Dilated Bronchial Arteries Research Articles

110 Elexacaftor-tezacaftor-ivacaftor improves bronchial artery dilatation detected using MRI in people with cystic fibrosis

110 Elexacaftor-tezacaftor-ivacaftor improves bronchial artery dilatation detected using MRI in people with cystic fibrosis

Elexacaftor/Tezacaftor/Ivacaftor Improves Bronchial Artery Dilatation Detected by Magnetic Resonance Imaging in Patients with Cystic Fibrosis.

Rationale: Magnetic resonance imaging (MRI) detects improvements in mucus plugging and bronchial wall thickening, but not in lung perfusion in patients with cystic fibrosis (CF) treated with elexacaftor/tezacaftor/ivacaftor (ETI). Objectives: To determine whether bronchial artery dilatation (BAD), a key feature of advanced lung disease, indicates irreversibility of perfusion abnormalities and whether BAD could be reversed in CF patients treated with ETI. Methods: A total of 59 adults with CF underwent longitudinal chest MRI, including magnetic resonance angiography twice, comprising 35 patients with CF (mean age, 31 ± 7 yr) before (MRI1) and after (MRI2) at least 1 month (mean duration, 8 ± 4 mo) on ETI therapy and 24 control patients with CF (mean age, 31 ± 7 yr) without ETI. MRI was assessed using the validated chest MRI score, and the presence and total lumen area of BAD were assessed with commercial software. Results: The MRI global score was stable in the control group from MRI1 to MRI2 (mean difference, 1.1 [-0.3, 2.4]; P = 0.054), but it was reduced in the ETI group (-10.1 [-0.3, 2.4]; P < 0.001). In the control and ETI groups, BAD was present in almost all patients at baseline (95% and 94%, respectively), which did not change at MRI2. The BAD total lumen area did not change in the control group from MRI1 to MRI2 (1.0 mm2 [-0.2, 2.2]; P = 0.099) but decreased in the ETI group (-7.0 mm2 [-8.9, -5.0]; P < 0.001). This decrease correlated with improvements in the MRI global score (r = 0.540; P < 0.001). Conclusions: Our data show that BAD may be partially reversible under ETI therapy in adult patients with CF who have established disease.

The HRCT Imaging Findings of the Peripheral Pulmonary Vessels in Patients with Pulmonary Hypertension (PH)

The prominence of the pulmonary vasculature and/or tortuosity (n = 16) and dilatation of the central PA (n = 39) with RV hypertrophy were frequently observed. The interlobular septal thickening (n = 18, 45%), and centrilobular (perivascular) ground glass opacities (n = 6, 15%) were clearly depicted on gapless HRCT. PA aneurysmal dilatation and irregular dilatation with arterio-venous fistula were observed in 2 (5%) and 3 cases (7.5%), respectively. Bronchial artery dilatation was observed in 5 cases.

Magnetic resonance imaging detects onset and association with lung disease severity of bronchial artery dilatation in cystic fibrosis.

Bronchial artery dilatation (BAD) is associated with haemoptysis in advanced cystic fibrosis (CF) lung disease. Our aim was to evaluate BAD onset and its association with disease severity by magnetic resonance imaging (MRI). 188 CF patients (mean±sd age 13.8±10.6 years, range 1.1-55.2 years) underwent annual chest MRI (median three exams, range one to six exams), contributing a total of 485 MRI exams including perfusion MRI. Presence of BAD was evaluated by two radiologists in consensus. Disease severity was assessed using the validated MRI scoring system and spirometry (forced expiratory volume in 1 s (FEV1) % pred). MRI demonstrated BAD in 71 (37.8%) CF patients consistently from the first available exam and a further 10 (5.3%) patients first developed BAD during surveillance. Mean MRI global score in patients with BAD was 24.5±8.3 compared with 11.8±7.0 in patients without BAD (p<0.001) and FEV1 % pred was lower in patients with BAD compared with patients without BAD (60.8% versus 82.0%; p<0.001). BAD was more prevalent in patients with chronic Pseudomonas aeruginosa infection versus in patients without infection (63.6% versus 28.0%; p<0.001). In the 10 patients who newly developed BAD, the MRI global score increased from 15.1±7.8 before to 22.0±5.4 at first detection of BAD (p<0.05). Youden indices for the presence of BAD were 0.57 for age (cut-off 11.2 years), 0.65 for FEV1 % pred (cut-off 74.2%) and 0.62 for MRI global score (cut-off 15.5) (p<0.001). MRI detects BAD in patients with CF without radiation exposure. Onset of BAD is associated with increased MRI scores, worse lung function and chronic P. aeruginosa infection, and may serve as a marker of disease severity.

