Imaging
Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.
The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.
Medical Image of the Week: Endovascular Intervention for Life-threatening Hemoptysis
Video 1. Pre-embolization video showing collateral vessels.
Video 2. Post embolization video showing the endovascular implants and cessation of collateral flow.
Idiopathic pulmonary arterial hypertension (PAH) is an uncommon life threatening disease characterized by a progressive increase in pulmonary vascular resistance with subsequent right ventricular failure and death. Hemoptysis is known to be one of the complications in PAH patients although the exact incidence and mechanism of hemoptysis remains unclear (1,2).
Ours is a case of a 40-year-old woman with known severe idiopathic pulmonary hypertension who was admitted for recurrent episodes of hemoptysis for the past one month. On her first presentation with non-massive hemoptysis, she underwent elective embolization with Amplatzer® vascular plug (St. Jude Medical, St. Paul, MN USA) of the aorto-pulmonary collaterals. These included a large collateral off the right subclavian artery, right internal mammary artery and a large collateral off the descending aorta to the right lung (Video 1). Her hemoptysis resolved. She was admitted seven days’ post first embolization with massive hemoptysis, and immediately underwent repeat embolization with Onyx® (Medtronic, Minneapolis, MN USA), a non-adhesive liquid embolic agent. Embolization was performed on the right intercostal arteries, left bronchial artery, with some abnormal vessels noticed (Video 2). No active bleeding was visualized during the procedure. Hemoptysis resolved once again.
The management of hemoptysis in patients with PAH remains indeterminate. However, embolization of bronchial arteries has been recommended as an effective method of managing PAH patients with recurrent hemoptysis to control the acute hemorrhage (2,3).
See-Wei Low MBBS1 Huthayfa Ateeli, MBBS2
1Department of Medicine and 2Division of Pulmonary, Allergy, Critical Care, and Sleep
Banner University Medical Center
Tucson, AZ, USA
References
- Broberg C, Ujita M, Babu-Narayan S, Rubens M, Prasad SK, Gibbs JS, Gatzoulis MA. Massive pulmonary artery thrombosis with hemoptysis in adults with Eisenmenger's syndrome: a clinical dilemma. Heart. 2004;90:e63. [CrossRef] [PubMed]
- Swanson KL, Johnson CM, Prakash UB, McKusick MA, Andrews JC, Stanson AW. Bronchial artery embolization: experience with 54 patients. Chest. 2002;121:789-95. [CrossRef] [PubMed]
- Reesink HJ, van Delden OM, Kloek JJ, Jansen HM, Reekers JA, Bresser P. Embolization for hemoptysis in chronic thromboembolic pulmonary hypertension: report of two cases and a review of the literature. Cardiovasc Intervent Radiol. 2007;30:136-9. [CrossRef] [PubMed]
Cite as: Low S-W, Ateeli H. Medical image of the week: endovascular intervention for life-threatening hemoptysis. Southwest J Pulm Crit Care. 2017;14(2):86-7. doi: https://doi.org/10.13175/swjpcc017-17 PDF
Medical Image of the Week: Fibrosing Mediastinitis
Figure 1. Panel A: Thoracic CT showing airway occlusion (arrowhead) from fibrosing mediastinitis. Panel B: pulmonary artery obstruction (arrow) from fibrosing mediastinitis.
Histoplasmosis is endemic to the Midwest US and commonly causes an acute infection that presents as a subacute pneumonia. Chronic sequelae of histoplasmosis range from asymptomatic nodules to debilitating fibrosing mediastinitis (1). Mediastinal fibrosis represents exuberant scarring in response to histoplasmosis infection. Fibrosis may occlude airways (Figure 1A, arrow head) obstruct pulmonary arteries (figure 1B, arrow) or veins and impinge upon the esophagus and other vital structures residing in the mediastinum. Chest imaging shows subcarinal or mediastinal widening. CT scans may reveal fibrotic encasing of mediastinal structures and calcification of regional lymph nodes. Recurrent and often serious hemoptysis results from lung or airway damage and vascular compromise. Respiratory failure can occur. Treatment rarely includes stenting of airways or surgery (2). Vascular stenting may be indicated in some cases. Regardless, these difficult cases must be referred to centers with experience in histoplasmosis related complications.
