Medical Malpractice Case of the Month
May 2002

We are closer to the goal of an entirely noninvasive diagnostic approach to pulmonary embolism (PE) because of the advent of spiral computed tomography scanning and D-dimer testing, although both of these tests have limitations.
French researchers examined the performance of a noninvasive strategy in 228 patients with suspected PE. Each patient underwent spiral CT, ventilation/perfusion lung scan, and plasma D-dimer testing; the algorithm was roughly as follows: (1) 11 spiral CT was positive, PE was diagnosed; (2) If spiral CT was negative, either a normal lung scan or a negative D-dimer test was required to rule out PE; (3) LI spiral CT was negative, and a lung scan was inconclusive and a D-dimer test was positive, then lower-limb compression ultrasound was performed; absence of deep venous thrombosis ruled out PE. PE was diagnosed in 96 patients. Among the 132 patients in whom PE was ruled out, researchers followed 117 for 3 months. Two of these 117 were diagnosed with PE during follow-up; neither case was fatal.

Comment: In this study, an entirely noninvasive strategy appeared relatively safe; among patients in whom PE was ruled out, there were no cases of fatal PE during 3 months of follow-up. The performance of any such strategy in a given institution depends on numerous factors, including the quality of the imaging studies, the quality of radiologic interpretation, and the particular o-dimer assay in use. 

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