Preexisting Chronic Thromboembolic Pulmonary Hypertension in Acute Pulmonary Embolism

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered a complication of pulmonary embolism (PE). However, signs of CTEPH may exist in patients with a first symptomatic PE. Which radiologic findings on CT pulmonary angiography (CTPA) at the time of acute PE could indicate the presence of preexisting CTEPH? This study included unselected patients with acute PE who were prospectively followed up for 2 years with a structured visit schedule. Two expert radiologists independently assessed patients' baseline CTPAs for preexisting CTEPH; in case of disagreement, a decision was reached by a 2:1 majority with a third expert radiologist. In addition, the radiologists checked for predefined individual parameters suggesting chronic PE and pulmonary hypertension. Signs of chronic PE or CTEPH at baseline were identified in 46 of 303 included patients (15%). Intravascular webs, arterial narrowing or retraction, dilated bronchial arteries, and right ventricular hypertrophy were the main drivers of the assessment. Five (1.7%) patients were diagnosed with CTEPH during follow-up. All four patients diagnosed with CTEPH early (83-108days following acute PE) were found in enriched subgroups based on the experts' overall assessment or fulfilling a minimum number of the predefined radiologic criteria at baseline. The specificity of preexisting CTEPH diagnosis and the level of radiologists' agreement improved as the number of required criteria increased. Searching for predefined radiologic parameters suggesting preexisting CTEPH at the time of acute PE diagnosis may allow for targeted follow-up strategies and risk-adapted CTEPH screening, thus facilitating earlier CTEPH diagnosis.

RADIOGRAPHIC FINDINGS OF CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION

RADIOGRAPHIC FINDINGS OF CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION

Endovascular management of hemoptysis in a known case of tetralogy of fallot and tuberculosis complicated with aspergilloma: a case report

BackgroundHemoptysis is a life-threatening complication due to bleeding either from hypertrophied bronchial arteries or enlarged non-bronchial systemic collaterals, having multiple etiologies. Bronchial artery embolization (BAE) is a minimally invasive modality of management that can effectively manage moderate-to-severe hemoptysis.Case presentationWe report the case of a 25-year-old female with moderate-to-severe hemoptysis. There was prior history of tuberculosis and treatment with anti-tubercular therapy 6 months back. There was also a background of tetralogy of Fallot(TOF) with symptoms of chronic breathlessness and palpitations. Imaging evaluation with X-ray and HRCT thorax revealed a cavity in the left upper lobe with dependent soft tissue, implying a diagnosis of aspergilloma in an old tubercular cavity. TOF and right-sided aortic arch were noted. CT bronchial angiography showed dilated and tortuous left bronchial artery, as well as non-bronchial systemic collaterals from the ipsilateral internal mammary artery. Endovascular management was achieved by super-selective catheterization and embolization of the involved branch of the left bronchial artery and selective embolization of non-bronchial systemic collaterals from the ipsilateral internal mammary artery.ConclusionsBAE has a high clinical success rate and is recommended as first-line therapy in the management of massive hemoptysis. The CT pulmonary angiography, as well as the pre-embolization angiogram, is very important to detect the source of hemoptysis from the non-bronchial systemic circulation, increasing the success rate and decreasing the incidence of recurrence. BAE is effective even in presence of underlying vascular anomalies such as Fallot of Tetralogy.

