Appropriate Use Criteria for Ventilation–Perfusion Imaging in Pulmonary Embolism

Perfusion lung imaging for diagnosing pulmonary embolism (PE) was introduced 50 y ago (1). At that time, it offered a noninvasive alternative to pulmonary angiography in patients with a clinical suspicion of PE. Because there are many causes of diminished regional blood flow in the lungs, particularly redistribution of blood flow away from regions with lung disease, the subsequent introduction of radionuclide ventilation studies added greater specificity to findings on radionuclide perfusion imaging. When appropriately used and interpreted, ventilation–perfusion (V/Q) scintigraphy is an important examination for the evaluation of patients suspected of having regional compromise of lung perfusion and ventilation. The purpose of this document is to describe the appropriate use of V/Q scintigraphy in patients suspected of having acute PE. It is hoped that through these recommendations, V/Q scintigraphy will be appropriately applied to benefit patients. Representatives from the Society of Nuclear Medicine and Molecular Imaging (SNMMI), the European Association of Nuclear Medicine (EANM), the American Society of Hematology (ASH), the Society of Thoracic Surgeons (STS), and the American College of Emergency Physicians (ACEP), as well as chest radiologists, emergency department physicians, pulmonary critical care physicians, and physician experts in thromboembolic disease, assembled as an autonomous workgroup to develop the following appropriate use criteria (AUC). This process was performed in accordance with the Protecting Access to Medicare Act of 2014 (2). This legislation requires that all referring physicians consult AUC using a clinical decision support mechanism before ordering any advanced diagnostic imaging service. Such services are defined as diagnostic MRI, CT, nuclear medicine procedures (including PET), and others as specified by the secretary of Health and Human Services in consultation with physician specialty organizations and other stakeholders (2). These AUC are intended to aid referring medical practitioners in the appropriate use of V/Q scans in patients suspected of having PE (3).