Abstract
Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH) is classified as group 4 pulmonary hypertension where unresolved thromboembolic disease obstructs the pulmonary artery. The resultant lung ischemia commonly leads to bronchopulmonary collateralization thought to lower pulmonary vascular resistance and reduce mortality. Here, we present a rare presentation of coronary-pulmonary collaterals in a 65-year-old former 40-pack year smoker with CTEPH, COPD requiring oxygen, AF, and DHF. Results: Dual-energy computed tomography (DECT) showed complete occlusion of the proximal right pulmonary artery. However, perfused blood volume (PBV) mapping of the DECT study revealed areas of the right lung that were still minimally perfused (Figure 1A, B). Pulmonary angiography confirmed occlusion of the right pulmonary artery (1C) . Subsequent coronary angiography revealed the presence of coronary to pulmonary collaterals that were providing limited perfusion to the right pulmonary circulation from the left circumflex artery (1D) . The patient underwent pulmonary thromboendarterectomy with removal of the clot en bloc without complication (1E) . Post-surgery DECT confirmed restoration of pulmonary arterial circulation and catheterization revealed an excellent hemodynamic response to surgery (1F, G) . Conclusions: DECT-derived PBV revealed significant perfusion to a proximally obstructed lung, hastening the discovery of rarely documented coronary-pulmonary artery collaterals via coronary angiography. We uniquely visualize via perfusion mapping that the collaterals provide an alternate vascular supply distal to the chronic pulmonary arterial obstruction until thromboendarterectomy can conclusively treat the occlusion. The presence of coronary-pulmonary collaterals may share similar pathophysiology to bronchial-pulmonary collaterals and be a positive prognosticator for robust post-operative hemodynamic improvement in CTEPH.
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