Bronchial artery hypertrophy-associated perioperative pulmonary hemorrhage in cardiovascular surgery: a case report

BackgroundPulmonary hemorrhage is a life-threatening complication of cardiovascular surgery. Bronchial artery hypertrophy, a rare pathology associated with inflammatory and ischemic respiratory diseases, increases the risk of pulmonary hemorrhage; however, its involvement in cardiovascular surgery is not well known. We present two cardiovascular surgical cases in which embolization of the hypertrophied bronchial artery was effective in controlling perioperative pulmonary hemorrhage.Case presentationThe first case was a 51-year-old man with chronic obstructive pulmonary disease who developed acute type A aortic dissection. After emergent surgery, his blood pressure suddenly dropped in the intensive care unit; computed tomography revealed a right hemothorax. Because a 4-mm dilated bronchial artery was identified on preoperative computed tomography, the hemothorax was suspected to be associated with bronchial artery hypertrophy. Selective bronchial arteriography was emergently performed and revealed a right pulmonary parenchymal blush. After subsequent coil embolization of the bronchial artery, the parenchymal blush disappeared, and his hemodynamic condition stabilized. The second case was a 66-year-old man with bronchiectasis who was referred for redo aortic valve replacement due to structural valve deterioration. A bioprosthesis was previously implanted to avoid permanent anticoagulation because the patient had repeated episodes of hemoptysis; however, he still had persistent hemosputum during admission for the redo aortic valve replacement. A dilated bronchial artery 3.7 mm in size was incidentally identified on preoperative computed tomography, and hence, the repeated hemosputum was suspected to be associated with bronchial artery hypertrophy. Bronchial arteriography revealed a right pulmonary parenchymal blush, and prophylactic embolization of the bronchial artery was performed. The hemosputum disappeared after the procedure, and redo aortic valve replacement was performed uneventfully 8 days later.ConclusionIn cardiovascular surgery, the risk of pulmonary hemorrhage associated with bronchial artery hypertrophy should be considered, especially in patients with inflammatory and ischemic respiratory diseases.

Circumflex-to-Bronchial Artery Fistulas in Behçet's Disease

A coronary-to-bronchial artery fistula is a rare entity that emerged in the case of chronic pulmonary thromboembolism (cPTE). We present a case of a 50-year-old man with coronary-to-bronchial artery fistula in Behçet's disease that had been hospitalized in consequence of pulmonary thromboembolism attacks and treated with anticoagulation therapy repeatedly. After myocardial infarction was ruled out, coronary computerized tomography angiography was performed, and demonstrated right pulmonary artery occlusion, delay of the contrast passage in the right pulmonary veins, dilated right lung bronchial arteries, and fistulas between the right lung bronchial arteries and the left circumflex artery due to cPTE. Diagnosis of coronary-to bronchial artery fistula and early treatment are very important for the prevention of fatal complications. Radiologist and clinician should be alerted for this entity.

Bronchial Artery Angiographic Aspects of COVID-19

Two patients with coronavirus disease 2019 (COVID-19) infection (65 and 67 years old, receiving oxygen therapy via high-flow nasal cannulae, with no history of chronic respiratory disease or hemoptysis) were treated for psoas hematomata secondary to therapeutic anticoagulation (1 patient for a subsegmental pulmonary embolism and the other for an elevation of D-dimer level). In both the patients, computed tomography of the chest showed typical features of parenchymal lung abnormalities, consistent with COVID-19, and no chronic thromboembolic disease, bronchiectasis, or other conditions associated with bronchial artery dilatation.

Density of aortopulmonary collaterals predicts in-hospital outcome in tetralogy of Fallot with pulmonary stenosis.

