CT findings of pulmonary artery dissection

Pulmonary artery dissection is a serious fatal complication of chronic pulmonary arterial hypertension, always occurring at the site of maximal dilatation of the artery. Diagnosis is made mainly at autopsy as many of these patients experience sudden death when the main pulmonary artery dissects into the pericardium, causing acute cardiac tamponade. To our knowledge, five reported cases have described CT imaging findings of acute pulmonary artery dissection in the literature.     

Pulmonary artery hypertension in chronic obstructive lung disease. The place of morphometric studies in thoracic radiography

Standard biplane chest X-rays were tested for the validity of morphometric criteria in the diagnosis of pulmonary artery hypertension. Twenty-seven patients suffering from chronic obstructive lung disease were examined and compared with a control group without cardiopulmonary disease. The diameter of the right and left pulmonary artery, pulmonary conus and the hilar-to-thoracic ratio were significantly increased in patients with chronic obstructive lung disease (p less than 0,0001). Measurement of the right pulmonary artery was 19.7 +/- 3.9 mm compared to 13.6 +/- 1.2 mm of the control group; mean hilar thoracic index was 0.35 compared to 0.31. Thus if the width of the descending branch of the right pulmonary artery was above 16 mm, pulmonary arterial hypertension was suggested, with a specificity of almost 100%, although the sensitivity of the diagnosis was only 59%. The mean pulmonary arterial pressure obtained by right heart catheterization correlated poorly with the morphometric criteria obtained.     

Radiologic detection of pulmonary artery hypertension

In 43 patients with obstructive and restrictive lung disease a catheterisation of the right heart with measurement of pulmonary artery pressure was performed. In a retrospective study several radiological parameters of pulmonary hypertension were evaluated on the chest radiographs of these patients. Considering those parameters on the p.a. and lateral chest radiograph, the diagnosis of pulmonary hypertension in patients with elevated pulmonary artery pressure at rest can be made with great accuracy. When pulmonary artery pressure is elevated only during exercise, the accuracy of radiological diagnosis is much lower.     

Reduced lung volume associated with acquired pulmonary artery obstruction in children.

The effect of postnatal pulmonary artery obstruction on lung growth has not previously been reported. This report describes two patients in whom pulmonary artery banding in early infancy was complicated by complete occlusion of the right pulmonary arter. In each case, the right lung became less voluminous than the left. In one patient, the alevoli of the affected lung were found to be smaller than normal at autopsy. In the other patient, surgical reconstitution of pulmonary arterial flow resulted in a return to normal volume of the affected lung. Observations suggest that pulmonary arterial flow should be restored as early as possible to minimize impairment of lung growth and to avoid irreversible pulmonary hypertension in the opposite lung.     

Pulmonary artery-to-pulmonary artery anastomoses: angiographic demonstration in patients with chronic thromboembolic pulmonary hypertension

AIM: To describe direct pulmonary artery-to-pulmonary artery anastomoses seen at pulmonary angiography in patients with chronic thromboembolic pulmonary hypertension and discuss their possible significance. MATERIALS AND METHODS: Between 1 August 2000 and 31 July 2004 43 patients (male-to-female ratio 25:18) with a diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) underwent selective pulmonary angiography to assess the extent of disease and suitability for surgical pulmonary endarterectomy. The mean pulmonary artery pressure ranged from 27-84 mmHg (average of 51 mmHg). Selective bilateral digital subtraction pulmonary angiograms performed in all individuals were reviewed for the presence of intrapulmonary collaterals. RESULTS: In 15 of the 43 patients (male-to-female ratio =7:8) definite (n = 12) or probable (n = 3) pulmonary artery-to-pulmonary artery anastomoses were demonstrated. Of the remaining 28 patients in whom intrapulmonary collaterals were not seen it was felt that in 16 the angiograms were of insufficient diagnostic quality (grades 4-5) to exclude their presence. Twelve patients, eight of whom had angiograms of sufficient diagnostic quality (grades 1-3), demonstrated one or more areas of luxury perfusion but intrapulmonary collaterals were not seen. CONCLUSION: Direct pulmonary artery-to-pulmonary artery anastomoses were demonstrated in patients with chronic thromboembolic pulmonary hypertension, which to our knowledge have not been previously described. The importance of these collateral vessels is unclear but they may play a role in the maintenance of pulmonary parenchymal viability in patients with chronic pulmonary embolic disease. The rate of development of these collaterals and their prognostic significance in patients with chronic thromboembolic pulmonary hypertension are areas worthy of further study.     

