Pulmonary angiography is the gold standard for diagnosis of segmental
pulmonary embolism, but no longer for subsegmental
pulmonary embolism because the inter-observer agreement for angiographically documented subsegmental
pulmonary embolism is only 60%. A normal rapid ELISA VIDAS
D-dimer test result and a normal perfusion scan exclude
pulmonary embolism with a negative predictive value of >99%, irrespective of clinical score. The positive predictive value for
pulmonary embolism of a high probability VP-scan compared to pulmonary angiography is 87% indicating that 13% of patients with a high probability VP-scan do not have
pulmonary embolism. The combination of a negative
CUS, a low clinical score, and a non-diagnostic VP-scan safely excludes
pulmonary embolism. Patients with a non-diagnostic VP-scan, a negative
CUS, but a moderate to high clinical score are candidates for pulmonary angiography. The positive predictive value of helical spiral CT is >95 to 99%. The combination of a negative
CUS, a low clinical score, and the presence of a clear alternative diagnosis is predicted to safely exclude
pulmonary embolism. Helical spiral CT detects all clinical relevant pulmonary emboli and a large number of alternative diagnoses in symptomatic patients with a non-diagnostic or a high-probability VP-scan. The negative predictive value during 3 months followup after a negative spiral CT for
pulmonary embolism in 4 retrospective studies and 1 prospective management study was >99%. Only a small group of patients (1-2%) with a non-diagnostic spiral CT are candidates for pulmonary angiography. Therefore, it is predicted that the spiral CT will replace both VP-scanning and pulmonary angiography to safely exclude or diagnose pulmonary emboli in patients with suspected
pulmonary embolism.