OBJECTIVESThe aim of this study was to characterize the anatomy of aortopulmonary collateral (APC) arteries in tetralogy of Fallot and pulmonary stenosis and to determine whether APC density identified on preoperative multidetector cardiac computed tomography predicts in-hospital outcome.METHODSThe retrospective single-centre study includes consecutive 135 (2015–2019) patients who underwent one-stage repair. Preoperative multidetector cardiac computed tomography, echocardiography and clinical outcomes were reviewed. The cut-off value of indexed total distal APC cross-sectional area (APC-CSA) was identified by receiver operating characteristic curve. Logistic regression was used for predictors analysis.RESULTSThe median age and body weight were 19.7 (10.1–89.7) months and 10 (8.3–18) kg. A total of 337 APCs were detected with only one demonstrating severe stenosis. There was a strong and significant correlation between mean APC diameter per patient and age (r = 0.70, P < 0.001). APCs were imaged but mainly received no interventions. In-hospital mortality was similar between patients with high (indexed APC-CSA ≥3.0 mm2/m2) and low (<3.0 mm2/m2) APC density (P = 0.642). Significantly greater patients with high indexed APC-CSA experienced the in-hospital composite outcome of death, arrest, renal/hepatic injury, lactic acidosis or extracorporeal membrane oxygenation (P = 0.007). High APC density was associated with greater dosing (P = 0.008) and longer (P = 0.01) use of inotropic support, prolonged pleural drainage (P = 0.013), longer ventilation (P = 0.042), intensive care unit (P = 0.014) and hospital (P = 0.027) duration. No reintervention and death occurred in the follow-up with the median duration of 24.4 (11–36.6) months. Multivariable analysis showed the Nakata index (P = 0.05) and high APC density (P = 0.02) independently predicted the composite outcome.CONCLUSIONSIn tetralogy of Fallot and pulmonary stenosis, APCs are likely to be dilated bronchial arteries. Preoperative multidetector cardiac computed tomography-derived APC density was as important as Nakata index in predicting the occurrence of in-hospital composite outcome. The APC-CSA of 3.0 mm2/m2 maybe considered as a threshold for risk stratification.

Differential diagnosis of acute and chronic pulmonary thromboembolism according to MSCT data

Introduction. One of the important problems of medical imaging is the differential diagnosis of patients with acute and chronic pulmonary embolism. The widely used minimally invasive technique of multispiral computed tomography with intravenous bolus contrast enhancement can serve to solve this problem, in particular, to assess the state of the parenchyma and vascular structures of the lungs.The purpose. To assess the state of bronchial arteries and parenchymal changes in the lungs in pulmonary thromboembolism based on the results of multispiral computed tomography and their role in the more precise diagnosis of this disease.Materials and methods. An analysis of CT-angiopulmonography of 600 patients with suspected PE was performed. 87 patients with confirmed pulmonary thromboembolism were selected and divided into groups according to the final diagnosis: group 1 — acute pulmonary embolism, group 2 — chronic pulmonary embolism. CT data were analyzed for the presence of pathologically changed bronchial arteries, as well as lung's parenchymal changes (including mosaic perfusion, fibrotic changes, bronchial dilatation with or without wall thickening).Results. Bronchial arteries were assessed in patients with acute and chronic pulmonary embolism and the diagnostic value of the detected changes was determined. Acute pulmonary embolism does not lead to such dilatation of the bronchial arteries as chronic pulmonary embolism. In diagnostically unclear cases, secondary parenchymal signs visible on CT (mosaic perfusion and dilated bronchi without wall thickening) can be useful in the differential diagnosis of acute and chronic pulmonary embolism.Conclusions. Most patients with chronic pulmonary embolism demonstrated dilated bronchial arteries, in contrast to patients with acute pulmonary embolism. Lung's parenchymal changes (a mosaic perfusion pattern and bronchial dilation without wall thickening) were more common in patients with chronic pulmonary embolism. These CT-signs can help differentiate acute from chronic pulmonary embolism in unclear clinical situations.