1Kenneth S. Knox, MD and 2Veronica A. Arteaga, MD
1University of Arizona College of Medicine- Phoenix
2University of Arizona College of Medicine- Tucson
References
- Peikert T, Colby TV, Midthun DE, Pairolero PC, Edell ES, Schroeder DR, Specks U.Fibrosing mediastinitis: clinical presentation, therapeutic outcomes, and adaptive immune response. Medicine (Baltimore). 2011 Nov;90(6):412-23. [CrossRef] [PubMed]
- Hammoud ZT, Rose AS, Hage CA, Knox KS, Rieger K, Kesler KA. Surgical management of pulmonary and mediastinal sequelae of histoplasmosis: a challenging spectrum. Ann Thorac Surg. 2009 Aug;88(2):399-403. [CrossRef] [PubMed]
Cite as: Knox KS, Arteaga VA. Medical image of the week: fibrosing mediastinitis. Southwest J Pulm Crit Care. 2017;14(2):85. doi: https://doi.org/10.13175/swjpcc015-17 PDF
Medical Image of the Week: Bronchial Clot Removal via Cryotherapy
Figure 1. Chest x-ray showing complete opacification of the left hemithorax.
Figure 2. Flexible bronchoscopy with cryotherapy was used to remove clot that formed casts of the bronchial tree. Black arrow: depicts segmental branch of the left upper lobe.
A 38-year-old man with a history of non-ischemic dilated cardiomyopathy presented with decompensated heart failure, acute renal failure, and possible sepsis. He underwent right cardiac catheterization but developed hemoptysis with concern for pulmonary artery rupture. Subsequently, the patient suffered a cardiac arrest but was resuscitated. Emergent bronchoscopy revealed copious amounts of blood and clot that could not be cleared at the time. The patient was then taken to the operating room and placed on A-A ECMO (left ventricle to aorta). The following morning chest x-ray (Figure 1) revealed a completely opacified left lung. Flexible bronchoscopy showed blood clot along the entire left bronchial tree. Initial attempts to remove the clot with suction and endobronchial graspers was unsuccessful. Ultimately, cryotherapy was used to remove the majority of the clot in fragments (Figure 2).
The use of cryotherapies and specifically, in this case, a cryoprobe, has been shown to safely and effectively remove thrombus from the bronchial tree. The basis behind this technique is the use of pressurized nitrous oxide or carbon dioxide to cool a metal probe tip. The probe then freezes any substance it comes in direct contact with, such as a blood clot. Thus, cryoadherence of the probe to the clot allows for effective removal via flexible endoscopy. Sriratanaviriyakul et al. (1) reported success rates for cryoextraction of blood clots to be >90%.
Cathy V. Ho MD, Ryan Matika MD, and Mimi Amberger MD
1Division of Trauma, Critical Care, Burn and Emergency Surgery. Department of Surgery
2The Department of Anesthesia
University of Arizona
Tucson, AZ USA
Reference
- Sriratanaviriyakul N, Lam F, Morrissey BM, Stollenwerk N, Schivo M, Yoneda KY.Safety and clinical utility of flexible bronchoscopic cryoextraction in patients with non-neoplasm tracheobronchial obstruction: a retrospective chart review. J Bronchology Interv Pulmonol. 2015 Oct;22(4):288-93. [CrossRef] [PubMed]
Cite as: Ho CV, Matika R, Amberger M. Medical image of the week: bronchial clot removal via cryotherapy. Southwest J Pulm Crit Care. 2016;13(5):253-4. doi: https://doi.org/10.13175/swjpcc109-16 PDF