated studies of the diagnostic accuracy of CTPA using newer techniques can be
expected.

CT Venography for Diagnosis of DVT

Duplex ultrasound, including both gray-scale and Doppler
imaging examination of the lower extremity venous system,
has replaced conventional venography as the first-line diagnostic test for DVT, with reported sensitivity and specificity

CT and MRI to Diagnose DVT and PE

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Advantages and Disadvantages of CTV

Advantages
One exam for both DVT and PE
High diagnostic accuracy similar to colorflow duplex and CTPA
Detects other nonthromboembolic pathology (eg, cancer)
After-hours availability (unlike duplex in many locations)
Drawbacks
Iodinate contrast nephrotoxicity
Radiation exposure
Cannot be performed at bedside (risk of transporting critically ill)
Higher cost
Accuracy in diagnosis of calf vein thrombosis
Streak artifact

above 90% in symptomatic patients.53 Ultrasound imaging

can be performed at the bedside, does not involve ionizing
radiation, is noninvasive, and is relatively inexpensive. The
technical quality of the examination depends on operator
skill, however, and evaluation of the pelvic and calf veins is
limited.54 56 In many institutions, ultrasound may not be as
readily available after hours as CTV.
CTV provides direct imaging of the inferior vena cava,
pelvic, and lower extremity veins immediately after CTPA
without injection of additional contrast material, adding only
a few minutes to the examination. Because DVT is the most
important factor predisposing to PE,56 a single examination
capable of evaluating both the pulmonary arterial system and
the pelvic and lower extremity venous system offers distinct
advantages over other tests directed at either diagnosis alone.
Combined CTPA/CTV fills this role, and the results of one
component can be used to guide therapy when the complementary component is not diagnostic, increasing the overall
cost-effectiveness.57,58
Like CTPA, CTV is occasionally plagued by technical
limitations such as streak artifact from orthopedic hardware
or poor venous enhancement. Table 1 summarizes the advantages and disadvantages of CTV. Additionally, errors in
interpretation related to anomalous vessels, adjacent pathology, and reader inexperience may result in inaccurate interpretation. The reported sensitivity and specificity of CTV has
been reported between 89% to 100% and 94% to 100%,
respectively.60 62 In one of the largest series, CTV was 97%
sensitive and 100% specific for femoropopliteal DVT.63 A
more recent study using multislice CT showed a sensitivity of
100% and specificity of 97% and positive and negative
predictive values of 92% and 100%, respectively.64
There are several drawbacks to combining CTV with
CTPA as a single comprehensive imaging modality for VTE.
In a number of published studies of combined CTPA and
CTV, 150 mL of iodinated contrast was required to produce
adequate opacification of the pulmonary arteries and pelvic
and lower extremity veins,61,63 68 more than the amount
usually required for adequate opacification of the pulmonary
arteries alone. Given that the nephrotoxicity of iodinated
radiocontrast is dose related,69 minimizing the dose is important, especially in critically ill patients with underlying renal

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March 30, 2004

Figure 4. Coronal image from MR pulmonary angiogram shows

focus of low signal (arrow) in the left main pulmonary artery
consistent with pulmonary embolism. The mural-based morphology suggests this clot is chronic (Courtesy of Michael B. Gotway, MD; San Francisco, Calif).

insufficiency or in those who require multiple imaging

procedures over a short period of time.
Exposure to ionizing radiation is also greater with combined CTRA/CTV over either test alone, and this is particularly pertinent to radiosensitive tissues such as the ovaries and
testes. Protocols using spaced sections rather than helical
acquisition help reduce radiation doses but risk missing
smaller venous thrombi.63 Although concern about exposure
need not preclude clinically indicated examinations, physicians should be aware of the deleterious effects, particularly
in younger patients, and remember that CT imaging contributes to the bulk of medical radiation exposure. In part because
of these issues, the value of combining CTV with CTPA is
still debated, and in many institutions, including our own,
CTV is not routinely included in the CTPA protocol.

