Routine Follow-Up CT Angiography After PE is Not Recommended
Routine follow-up CT pulmonary angiography at three months to check for resolution of pulmonary embolism is not recommended in asymptomatic patients. 1
Guideline Recommendations
The 2019 European Society of Cardiology guidelines explicitly state that follow-up imaging is not routinely recommended in asymptomatic patients after acute PE. 1 However, follow-up imaging may be considered in patients with specific risk factors for development of chronic thromboembolic pulmonary hypertension (CTEPH). 1
When Follow-Up Should Occur (Clinical, Not Imaging)
All patients should be re-examined after the first 3-6 months of anticoagulation to assess for signs of VTE recurrence, cancer, bleeding complications, or new-onset dyspnea/functional limitation. 1
If patients develop persisting or new-onset dyspnea or functional limitation, implement a staged diagnostic workup to exclude CTEPH or chronic thromboembolic disease. 1
Regular clinical follow-up examinations should occur at yearly intervals to monitor for recurrence risk and complications. 1
Evidence on PE Resolution Timing
Research demonstrates that most pulmonary emboli resolve without the need for imaging confirmation:
Complete CT angiographic resolution occurs in 81% of patients after 28 days, with faster resolution in main and lobar arteries (94%) compared to segmental branches (100% after 28 days). 2
The main clinical concern is not radiographic resolution but rather clinical outcomes, as the 3-month VTE recurrence rate after negative CTPA is only 1.2%, with a fatal PE rate of 0.11%. 3
Radiation Risk Considerations
Follow-up CT angiography exposes patients to unnecessary radiation without clear clinical benefit:
In one study, 23.5% of PE patients received at least one follow-up CTPA within one year, with young women (aged ≤29 years) receiving follow-up scans in 47.6% of cases—the population at highest risk for radiation-induced cancer. 4
Among patients who received follow-up imaging, only 10.6% had recurrent PE diagnosed on first follow-up, suggesting most scans were unnecessary. 4
Specific Indications for Follow-Up Imaging
Follow-up imaging should be reserved for:
Symptomatic patients with new or worsening dyspnea, chest pain, or functional limitation suggesting possible CTEPH or recurrent VTE. 1
Patients with risk factors for CTEPH, though the guidelines do not specify which risk factors warrant imaging. 1
Clinical suspicion of recurrent PE based on symptoms, not routine surveillance. 1
Common Pitfall to Avoid
The major pitfall is ordering routine follow-up imaging in asymptomatic patients "to document resolution." This practice:
- Exposes patients to unnecessary radiation risk, particularly problematic in young women. 4
- Does not change management in asymptomatic patients on appropriate anticoagulation. 1
- Wastes healthcare resources without improving outcomes. 4
Instead, focus on clinical follow-up to assess symptoms, anticoagulation duration decisions, and screening for complications. 1