The extent of enlarged bronchial arteries is not correlated with the development of reperfusion pulmonary edema after pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension.

This study investigated whether dilated bronchial arteries are associated with reperfusion pulmonary edema in patients with chronic thromboembolic pulmonary hypertension. Results showed that the extent of enlarged bronchial arteries was not associated with the development of reperfusion pulmonary edema, whereas the residual pulmonary hypertension had a significant association.

HEMOPTYSIS IN EISENMENGER SYNDROME-ASSOCIATED PULMONARY ARTERIAL HYPERTENSION (PAH): FORGOT ABOUT BRONCHIAL ARTERY EMBOLIZATION

SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: Anticoagulation in Eisenmenger syndrome (ES) associated PAH (ES-PAH) presents a clinical challenge, as there is both an increased prevalence of pulmonary artery thrombosis and hemoptysis. We present a case of ES-PAH complicated by hemoptysis and treated successfully with multi-vessel bronchial artery embolization (BAE). CASE PRESENTATION: A 52-year-old female with an atrial septal defect complicated by ES-PAH treated with continuous epoprostenol infusion, ambrisentan, supplemental oxygen, and thrombophilia previously managed with warfarin; presented with a one-week history with multiple episodes of hemoptysis and chest tightness. She reported a similar episode of hemoptysis one-year previously with no specific source of bleeding identified. At the time of her hemoptysis had resolved with discontinuation of warfarin.On this presentation, her vital signs were unremarkable on 3 LPM nasal cannula. Physical examination demonstrated a right ventricular heave, a loud and prominent P2, and a third heart sound. Electrocardiography revealed normal sinus rhythm and bifascicular block (RBBB and LPFB). CT angiography (CTA) of the chest demonstrated dilated bronchial arteries and patchy ground glass opacities within the left upper and lower lobes, consistent with alveolar hemorrhage.Otorhinolaryngology and interventional pulmonology found no discrete bleeding in the upper or lower respiratory tract. After discussion, prophylactic embolization of the dilated right and left bronchial arteries was performed successfully. No further episodes of hemoptysis were reported post embolization. On outpatient follow-up the patient has remain hemoptysis free. DISCUSSION: Eisenmenger physiology results from chronic left-to-right shunting of blood, leading to increased right-sided pressures, and reversal of shunt flow. Patients with ES-PAH are at increased risk of pulmonary artery thrombosis with concurrent increased risk of hemoptysis and pulmonary hemorrhage(1). Thrombo-embolic risks include atrial fibrillation and indwelling central catheters. Hemoptysis is often due to bronchial artery dilatation and/or rupture. The use of anticoagulation in ES-PAH patients is controversial due to balancing risk between thrombosis and hemoptysis, and survival benefits are unclear(2). BAE in PAH patients is more complex than in patients without PAH, due to frequent higher numbers of culprit arteries and increased anatomical/morphological variability(3). However, BAE has been demonstrated to be a safe and reliable intervention for hemoptysis in PAH3. There is no definitive treatment and repeated BAE for reoccurrence is common. CONCLUSIONS: Anticoagulation in ES-PAH should be used conservatively in an individualized approach. Hemoptysis is an uncommon in ES-PAH and may result from bronchial artery dilatation and rupture. We demonstrated the safety of multi-vessel BAE in ES-PAH and encourage its consideration within this cohort. Reference #1: Wan D, Tsui C, Kiess M, et al. Anticoagulation for Thromboembolic Risk Reduction in Adults With Congenital Heart Disease. Canadian Journal of Cardiology 2017; 33: 1597–1603. Reference #2: Sandoval J, Santos LE, Córdova J, et al. Does Anticoagulation in Eisenmenger Syndrome Impact Long-term Survival?: Anticoagulation in Eisenmenger Syndrome. Congenital Heart Disease 2012; 7: 268–276. Reference #3: Rasciti E, Sverzellati N, Silva M, et al. Bronchial artery embolization for the treatment of haemoptysis in pulmonary hypertension. La radiologia medica 2017; 122: 257–264. DISCLOSURES: No relevant relationships by Olayiwola Amoran, source=Web Response no disclosure on file for Christine Archer-Chicko; Advisory Committee Member relationship with Actelion/Janssen Please note: $5001 - $20000 Added 02/07/2019 by Harold Palevsky, source=Web Response, value=Honoraria Advisory Committee Member relationship with United Therapeutics Please note: $1001 - $5000 Added 02/07/2019 by Harold Palevsky, source=Web Response, value=Honoraria DSMB relationship with Eiger Please note: $1001 - $5000 Added 02/07/2019 by Harold Palevsky, source=Web Response, value=Honoraria No relevant relationships by cyrus vahdatpour, source=Web Response