MR Pulmonary Angiography
In the 1990s, MRPA involved mainly two-dimensional timeof-flight (TOF) techniques with limited anatomic coverage.
Breath-holding capability, registration artifacts, and poor
differentiation of slow blood flow from thrombus also compromised image quality.70,71 The advent of faster gradients
and better reconstruction algorithms has made threedimensional contrast MR angiography feasible. These scans
can be completed in 10 to 30 seconds during a single
breath-holdwith increased signal-to-noise ratio and improved image quality through administration of intravenous
gadolinium (Figure 4). Despite these advances, limitations on
spatial resolution and breath-holding71,72 make evaluation of
the segmental and subsegmental pulmonary arteries difficult.
Increasing the image matrix size can improve spatial resolution at the cost of longer imaging time and, therefore, require
breath-holding for longer intervals. Additionally, because the
acquisition time for MR exceeds that for CT or conventional
angiography, selective pulmonary arterial phase enhancement

cannot be achieved,71 making it difficult to distinguish arterial

from venous structures.
In an animal model, 81% and 61% of fifth-order (subsegmental) vessels were visualized using 192192 and
160160 matrices, respectively, on a single breath-hold scan.
Without breath-holding, the same matrices yielded definition
of only 26% (192192) and 20% (160160) of subsegmental pulmonary arteries.73 In another study, the sensitivity and
specificity for detection of lobar and segmental emboli was
87% and 97%, respectively.74 In a subsequent study, sensitivity for detection of subsegmental emboli was only 68%,75
making this technique inferior to CTPA or angiography.
Newer techniques using navigator pulses that allow free
breathing are promising for dyspneic patients undergoing
MR, as tracking of diaphragmatic excursions facilitate cumulative data acquisition at the same phase of the respiratory
cycle. Additionally, improved gating reduces the cardiac
pulsation artifact that affects MR more than CT imaging.
Improvements in the speed of data acquisition, faster gradients, and radial acquisition of raw data rather than current
Cartesian acquisition methods promise to further improve the
future diagnostic accuracy of MRPA.76,77

MR Venography
MRV may be used to evaluate central venous pathology,
anatomic variants, and DVT of the extremities (Figure 5).
The technique is less stringent than most MR angiography
techniques because venous flow profiles are relatively uniform, vessel size is greater, and flow is slower. Additionally,
venous pathology is usually more extensive than arterial
pathology, requiring lower image resolution. MRV can be
performed without intravenous contrast using TOF and
phase-contrast (PC) techniques. Alternatively, intravenous
gadolinium can be administered to enhance the venous signal.
Contrast-enhanced MRV has several advantages over both
TOF and PC techniques, including faster acquisition, better
signal-to-noise ratio, and greater accuracy in states of slow
flow or tortuous venous anatomy.78
MRV shares with CTV the advantage of better delineating
the inferior vena cava and pelvic veins than does sonography,
and does not require venous compression, which is pertinent
to examination of limbs in plaster casts or other impediments
to compression sonography. Studies comparing MRV with
sonography have found MRV superior for diagnosis of DVT
in the thigh.79 84 One study of 25 patients undergoing both
MRV and sonography of the pelvic and common femoral
veins found the sensitivity and specificity of MRV to be
100% and 98%, respectively, whereas sonography had a
sensitivity of 91% and a specificity of 97%.83

Conclusions
Even with modern technology, VTE is an elusive clinical
entity and no perfect diagnostic test has been developed.
Helical CTPA will likely continue to serve as the initial
diagnostic imaging examination of choice for patients with
clinically suspected acute PE in the absence of contraindications to radiograph contrast material, especially as multislice
technology proliferates. Should future studies find multislice
CTPA technology superior to pulmonary angiography at the

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CT and MRI to Diagnose DVT and PE

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sure, it may prove more cost-effective and result in appropriate anticoagulation therapy for a higher proportion of patients
with DVT, thereby reducing the risk of a life-threatening PE.
MRV and MRPA remain second-line diagnostic tools
because of higher cost, technical limitations, limited availability, and logistical constraints. As MR technology improves and becomes more readily available, the role of MRV
and MRPA in evaluating venous thromboembolic disease
may expand. Pulmonary angiography is generally reserved
for patients in whom the clinical suspicion of PE remains
high despite negative CTPA and bilateral lower extremity
venous evaluations (by CTV or ultrasound), or for those with
contraindications to CTPA and an indeterminate V/Q scan.

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Figure 5. Ovarian vein thrombophlebitis in a 44-year-old

woman. A, Axial post-gadolinium T1 SPGR image shows thrombus (arrow) in and inflammation of the left ovarian vein. B-C,
Coronal post-gadolinium T1 SPGR images confirm ovarian vein
thrombophlebitis (arrows).

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Several authors advocate including CTV in the CTPA
protocol for more complete evaluation of VTE and to
increase the overall sensitivity of the examination. This
technique seems comparable to ultrasound in the femoropopliteal region and superior in the pelvis. Although involving a
larger iodinated contrast load and additional radiation expo-

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Role of Computed Tomography and Magnetic Resonance Imaging for Deep Venous
Thrombosis and Pulmonary Embolism
Jeffrey P. Kanne and Tasneem A. Lalani
Circulation. 2004;109:I-15-I-21
doi: 10.1161/01.CIR.0000122871.86662.72
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