Ignite Creation Date:
2024-05-05 @ 11:44 AM
Last Modification Date:
2024-10-26 @ 9:12 AM
Study NCT ID:
NCT00117169
Status:
COMPLETED
Last Update Posted:
2012-10-15
First Post:
2005-06-30
Brief Title:
Multi-Detector Spiral Computed Tomography Alone Versus Combined Strategy With Lower Limb Compression Ultrasonography in Outpatients Suspected of Pulmonary Embolism
Sponsor:
University Hospital Geneva
Organization:
University Hospital Geneva
Study Overview
Official Title:
Multi-Detector Spiral Computed Tomography Alone Versus Combined Strategy With Lower Limb Compression Ultrasonography in Outpatients Suspected of Pulmonary Embolism A Randomised Non-Inferiority Trial CTEP4
Status:
COMPLETED
Status Verified Date:
2012-10
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
None
Brief Summary:
The main hypothesis for this study is that the diagnostic approach of pulmonary embolism PE by evaluation of clinical probability D-dimer test dosage and multi-detector helical computed tomography hCT is as safe as the classical approach using clinical probability D-dimer test lower limb compression ultrasonography and multi-detector helical computed tomography
The second hypothesis involves evaluating the role of searching distal ie infrapopliteal deep venous thromboses DVTs in the diagnostic approach of pulmonary embolism
The second hypothesis involves evaluating the role of searching distal ie infrapopliteal deep venous thromboses DVTs in the diagnostic approach of pulmonary embolism
Detailed Description:
Suspected pulmonary embolism PE is a frequent clinical problem and remains a diagnostic challenge The diagnostic approach of PE relies on sequential diagnostic tests such as plasma D-dimer measurement lower limb compression ultrasonography ventilation-perfusion lung scan or helical computed tomography hCT and pulmonary angiography In addition the diagnostic workup is usually stratified according to the clinical probability of pulmonary embolism
First-generation hCTs were based on a single-detector technique and had a limited 70 sensitivity Moreover in two recent outcome studies a proximal deep venous thrombosis diagnosed by lower limb compression ultrasonography was found in 15 of patients with a normal single-detector hCT However in management studies the association of a normal lower limb compression ultrasonography and a normal single-detector hCT has been proved safe to rule out PE in patients with a non-high clinical probability with a less than 2 rate of thromboembolic events during a 3-month follow-up in patients left untreated based on that combination Hence lower limb compression ultrasonography must be combined with a single-detector CT to safely rule out pulmonary embolism
More recently the multi-detector hCT has become widely available These new scanners allow one to improve image definition and to diminish slice thickness without increasing acquisition time and hence to better visualize the segmental and sub-segmental pulmonary arteries In a recent study CTEPm the investigators evaluated the performances of a multi-detector hCT The rate of false negative results assessed by the rate of patients with proximal DVT on ultrasonography and a negative hCT was much lower using the multi-detector CT 09 95 confidence interval 03-33 than with the single-detector technique 15 This raises the possibility that hCT might be used as a single test to rule out PE in patients with an elevated D-dimer level Indeed ELISA plasma D-dimer measurement in patients with a non-high clinical probability of PE remains a logical first step since it safely rules out PE in approximately 30 of patients Such a strategy should now be validated in a prospective randomised outcome study to compare its safety and cost-effectiveness with that of a previously validated strategy combining D-dimer lower limb compression ultrasonography and hCT
Therefore the investigators plan to compare the efficacy and cost-effectiveness of two distinct diagnostic strategies for suspected pulmonary embolism in emergency center patents in a non-inferiority trial The strategies are 1 an algorithm based on clinical assessment D-dimer and multi-detector hCT DD-hCT and 2 a previously validated strategy that includes lower limb compression DD-US-hCT The main outcome will be the rate of thromboembolic events during a formal 3-month follow-up in patients not anticoagulated on the basis of a PE ruled out by the diagnostic criteria in each study arm A secondary outcome will be the costs of diagnosis in each study arm including the costs of suspected andor confirmed thromboembolic events during follow-up
In addition the investigators aim to prospectively and pragmatically validate the revised Geneva score for assessing the clinical probability of PE by using it in the sequential diagnostic work-up for PE Classification performances of this score will be assessed by checking its capacity to discriminate between patients having a low intermediate or high probability of PE
