Lobar Branches Research Articles

Cholecystic Venous Anatomy: A Cadaveric Study with Implications for Portal Venous Interruption Procedure

The techniques of portal vein embolization (PVE) or ligation (PVL) have the goals of combining an induced atrophy of metastatic segments with the rapid relative compensatory hypertrophy of the postresection future liver remnant (FLR). Our study examines the anatomy of right-left hepatic lobar venous connections in the adult cadaver using corrosion cast analysis in an effort to define some of the inherent anatomical reasons why both PVL and PVE may be technically unsuccessful. Corrosion cast models of 215 cadaveric liver specimens were evaluated for hepatopetal venous blood flow, with a particular emphasis on cholecystic venous drainage patterns, including 57 cases prepared after lobar portal venous ligation. In 88.8 per cent of corrosion casts, there was a segmental venous communication between the gallbladder and all segments of the liver, except segment II. There was cystic vein drainage directly into a main lobar branch or directly into the portal vein itself in 11.2 per cent of cases. In all 57 cases, after portal lobar venous division, in situ cystic veins allowed persistent venous communication between lobes. Our cadaveric corrosion cast study has suggested that there is extensive intrahepatic cholecystic venous drainage to many segments of the liver. Perfusion from the gallbladder may potentially contribute to a limited response to procedures which interrupt the portal venous flow and could affect their capacity to induce an adequate FLR which would permit a wider hepatectomy.

A Case of Congenital Bronchial Pulmonary Arterial Malformation Successfully Treated by Embolization

AbstractIdiopathic bronchial pulmonary arterial malformation (BPAM) is a very rare condition. The authors present a case of BPAM in which a right bronchial artery communicates with a main upper lobe branch of the right pulmonary artery. It was successfully treated by embolization in one setting. The patient remained asymptomatic and well during the follow-up period. The authors therefore conclude that if the embolic material/device is carefully chosen, it is a safe and effective means of treating BPAM.

Thoracic aorta aneurysm- a rare cause of chronic backache with mediastinal shadow: case report

<p class="abstract">Thoracic aortic aneurysms (TAA) are rarely symptomatic. A 55 year old male presents with longstanding chronic backache. CXR showed left hilar shadow with collapse of left lung. Considering the CXR findings and with the patient being chronic smoker a strong possibility of carcinoma lung with bony metastasis was kept and further CECT chest was done. The CECT chest was suggestive of a thoracic aorta aneurysm with thrombosis compressing left principal bronchus and its lower lobar branch resulting in distal area of collapse and consolidation of left lower lobe. These findings were further confirmed on CT angiography. The patient was thus diagnosed as a case of descending thoracic aorta aneurysm probably of atherosclerotic etiology with thrombosis. Patient was started on beta blockers and ACE inhibitors along with supportive and symptomatic treatment and was further transferred to the department of CTVS for surgical intervention. Thus, this case report here signifies that possibility of thoracic aorta aneurysm should always be considered in a patient with chronic backache specially in presence of mediastinal shadow on CXR.</p>

Designing Triple Adult Liver Grafts From an Ideal Deceased Liver

Splitting deceased donor livers and creating 3 grafts from a whole liver may be feasible and shorten the waiting time for organ donation in patients with high mortality rates. We hypothesized that it might be reasonable to procure 3 grafts for donation from one deceased donor liver by splitting the liver into left (segment II, III, IV), right anterior (segment V, VIII), and right posterior lobes (segment VI, VII) for liver transplantation according to the portal system trifurcated variations. We designed the right anterior branch with the main portal trunk and middle hepatic artery to become inflow of right anterior lobe, the left portal vein and left hepatic artery to become the inflow of left lobe and right posterior branch, and right hepatic artery to become the inflow of right posterior lobe. We retrospectively reviewed the volumetric computed tomography and magnetic resonance cholangiopancreatography of 153 liver donors. The hepatic and portal veins, hepatic artery, and biliary system were reorganized and classified. The volumetric proportions of the liver grafts were measured. Trifurcation of the portal vein variation was found in approximately 13.7% of portal systemic variations. The left lobe accounted for 29.18% of the total liver volume, the right anterior lobe, 35.22%, and the right posterior lobe, 35.6%. We validated this principle by dissecting the explanted liver and identified the triple grafts' weights, percentages, vessels, and biliary ducts system. The splitting of deceased donor livers into 3 split liver grafts for use in liver transplantation surgery can be clinically useful.

