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.

Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Pulmonary Vein Thrombosis

Figure 1. Axial CT view shows the thrombus in the pulmonary vein (arrows) and collateral formation.

 

Figure 2. Coronal view of thoracic CT angiography  showing thrombus in the pulmonary vein (arrow).

 

A 71-year-old woman with chronic lymphocytic leukemia and remote left lower lobe pneumonectomy presented to the emergency department from an outpatient clinic with symptoms of cough, progressive shortness of breath, and fatigue for 2 weeks.  Pertinent physical examination findings included adequate oxygen saturation at room air, known II/VI systolic mitral murmur with radiation through the precordium, and a well-healed left lower lobe pneumonectomy scar.  Imaging was remarkable for acute pulmonary venous thrombosis (PVT) of the left inferior pulmonary vein with involvement of several tributary veins (Figures 1 and 2). Given the rarity of PVT, treatment guidelines have yet to be established (1); however, consensus appears to be systemic anticoagulation, thrombectomy, or resection (1-3).  Therefore, the patient was initially placed on a heparin drip upon admission and was discharged on an oral anticoagulant.

Pulmonary vein thrombosis (PVT) is a rare condition only described through case reports, that is potentially life threatening and presents with nonspecific symptoms. Common inciting events are lung transplantation, pneumonectomy (typically early after surgery and mainly left upper lobe pneumonectomy), radiofrequency ablation complication, malignancy (either lung or metastatic), idiopathic and atrial fibrillation (1-3). 

Close clinical follow up is necessary as life-threatening complications can occur, such as gangrene of the lung (which can occur if there is no collateral circulation from the intercostal veins) or embolic stroke (3). Current literature review suggests CT or MRI as imaging modality of choice for tracking regression or resolution of disease. TEE may also be used to assess for extension of thrombi into the left atrium (1,3).

Jessica Vondrak, MD and Bonnie Barbee, MD

Department of Internal Medicine

Banner University Medical Center

Tucson, AZ USA

References

  1. Chaaya G, Vishnubhotia P. Pulmonary Vein Thrombosis: A Recent Systematic Review. Cureus. 2017 Jan 23;9(1):e993. [CrossRef] [PubMed]
  2. Selvidge SD, Gavant ML. Idiopathic pulmonary vein thrombosis: detection by CT and MR imaging. AJR AM J Roentgenol. 1999 Jun;172(6):1639-41. [CrossRef] [PubMed]
  3. Porres DV, Morenza OP, Pallisa E, Rogue A, Andreu J, Martinez M. Learning from the pulmonary veins. Radiograhpics. 2013 Jul-Aug;33(4):999-1022. [CrossRef] [PubMed]

Cite as: Vondrak J, Barbee B. Medical image of the week: pulmonary vein thrombosis. Southwest J Pulm Crit Care. 2017;14(5):228-9. doi: https://doi.org/10.13175/swjpcc048-17 PDF 

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Rick Robbins, M.D. Rick Robbins, M.D.

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

  1. 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]
  2. 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]
  3. 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

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