Stephanie Tan

@CBoonie_nanoIR @AJR_Radiology Interpretation of contrast reflux in the IVC should be done with care as it is specific but insensitive with injection rates of less than 3 mL/s (Sn, 31%; Sp, 98%), with decreased significance at higher injection rates (Sn, 81%; Sp, 69%) (Yeh et al. AJR 2004). #AJRChat

@StephTanMD @AJR_Radiology Sometimes I’ve seen contrast reflux into the hepatic veins or just a little bit in the IVC. Are there any thoughts about the significance of how far the reflux in the IVC goes? #AJRChat

Q1: What are the most important prognostic findings to include in the pulmonary CTA report impression and why? #AJRChat

@CBoonie_nanoIR @AJR_Radiology I wouldn't rely on how far the contrast reflux as there are too many factors to take into account. #AJRChat

@AJR_Radiology Thank you @AJR_Radiology @CBoonie_nanoIR @drcyncity for the invitation and for offering this platform to discuss about this interesting topic! A big thank you to @grelegal and our other co-authors for collaborating with us on the article. #AJRChat

Closing thoughts? #AJRChat

@AJR_Radiology Don't be complacent when writing your pulmonary CTA reports. It's a common and serious diagnosis that can have significant consequence on patients even long term (anticoagulation). Always try to improve even it it's your 50 000th pulmonary CTA report. #AJRChat

@grelegal @AJR_Radiology A useful tip from @grelegal that was brought up during our previous discussions when writing the article: always mention if PE is new or if it was already there compared to a prior study (pulmonary CTA, V/Q study). It will make your clinicians happy to have that info. #AJRChat

@AJR_Radiology Q4 An added benefit of standardized reporting is that it lends itself well for data mining as opposed to free-form reports. Therefore, statistics may easily and accurately be retrieved from an itemized format, allowing for future improvements. #AJRChat

Q4: What is the role of standardized structured reporting for pulmonary CTA? #AJRChat

@AJR_Radiology Q4 In a survey, referring physicians showed a preference for structured reporting as it favors consistency, clarity, and confidence (Spandorfer et al, Eur Radiol Exp 2019). Omitted information may create confusion among clinicians and subsequently affect patient care. #AJRChat

@AJR_Radiology Q4: It has been shown that only 16% of free-form pulmonary CTA reports have all elements of the RSNA report template, and that consistency varied according to radiologists’ subspecialty (Carter et al, JACC 2017). #AJRChat

@AJR_Radiology Q4: Structured reporting allows uniformity among radiologists and ensures a baseline level of quality amongst readers who may have different experience and expertise. #AJRChat

@AJR_Radiology Q3 Ideally, reasons for the suboptimal study should be identified and mentioned in the report. If repeat pulmonary CTA is recommended in the impression, suggestions on how to improve the next study should be given(increased contrast rate and volume, increasing kVp, etc). #AJRChat

Q3: What are the key considerations to document for describing pulmonary CTA diagnostic quality? #AJRChat

@AJR_Radiology Q3 A threshold of 250HU in the MPA may be used for a rough assessment of the quality of the study, but other factors need to be taken into account (noise profile, breathing artifact, etc.). Therefore, we do not recommend systematically reporting this value. #AJRChat

@AJR_Radiology Q3: CTA diagnostic quality should mention up to which level the pulmonary arteries can be satisfactorily evaluated for pulmonary embolism (ex: first, second, third generation subsegmental pulmonary arteries) and in which lobes. #AJRChat

@AJR_Radiology Q2: That's why clinicians' input like @grelegal is very important. The exchange between radiologists and clinicians in some equivocal cases can be very helpful for patient management.

@AJR_Radiology Q2: Keeping an open discussion with referring physicians is encouraged. A clear picture of the findings on pulmonary CTA from the radiologists’ perspective along with the clinicians’ clinical assessment allows for personalized and appropriate patient management. #AJRChat

Q2: Clinical teams vary widely in interpretation of inconclusive pulmonary CTA studies, with 33-83% considering these negative. How can the differentiation of equivocal and negative examinations be better communicated? #AJRChat

@AJR_Radiology Q2: The impression should report actionable findings. If study limitations are significant, the impression should state it as such and suggest further studies. Otherwise, the impression should simply report “No PE” without further suggestions. #AJRChat

@AJR_Radiology Q2: Patients with inconclusive pulmonary CTA have similar outcome as those with negative studies. Therefore, care must be taken when reporting limitation as it may lead to additional unnecessary imaging studies and therapies. #AJRChat

@AJR_Radiology Q1: Other findings that may be concerning for poor prognosis: dilated SVC or azygos vein, dilated RA, dilated main pulmonary artery, leftward bowing of the interventricular septum and reflux of contrast in the IVC. #AJRChat

@AJR_Radiology Q1: Of note, the largest RV and LV diameters can be found on different axial slices. A more dilated RV reflects the body’s attempt to compensate for a significant PE. Chronically dilated right heart chambers suggests poor cardiopulmonary reserve. #AJRChat

@AJR_Radiology Q1: Acute increase in RV/LV ratio measured on axial plane has been shown to be the best predictor of adverse events suggesting an increase of 2.5X for all-cause mortality and 5X for PE-related mortality. (Meinel et al. Am J Med 2015). #AJRChat