Bronchial Dieulafoy\u2019s disease: a retrospective analysis of 73 cases

BackgroundBronchial Dieulafoy’s disease (BDD) is a rare disease that is known to be a cause of hemorrhage. The characteristics of this disease are still unknown. The present study describes the disorder based on a review of the world’s literature, emphasizing the diagnostic and therapeutic views.MethodsA comprehensive research of BDD of the PubMed, Google Scholar, and Web of Science databases was performed. The following data were collected: patient characteristics; chest imaging, bronchoscopy, vascular angiography, and histopathologic examination findings; and treatment rendered.Results73 cases of BDD have been reported from 1995 to 2019. Most of the cases occurred in Asia (52.1%), followed by Europe (31.5%). Chest imaging findings were non-specific. The main bronchoscopy finding was a nodular or protruding lesion (60.9%). 19 patients underwent bronchoscopic biopsies, 17 had bleeding, and 6 died. Four patients were successfully shown to have vascular malformations under mucosal protrusion by endobronchial ultrasound scan (EBUS). Vascular angiography mainly showed tortuous, dilated bronchial arteries. Vascular angiography mainly showed tortuous, dilated bronchial arteries. The arterial supply was mainly provided by bronchial arteries (48 cases) and the pulmonary circulation (4 cases). The lesions were mainly located in the right bronchus (53 cases). Selective bronchial artery embolization (BAE) was attempted in 38 patients and 20 patients underwent lobectomies. Emergency resection was performed in 15 patients, all of whom survived and had no recurrent hemoptysis.ConclusionsMassive hemoptysis was the common manifestation of BDD. Vascular angiography and EBUS is a very useful examination before biopsy. BAE may be used in stable patients, or patients who cannot tolerate surgery, while surgical resection should be considered in patients who are unstable, patients with uncontrolled hemoptysis, or following BAE failure.

Usefulness of standard computed tomography pulmonary angiography performed for acute pulmonary embolism for identification of chronic thromboembolic pulmonary hypertension: results of the InShape III study.

Chronic thromboembolic pulmonary hypertension (CTEPH) is often diagnosed after a long delay, even though signs may already be present on the computed tomography pulmonary angiogram (CTPA) used to diagnose a preceding acute pulmonary embolism (PE). In this setting of suspected acute PE, we evaluated the diagnostic accuracy of dedicated CTPA reading for the diagnosis of already existing CTEPH. Three blinded expert radiologists scored radiologic signs of CTEPH on initial CTPA scans with confirmed acute PE in 50 patients who were subsequently diagnosed with CTEPH during follow-up (cases), and in 50 patients in whom sequential echocardiograms performed >2 years after the acute PE diagnosis did not show any signs of pulmonary hypertension (controls). All 50 control index CTPA scans had signs of right ventricular (RV) overload. Sensitivity and specificity of expert CTPA reading was calculated, and best-predicting radiologic parameters were identified. The overall expert reading yielded a sensitivity of 72% (95% confidence interval [CI] 58%-84%) and a specificity of 94% (95% CI 83%-99%) for CTEPH diagnosis. Multivariate analysis identified 6 radiologic parameters as independent predictors: intravascular webs; pulmonary artery retraction or dilatation; bronchial artery dilatation; right ventricular (RV) hypertrophy; and interventricular septum flattening. The presence of 3 or more these parameters was associated with a sensitivity of 70% (95% CI 55%-82%), a specificity of 96% (95% CI 86%-100%), and a c-statistic of 0.92. Standardized reading of CTPA scans performed for acute PE can be useful for the diagnosis of CTEPH when structured identification of 6 characteristics is employed during interpretation. The use of this strategy may help reduce diagnostic delay of CTEPH.

