From the Guidelines
The patient's CTA chest report indicates a moderate right-sided pulmonary embolism (PE) with a small subsegmental infarct in the middle lobe, which requires immediate anticoagulation therapy to prevent clot extension and recurrence. The recommended treatment is to start with a direct oral anticoagulant (DOAC) such as apixaban (5mg twice daily for 7 days, then 2.5mg twice daily) or rivaroxaban (15mg twice daily for 21 days, then 20mg daily) for at least 3 months, as suggested by recent guidelines 1. If DOACs are contraindicated, low molecular weight heparin bridging to warfarin is an alternative. The 4mm middle lobe nodule is likely benign, but follow-up CT in 12 months is recommended if the patient has a smoking history or other risk factors for malignancy, according to the Fleischner Society guidelines 1. The report also notes healed granulomatous disease, gallstones (cholelithiasis), and a small liver cyst or biliary hamartoma, which typically require no immediate intervention, as stated in the EASL clinical practice guidelines on the management of cystic liver diseases 1. Key elements in the description of hepatic cyst(s) include the number of lesions and architecture, and it is not recommended to follow asymptomatic patients with simple hepatic cysts, biliary hamartomas, or peribiliary cysts 1. The pulmonary embolism is the most urgent finding requiring prompt treatment, while the other findings can be addressed during follow-up care. In terms of the liver cyst or biliary hamartoma, MRI with heavily T2-weighted sequences and MR cholangiography sequences can be used for diagnosis, but routine follow-up with imaging is not recommended 1. Overall, the patient's treatment plan should prioritize the pulmonary embolism, with anticoagulation therapy and follow-up care for the other findings.
From the Research
CTA Chest Read Findings
The CTA chest read reveals several key findings, including:
- Moderate right-sided pulmonary embolism (PI) with a small subsegmental middle lobe infarct
- A noncalcified 4mm middle lobe nodule
- Healed pulmonary granulomatous disease
- Cholelithiasis (gallstones)
- A small cyst or biliary hamartoma in the liver
Clinical Implications
These findings have significant clinical implications, as discussed in various studies 2, 3, 4, 5, 6. The presence of a moderate right-sided pulmonary embolism (PI) is a critical finding that requires prompt attention and management. The small subsegmental middle lobe infarct is also a significant finding that may indicate a higher risk of complications.
Diagnostic Confidence
The diagnostic confidence of the CTA chest read is influenced by various factors, including the tube voltage and contrast injection rate used during the scan 6. A study comparing different scan protocols found that a tube voltage of 120 kVp and a contrast injection rate of 5 cc/s resulted in higher diagnostic confidence compared to other protocols.
Risk Stratification
The CTA chest read can provide valuable information for risk stratification in patients with acute chest pain 4, 5. The triple rule-out computed tomography angiography (TRO-CTA) protocol can help diagnose or exclude life-threatening conditions such as acute coronary syndromes, pulmonary embolisms, and acute aortic syndromes.
Management
The management of patients with these findings will depend on various factors, including the severity of the pulmonary embolism, the presence of other comorbidities, and the patient's overall clinical condition. The CTA chest read can provide valuable information to guide management decisions, as discussed in studies 2, 3.