Percutaneous transluminal angioplasty for treatment of renal artery stenosis in children

Angioplasty was carried out in four children with hypertension and renal artery stenosis, including one patient with neurofibromatosis and one patient with multiple arterial stenoses. Two patients did not respond. In the patient with neurofibromatosis the stenosis persisted unchanged despite multiple balloon inflations. In one patient hypertension persisted despite successful dilatation, and was probably related to longstanding contralateral kidney disease. Two patients had excellent blood pressure response to dilatation. One of these patients required redilatation of bilateral recurrent stenoses.     

CT measurement of main pulmonary artery diameter

The aim of this study was to determine the upper limit of the normal main pulmonary artery diameter using a modern CT system. This was measured at the level of the pulmonary artery bifurcation in 100 normal subjects using unenhanced contiguous 10 mm CT slices viewed at fixed mediastinal window settings (400/20). These normal subjects were then compared with similar unenhanced 10 mm images from 12 patients with proven pulmonary arterial hypertension (mean pulmonary artery pressure > 20 mmHg). The main pulmonary artery diameter in normal subjects was 2.72 cm (SD = 0.3). Main pulmonary artery diameter in patients with pulmonary arterial hypertension was significantly greater (p < 0.01) at 3.47 cm (SD = 0.33). A pulmonary artery diameter of 3.32 cm (main pulmonary artery diameter + 2 SD) had a 58% sensitivity and 95% specificity for the presence of pulmonary arterial hypertension. It is concluded that, using unenhanced axial 10 mm CT sections, the upper limit of normal main pulmonary artery diameter is 3.32 cm. Pulmonary arterial hypertension should be considered in patients with values above this level.     

Early onset of retrograde flow in the main pulmonary artery is a characteristic of pulmonary arterial hypertension

Purpose:

To evaluate if early onset of retrograde flow in the main pulmonary artery is a characteristic of pulmonary arterial hypertension (PAH).

Materials and Methods:

Fifty‐five patients with suspected pulmonary hypertension (PH) underwent right‐sided heart catheterization and retrospectively ECG‐gated MR phase‐contrast velocity quantification in the main pulmonary artery. Pulmonary hypertension was defined by a mean pulmonary artery pressure being larger than 25 mmHg. The onset time of the retrograde flow relative to the cardiac cycle duration (Relative Onset Time = ROT) was compared with mean pulmonary artery pressure.

Results:

By the catheterization, 38 patients were identified as having PAH. The ROT for these PAH patients was significantly different from those found in the 17 non‐PH subjects (0.14 ± 0.06 versus 0.37 ± 0.06, P < 0.001). The mean pulmonary artery pressure was related to the ROT (r² = 0.62, P < 0.001) and could be estimated from the ROT with a standard deviation of 11.7 mmHg. With a cutoff value of 0.25, the ROT distinguished PAH patients from non‐PH subjects.

Conclusion:

Early onset of retrograde flow in the main pulmonary artery is a characteristic of pulmonary arterial hypertension and is visible by standard MR phase‐contrast velocity quantification. J. Magn. Reson. Imaging 2011;33:1362–1368. © 2011 Wiley‐Liss, Inc.     