Finally in a nested study the investigators aim to compare the clinical usefulness of a complete lower limb compression ultrasonography versus a classical 4-points ultrasonography ultrasonography of the proximal veins in the patients from the ultrasound arm of the study DD-US-hCT Indeed preliminary data indicate that complete ultrasound detects a DVT in a higher proportion of patients with PE than proximal ultrasound US and hence has the potential for further limiting the requirement for chest imaging in patients with suspected PE Because finding a distal DVT is of uncertain clinical significance such a finding will not be reported to the clinicians in charge of the patient and those patients will undergo a helical CT and be treated or not according to the CT result Outcome measurements will be the number of patients in whom hCT could have been avoided by ruling in the diagnosis of PE in the presence of a distal DVT proportion of patients with both distal DVT on ultrasonography and pulmonary embolism on multi-detector hCT and the number of patients who would have been unduly anticoagulated if considering the presence of a distal DVT in the complete compression ultrasonography proportion of patients with distal DVT on ultrasonography but without pulmonary embolism on multi-detector hCT and without a thromboembolic event during the 3 month follow-up
First-generation hCTs were based on a single-detector technique and had a limited 70 sensitivity Moreover in two recent outcome studies a proximal deep venous thrombosis diagnosed by lower limb compression ultrasonography was found in 15 of patients with a normal single-detector hCT However in management studies the association of a normal lower limb compression ultrasonography and a normal single-detector hCT has been proved safe to rule out PE in patients with a non-high clinical probability with a less than 2 rate of thromboembolic events during a 3-month follow-up in patients left untreated based on that combination Hence lower limb compression ultrasonography must be combined with a single-detector CT to safely rule out pulmonary embolism
More recently the multi-detector hCT has become widely available These new scanners allow one to improve image definition and to diminish slice thickness without increasing acquisition time and hence to better visualize the segmental and sub-segmental pulmonary arteries In a recent study CTEPm the investigators evaluated the performances of a multi-detector hCT The rate of false negative results assessed by the rate of patients with proximal DVT on ultrasonography and a negative hCT was much lower using the multi-detector CT 09 95 confidence interval 03-33 than with the single-detector technique 15 This raises the possibility that hCT might be used as a single test to rule out PE in patients with an elevated D-dimer level Indeed ELISA plasma D-dimer measurement in patients with a non-high clinical probability of PE remains a logical first step since it safely rules out PE in approximately 30 of patients Such a strategy should now be validated in a prospective randomised outcome study to compare its safety and cost-effectiveness with that of a previously validated strategy combining D-dimer lower limb compression ultrasonography and hCT
Therefore the investigators plan to compare the efficacy and cost-effectiveness of two distinct diagnostic strategies for suspected pulmonary embolism in emergency center patents in a non-inferiority trial The strategies are 1 an algorithm based on clinical assessment D-dimer and multi-detector hCT DD-hCT and 2 a previously validated strategy that includes lower limb compression DD-US-hCT The main outcome will be the rate of thromboembolic events during a formal 3-month follow-up in patients not anticoagulated on the basis of a PE ruled out by the diagnostic criteria in each study arm A secondary outcome will be the costs of diagnosis in each study arm including the costs of suspected andor confirmed thromboembolic events during follow-up
In addition the investigators aim to prospectively and pragmatically validate the revised Geneva score for assessing the clinical probability of PE by using it in the sequential diagnostic work-up for PE Classification performances of this score will be assessed by checking its capacity to discriminate between patients having a low intermediate or high probability of PE
Finally in a nested study the investigators aim to compare the clinical usefulness of a complete lower limb compression ultrasonography versus a classical 4-points ultrasonography ultrasonography of the proximal veins in the patients from the ultrasound arm of the study DD-US-hCT Indeed preliminary data indicate that complete ultrasound detects a DVT in a higher proportion of patients with PE than proximal ultrasound US and hence has the potential for further limiting the requirement for chest imaging in patients with suspected PE Because finding a distal DVT is of uncertain clinical significance such a finding will not be reported to the clinicians in charge of the patient and those patients will undergo a helical CT and be treated or not according to the CT result Outcome measurements will be the number of patients in whom hCT could have been avoided by ruling in the diagnosis of PE in the presence of a distal DVT proportion of patients with both distal DVT on ultrasonography and pulmonary embolism on multi-detector hCT and the number of patients who would have been unduly anticoagulated if considering the presence of a distal DVT in the complete compression ultrasonography proportion of patients with distal DVT on ultrasonography but without pulmonary embolism on multi-detector hCT and without a thromboembolic event during the 3 month follow-up
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None
Secondary IDs
| Secondary ID | Type | Domain | Link |
|---|---|---|---|
| FNRS Grant No 3200B0-105988 | None | None | None |