CT-pathologic correlation in lung adenocarcinoma and squamous cell carcinoma.

Distinguishing lung adenocarcinoma from squamous cell carcinoma (SCC) is clinically important. Computed tomography (CT) scan is an economical, effective, noninvasive, commonly available, and quick diagnostic way for lung cancer. In this study, we aim to compare the CT characteristics in adenocarcinoma and SCC.Data from 275 cases (259 adenocarcinoma and 16 SCC) were retrospectively compared. CT characteristics, including lesion size and shape, single/multifocal lesions, location of the tumor, the margin of lobes, whether the lesion had deep lobulated margin, bronchial cut-off sign, signs of dilated bronchial arteries, signs of vascular bundle thickening, signs of short burrs, spinous processes, and pleural indentation, were compared in 148 cases (137 adenocarcinoma and 11 SCC).Patients with adenocarcinoma were more likely to be female (44.2% vs 25.0%, P = .017). Compared with SCC, adenocarcinomas were more likely to have deep lobulated margin (81.0% vs 54.5%, P = .038), less likely to have smooth lobes margin (2.7% vs 83.3%, P < .001), more likely to have vascular bundle thickening (37.2% vs 0, P = .016) and pleural indentation (59.9% vs 18.2%, P = .01), and marginally less likely to have dilated bronchial arteries (17.5% vs 45.5%, P = .064). No significant difference was observed regarding to characteristics, including tumor size, location of the tumor, signs of bronchial cut-off, dilated bronchial arteries, short burrs, or spinous processes.CT scan has the potential to help to distinguish lung adenocarcinoma and SCC in a fast and commonly available way. CT could be a rough but fast way to diagnosis, and may thus shorten the waiting time to treatment and allow more time for clinicians, patients, and their families to prepare for future treatment.

An unusual presentation of anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome in a 70-year-old man: a case report

BackgroundWe present a rare case of anomalous origin of the left coronary artery from the pulmonary artery syndrome in an elderly man, and we describe coronary computed tomographic angiographic imaging findings to improve diagnostic confidence for the evaluation of this uncommon coronary artery anomaly.Case presentationA 70-year-old Caucasian man came to our hospital with slight limitation of physical activity (New York Heart Association class II). He was asymptomatic for angina, syncope, and palpitations. Cardiac magnetic resonance imaging was performed after echocardiography because a hypertrophic cardiomyopathy was suspected; a plausible coronary artery anomaly was demonstrated as collateral evidence. Subsequently, coronary computed tomographic angiography showed the anomalous origin of left coronary artery from the pulmonary artery; the coronary vessels appeared markedly dilated and tortuous. Dilated intercoronary vessels along the epicardial surface of the heart and dilated bronchial arteries, corresponding to collateral pathways, were observed. Left ventricular hypertrophy, delayed subendocardial enhancement, and mitral insufficiency were better evaluated on magnetic resonance images. Invasive coronary angiography confirmed the main findings. Given the patient’s age and clinical performance, surveillance with medical management was considered appropriate, and surgical repair was avoided.ConclusionsConfidence with the anatomic pattern and clinical significance of this anomalous condition is necessary to improve cardiac imaging evaluation ability. In our patient, coronary computed tomographic angiography proved to be a reliable imaging approach, superior to invasive coronary angiography in terms of diagnostic performance and patient safety.