Pulmonary artery dissection in long standing idiopathic pulmonary arterial hypertension: A case report

Pulmonary arterial dissection (PAD) is a rare and often lethal complication of chronic pulmonary arterial hypertension (PAH), which may occurs in patients with idiopathic pulmonary arterial hypertension (IPAH) and potentially in those with connective tissue disorders. While rare, sudden death often occurs secondary to acute cardiac tamponade, as the pulmonary artery dissects into the pericardium; this diagnosis is often made postmortem. Nevertheless, with the proliferation of multidetector computed tomography (MDCT) as a diagnostic test, patients may be identified very early after symptom onset, prompting rapid intervention with decreased morbidity and mortality. We report a case of IPAH complicated by pulmonary artery aneurysm (PAA) and PAD, diagnosed by CT pulmonary angiogram (CTPA), and treated with bilateral lung transplantation, pulmonic valve replacement, and re-anastomosis of the donor main PA to a pulmonary valve conduit.     

Postatelectatic ventilation-perfusion mismatch simulating a pulmonary embolus

Ventilation-perfusion imaging was performed on a patient with chronic intermittent atelectasis of the right lung and revealed a mismatch simulating a pulmonary embolus in the right lung. A pulmonary arteriogram revealed no evidence of embolic disease; however, there was reduced capillary phase opacification of the right lung and increased pulmonary artery pressure. The findings are consistent with an isolated right pulmonary artery hypertension secondary to prolonged atelectasis causing an apparent mismatch on the ventilation-perfusion scan.     

利伐沙班抗凝治疗慢性阻塞性肺疾病合并肺动脉高压的疗效

目的 探讨利伐沙班抗凝治疗慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)合并肺动脉高压(pulmonary hypertension,PH)的临床疗效.方法 选取2016-01至2018-01秦皇岛市第一医院呼吸科COPD合并PH住院患者163例为研究对象.收集...     

In situ central pulmonary artery thrombosis in primary pulmonary hypertension

A rare case of extensive in situ central pulmonary artery thrombosis in primary pulmonary hypertension (PPH) is presented. The differentiation from chronic thromboembolic pulmonary arterial hypertension (CTEPH) is of paramount importance because of different therapeutic strategies. In this case, the presence of mural thrombus in the central pulmonary arteries on computed tomography made the distinction difficult. However, the possibility of in situ thrombosis was suggested on the basis of absence of other findings of CTEPH (abrupt narrowing/truncation of segmental arteries, variation in size of segmental vessels, arterial webs, mosaic attenuation, pulmonary infarcts, and dilated bronchial arteries), and this was confirmed on final pathology.     

Renal uptake on lung perfusion scintigraphy in a patient with primary pulmonary hypertension

An 18-year-old woman presented with primary pulmonary hypertension (PPH) and was hospitalized because of hemoptysis and was referred to our department for a differential diagnosis pulmonary thromboembolism. Doppler ultrasonography of the lower extremities was normal. Echocardiography and cardiac catheterization showed right ventricular dilatation and increased pulmonary artery pressure without anatomic (intracardiac) shunt. The mean pulmonary arterial pressure was 110 mm Hg. Tc-99m MAA lung perfusion scans showed nonsegmental patchy defects. Extrapulmonary renal uptake and increased systemic deposition of radiotracer were seen in the MAA scintigraphy. It could be related to a functional intrapulmonary shunt resulting in increasing pressure in the pulmonary artery in PPH.     

Comparison of computed tomographic lung density with haemodynamic data of the pulmonary circulation

Computed tomographic (CT) lung density measurements were prospectively correlated with pulmonary haemodynamic data in 33 patients with chronic heart disease. Cardiac catheterisation and five specific computed tomographic scans (three at nearly total lung capacity, one at functional residual capacity, and one at residual volume) were performed. There was a significant correlation between anterior lung density and mean pulmonary artery pressure (r = 0.86), pulmonary vascular resistance (r = 0.80), and pulmonary artery wedge pressure (r = 0.65). Lung density, as measured by CT, thus provides a valuable estimate of pulmonary arterial pressure and pulmonary vascular resistance, but is affected by other pathological conditions, such as emphysema and congestional or post-inflammatory fibrosis.     

