Introduction Computed tomography pulmonary angiography (CTPA) is the reference investigation of choice to diagnose pulmonary embolism (PE). Nevertheless, the use of CTPA should be weighed against its risks, such as radiation and contrast-induced nephropathy. We aim to assess the yield of CTPA in diagnosing PE at a tertiary centre in Malaysia. We also identify predictive factors associated with the yield of CTPA in this cohort. Methods This was a cross-sectional study involving all patients who had had CTPA done at Hospital Tengku Ampuan Afzan, Kuantan, Malaysia, from January 1, 2021, to November 30, 2021. All patients' records were retrieved and reviewed. CTPA images were retrieved from the Radiology Information System (RIS) and Picture Archiving and Communication System (PACS). They were double-reviewed by the authors, with the initial reports redacted from reporting radiologists to prevent reporting bias. The predictive factors were determined using simple logistic regression and multiple logistic regression. Results A total of 351 CTPAs were reviewed, of which 93 were found to be positive for PE, giving rise to an overall CTPA yield of 26.5%. Upon simple logistic regression, factors such as gender, discipline, history of trauma, presence of COVID-19 infection, and pneumonia were found to be associated with positive CTPA. Upon multiple logistic regression, male patients were found to have a higher chance of positive CTPA results. On the other hand, patients with COVID-19 infection and pneumonia have a lower chance of positive results in CTPA. Conclusion The yield of CTPA in diagnosing PE at our institution was acceptable at 26.5%. Upon multiple logistic regression, patients with COVID-19 infection and pneumonia were more likely to have a negative CTPA result, highlighting the need for clinicians to be more prudent in requesting CTPAs in these patients.
CT pulmonary angiography (CTPA) is the investigation of choice for diagnosing pulmonary embolism (PE). Due to the speed and ease of performing the CTPA scans, more clinicians are becoming overly reliant on them, even for patients without strong suspicion of PE. We conducted a bibliometric analysis on the PubMed database from 1990 to 2022 to investigate the literature on the diagnostic yield of CTPA in the diagnosis of PE. A total of 166 articles were published in 98 journals. The number of publications has steadily increased since 2010 and peaked in 2020. Authors from 24 countries contributed to these publications, with the overwhelming majority emanating from United States of America, totaling 66 articles. The authors' contributions were relatively well spread out, with the top four authors publishing the highest number of articles at six each. When we investigated the collaboration between the authors, we found limited multinational and multi-institutional collaborations on this topic. Therefore, more multinational and multi-institutional collaborations will be valuable in future studies. In conclusion, this bibliometric analysis summarizes the literature on diagnostic yield of CTPA in the diagnosis of PE and sheds light on the future pathway that researchers and institutions can focus on.
Background A soft tissue defect resulting from a diabetic heel ulcer can be difficult to address due to limited reconstructive options and unique local area demand. The medial plantar artery flap is ideal for heel defect coverage as it provides a thick glabrous skin with good sensory feedback. The prerequisite of medial plantar artery flap surgery is a patent medial plantar artery, which is a branch of the posterior tibial artery (PTA). Nevertheless, no feasibility study of the medial plantar artery flap in diabetic patients with vascular insufficiency has been reported so far. We conducted a pilot study with the aim of investigating the patency of the medial plantar artery in diabetic patients with suspected peripheral artery disease to determine the vascular feasibility of the medial plantar artery flap in these patients. Material and methods A pilot study was performed at Sultan Ahmad Shah Medical Centre at International Islamic University Malaysia (IIUM). A total of 15 diabetic patients with suspected vascular insufficiency who had undergone lower limb computed tomography angiography (CTA) from January 2022 to June 2023 were included in this study. All patients were identified via the electronic record system. Lower limb CTA images were retrieved from the Radiology Information System (RIS) and Picture Archiving and Communication System (PACS) and were double-reviewed. Both the posterior tibial artery (PTA) and medial plantar artery (MPA) were assessed for their patency, and the diameter of the lumens was measured if they were patent. Bedside clinical assessments such as palpation of pulses and portable Doppler assessment were evaluated to determine whether they could serve as substitutes for computed tomography angiography (CTA) in assessing the feasibility of medial plantar artery flap using the McNemar test. Results In this study cohort, the medial plantar artery was present in 16 legs and absent in another 14 legs. The largest diameter of the medial plantar artery was 2.5mm (range 0-2.5mm). Palpation of the posterior tibial artery was not optimal for predicting the patency of the medial plantar artery, with a false positive of 21.4% and a false negative of 68.7%. Similarly, a hand-held Doppler assessment of the posterior tibial artery was also ineffective, with a false positive of 64.3% and a false negative of 18.8%. While the medial plantar artery is a continuation of the posterior tibial artery (PTA), PTA patency did not necessarily correlate with medial plantar artery patency. This was demonstrated on CTA assessment, where two legs with absent PTA still have reconstitution, resulting in patency of the medial plantar artery. Additionally, one leg with patent PTA did not have a patent medial plantar artery distally due to calcified vessels. Conclusion This is a first-of-its-kind pilot study attempting to determine the feasibility of medial plantar artery in diabetic patients with vascular insufficiency. The medial plantar artery was present in more than 50% of the investigated lower limbs, paving the way for using the medial plantar artery flap in these patients. Nevertheless, a computed tomography angiogram is essential to determine the patency of the medial plantar artery prior to the flap procedure, as palpation and hand-held Doppler were inadequate to predict the patency of the medial plantar artery in these high-risk patients.