P1625Identification of chronic thromboembolic pulmonary hypertension on standard computed tomography pulmonary angiography for suspected acute pulmonary embolism

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is often diagnosed after a long delay, even though signs of CTEPH may already be present on the computed tomography pulmonary angiogram (CTPA) used to diagnose a preceding acute pulmonary embolism (PE). Diagnostic delay may be associated with worse prognosis. In this study we evaluated the diagnostic accuracy of extensive CTPA reading for predicting a future CTEPH diagnosis after acute PE. Method(s): Three expert radiologists scored radiological signs of CTEPH on CTPA performed for suspected acute PE in 50 PE patients who were subsequently diagnosed with CTEPH during follow-up with right heart catheterisation (cases), and in 50 PE patients, in whom sequential echocardiograms performed >2 years after the acute PE diagnosis had not shown any signs of pulmonary hypertension (controls). Cases and controls were matched on RV-to-LV ratio on baseline CTPA. Sensitivity and specificity of expert CTPA reading for predicting future CTEPH was calculated, and best predicting radiological parameters were identified by conditional backward multivariate analysis. Result(s): 75% of cases had signs of acute PE and 94% signs of chronic PE and/or PH. The overall expert adjudication yielded a sensitivity of 72% (95% CI 58-84%) and a specificity of 94% (95% CI 83-99%) for a future CTEPH diagnosis. We identified six objective, independent radiological predictors of CTEPH: intravascular webs, pulmonary artery retraction or dilatation, bronchial artery dilatation, right ventricle hypertrophy and interventricular septum flattening (Figure 1). The presence of >=3 of these parameters was associated with a sensitivity of 70% (95% CI 55-82%), a specificity of 96% (95% CI 86-100%) and a c-statistic of 0.92. Conclusion(s): In our cohort, expert radiologists identified 36 out of 50 PE patients with a future CTEPH diagnosis. The most probable explanation is that most of them already had CTEPH at the moment of the PE diagnosis. Our findings support the hypothesis that dedicated CTPA reading in patients with confirmed PE may lead to faster CTEPH diagnosis.

Postoperative Hemorrhage From Racemose Hemangioma of the Bronchial Artery After Esophageal Cancer Surgery

Racemose hemangioma of the bronchial artery is a rare disease. The diagnosis of racemose hemangioma is difficult when affected patients are asymptomatic and causes unexplained hemoptysis. Selective bronchial artery embolization has become the first-line treatment for this rare disease. However, feasibility and safety of bronchial artery embolization was not reported in the case with permanent tracheostomy. A 44-year-old woman underwent endoscopic screening during which a circular tumor was detected in the cervical esophagus, which was confirmed as squamous cell carcinoma on biopsy. She underwent cervical esophagectomy with pharyngolaryngectomy through a cervical incision. Reconstruction was performed by free jejunal transfer and permanent tracheostomy. Six weeks after surgery, hemoptysis from permanent tracheostomy was observed. Computed tomography (CT) scan revealed no bleeding around the tracheostomy, and bronchoscopy could not identify the origin of the bleeding due to a large amount of blood clots obscuring the visual field. Bronchial arteriography showed a bent, meandering and dilated bronchial artery, extending to the right bronchus with vascular hyperplasia. We diagnosed primary racemose hemangioma of the bronchial artery, which was successfully treated by transcatheter arterial embolization of the bronchial artery. After embolization, bronchoscopy revealed no bleeding. Findings from this case suggest that bronchial angiography is essential for diagnosis of this disease, and selective bronchial artery embolization appears to be effective in treating this disease in patients with permanent tracheostomy. Accumulation of similar cases will help to elucidate the optimal diagnosis and treatment strategy for this condition.