CT-determined pulmonary artery diameters in predicting pulmonary hypertension

This study was to determine if the diameters of pulmonary arteries measured from computed tomographic (CT) scans could be used 1) as indicators of pulmonary artery hypertension and 2) as a reliable base for calculating mean pulmonary artery pressure. The diameters of the main, left, proximal right, distal right, interlobar, and left descending pulmonary arteries were measured from CT scans in 32 patients with cardiopulmonary disease and in 26 age- and sex-matched control subjects. Diameters were measured using a special computer program that could display a CT density profile of the artery and its adjacent tissues. The upper limit of normal diameter for the main pulmonary artery was found to be 28.6 mm (mean + 2 SD). In the patient group, the diameters were correlated with data from cardiac catheterization. In these patients, a diameter of the main pulmonary artery above 28.6 mm readily predicted the presence of pulmonary hypertension. The calculated cross-sectional areas of the main and interlobar pulmonary arteries (normalized for body surface area [BAS]) were found to give the best estimates of mean pulmonary artery pressure (r = 0.89, P less than 0.001 and r = 0.66, P less than 0.001). Multiple regression analysis gave the useful equation: mean pulmonary artery pressure = -10.92 + 0.07646 X area of main pulmonary artery/BSA + 0.08084 X area of the right interlobar pulmonary artery/BSA (r = 0.93, P less than 0.0001). Because CT allows precise, noninvasive measurement of the diameter of pulmonary arteries, it can be of value in detecting pulmonary hypertension and estimating mean pulmonary artery pressure.     

肺动脉化疗药盒埋置术治疗肝癌肺转移

目的 研究肺动脉化疗导管药盒置术治疗原发性治疗原发性肝癌肺转移的疗效。方法 原发性癌肺转移病例６２例,其中一侧肺转移者１９例,两侧肺转移者４３例。除常规肝动脉化疗栓塞治疗外,加作经锁骨下静脉穿刺肺动脉化疗导管药盒埋置术。一侧肺转移病灶者,导管头端埋于患者侧肺动脉内;两侧转移灶者,导管头端埋于肺部动脉处。化疗方案为ＦＤＭ或ＦＤＡ。如果肝癌控制良好,则在药盒内每月注入化疗药物１次。结果 肺动脉化疗药盒     

Lung neovascularity in pulmonary arterial hypertension associated with congenital heart defects and idiopathic pulmonary arterial hypertension: study of 198 patients

Objectives

To correlate the severity of lung neovascularity (Sheehan vessels) with the cause and haemodynamic severity of pulmonary arterial hypertension (PAH), pulmonary artery (PA) size and heart disease type in patients with PH associated with congenital heart diseases (PAH-CHD) and idiopathic PH (IPAH).

Methods

We reviewed the HRCT and CT pulmonary angiography studies of 87 patients with PAH-CHD and 111 with IPAH; all had undergone right heart catheterisation. We evaluated the PA size and severity of neovascularity on CT.

Results

Neovascularity, which was found in 72% of PAH-CHD (56% with Eisenmenger’s syndrome) and in 22% of IPAH patients, is significantly related to the severity of PH and all patients with severe neovascularity had intermediate or high PH. All PAH-CHD patients had a dilated PA with a greater risk of developing severe dilatation (diameter >5?cm). The neovascularity correlated with the PA size only in IPAH.

Conclusions

Neovascularity even if not pathognomonic for PAH-CHD, is significantly more common in these patients, especially in Eisenmenger’s syndrome. It is often the first CT sign to indicate the severity of PH in PAH-CHD and IPAH. A neovascularity ≥5 on CT indicates a intermediate or high PH.

Key Points

? Large retrospective studying specific lung disorders in patients with pulmonary arterial hypertension. ? Neovascularity is often the first CT sign indicating the severity of pulmonary hypertension Alterations of lung parenchyma on CT in pulmonary hypertension are described ? The first study to assess the severity of pulmonary hypertension by CT ? If substantiated, CT might eventually replace some cardiac catheterisation for evaluating PH     

The assessment of pulmonary arterial pressure by pulsed Doppler in patients with obstructive pneumopathy]

The severity of pulmonary arterial hypertension can be assessed by duplex-Doppler echocardiography, a subxiphoid approach and a general-purpose duplex device. Normally, the peak Doppler flow velocity occurs in midsystole and the flow profile is parabolic (bullet-like). In pulmonary arterial hypertension, changes in vascular compliance cause maximal acceleration of blood in early systole, with shortening of pulmonary acceleration time (AcT, or time to peak velocity). In the more severe cases, a midsystolic notching is visible, related to rapid deceleration of blood flow, followed by a brief secondary increase in velocity in the late systole. We studied 19 adult patients with chronic obstructive pulmonary disease with duplex-Doppler examination, with a subxiphoid approach and right heart catheterization. The study was diagnostic in all cases with Doppler recordings of good quality. An relationship was found between AcT and pulmonary mean or systolic arterial pressure at rest. An evident accurate prediction of pulmonary arterial pressure in emphysematous patients is possible by means of pulsed Doppler, also in case of low-level hypertension. We believe this method to be a simple and reliable adjunct to the non-invasive work-up of emphysematous patients and to represent a good alternative to the classical parasternal approach, which is often not feasible in these patients.     

Imaging findings of pulmonary vascular disorders in portal hypertension

PURPOSE: The purpose of this study was to demonstrate and compare the imaging findings of hepatopulmonary syndrome and portopulmonary hypertension. MATERIALS AND METHODS: We retrospectively reviewed the imaging findings of five patients with hepatopulmonary syndrome and four patients with portopulmonary hypertension. We evaluated chest radiographs, chest and abdominal computed tomography (CT) scans, 99mTc-macroaggregated albumin (MAA) lung perfusion scans, and pulmonary angiograms. RESULTS: In patients with hepatopulmonary syndrome, the presence of peripheral pulmonary vascular dilatation was detected by chest radiograph, chest CT scan, and pulmonary angiogram, especially the basilar segment. 99mTc-MAA lung perfusion scan showed extrapulmonary tracer distribution (brain, thyroid, and kidney), which revealed pulmonary R-L shunting. In patients with portopulmonary hypertension, chest radiographs and chest CT scans showed the classic findings of primary pulmonary hypertension. In patients with both disorders, extrahepatic features of portal hypertension including ascites, splenomegaly, and portosystemic collateral vessels were seen on abdominal CT. CONCLUSION: In conclusion, chest radiographs and CT in hepatopulmonary syndrome usually showed peripheral pulmonary vascular dilatation, whereas those in portopulmonary hypertension showed central pulmonary artery dilatation. The extrahepatic features of portal hypertension might be helpful for the diagnosis of both disorders.     

Rupture of a solitary,erosive peripheral pulmonary artery aneurysm

Aneurysms of the pulmonary arteries and their branches are rare. Although they may occur as isolated congenital anomalies, they more frequently are associated with congenital heart disease and pulmonary arterial hypertension. Less common predisposing factors include primary pulmonary hypertension, collagen vascular disease, trauma, and pulmonary banding. Inflammatory or infectious contributing factors include chronic granulomatous infection, infective endocarditis, pneumonia, and the Hughes-Stovin and Behçet's syndromes. Chronic pulmonary arterial hypertension, due to an underlying left-to-right shunt, as well as a superimposed focal bacterial pneumonia were the etiologic factors in the development of the segmental pulmonary artery aneurysm in our patient. The rarity of this constellation of predisposing factors and the diagnostic dilemma posed by the findings in our patient led us to report our case and review the pertinent literature.