Pyramidal Artery: An Artery to Pyramidal Lobe-A New Nomenclature.

Thyroid lobes are supplied by superior and inferior thyroid arteries. We dissected out a specific arterial pattern always present along with a well developed pyramidal lobe. Authors named this as "Pyramidal Artery". This may be a common unnoticed bleeding site during surgery. Thyroid anomalies are commonly observed as incidental finding during surgery. Presence of pyramidal lobe is the most common finding among other thyroid anomalies due to persistence of thyroglossal duct. Present study reported incidence of pyramidal lobe in 41.46% cases and pyramidal lobe branches off more frequently from left lobe than right. Special attention has to be paid during total thyroidectomy in order not to leave the thyroid tissue. Few such anatomical variations and surgical importance of vascular pattern in such cases is discussed in paper.

区域切除を行った肺動脈縦隔型分岐の1例

肺動脈走行異常に対する肺葉切除術は散見されるが，区域切除術を行った報告はみられない．症例は60歳男性．2ヵ月前に右肺腺癌に対して右下葉切除とS2区域切除を施行した．さらに左下葉S8肺癌，左上葉肺癌に対して左S8＋9区域切除と左上葉部分切除術を行った．術前3D-CTにて左A8b＋9b＋10bが縦隔枝で上肺静脈と気管支の間からS8，S9に分布し，A8b＋9bは下肺静脈の腹側，A10bは背側を走行していた．術中は葉間から全ての血管同定を行った．もう1本のA8bがA10bからも分岐し，術前3D-CTでは描出されていなかった．手術時間315分，出血量60 g．完全胸腔鏡下手術で安全に完遂できた．肺動脈走行異常がある場合，術前3D-CT，葉間からの分枝確認が重要である．

Acute pulmonary embolism in a dengue fever patient co-infected with influenza B

Introduction The main pulmonary embolism is a blockage of blood flow to the lungs by a blood clot which is composed of clumped platelets and condensed fibrin lodged into an artery in the lungs. A condition associated with thrombotic events due to loss of endothelium non-thrombogenic protective factors and severe dehydration might occur in the early course of severe dengue, thereby increasing the risk of embolic formation. We report acute pulmonary embolism in a severe dengue patient co-infected with influenza B, which might additionally predispose to an acute embolic event. Case description This 71-year-old diabetic woman with hypertension suffered from the dizziness, episodic fever, and general weakness since September 13, 2015. The data of dengue virus IgM, IgG and NS1 antigen were all positive. The presenting platelet count was 11000/uL. She felt worsening malaise, dizziness, anorexia, and newly developed dyspnea. The brain CT did not indicate obvious lesion except mild atrophy. The chest X-roentgenogram (CXR) revealed the opacity in left lower lung field. Abnormal liver function tests were noted, including S-GOT (AST), 1526 U/L; S-GPT (ALT), 709 U/L; total bilirubin, 2.71 mg/dL and direct bilirubin, 1.84 mg/dL. Under the impression of severe dengue with pneumonia, she was admitted for the further management. Antibiotic therapy with cefuroxime was given. However, the patient had worsening dyspnea and tachycardia 5 days later. Laboratory data showed elevated lactate (4.1 mmole/L), hypoxemia with mild decrease PaO2/FiO2 ratio, and elevated D-dimer (3271 ng/m). CXR showed resolution of pneumonia patch. As suspected pulmonary embolism, chest CT was arranged, which revealed partial thrombosis of right pulmonary artery at superior lobar branch. Therefore, she was admitted to the intensive care unit. In addition, the result of rapid influenza diagnostic test for influenza B antigen was positive. A 5-day course of oseltamivir and antibiotic therapy with levofloxacin were given. After treatment, fever subsided and dyspnea was improved. Follow-up platelet count rose to 91000/uL. Then, she was transferred to ward. After heparin therapy, subsequent daily warfarin was titrated to daily 2.5mg to achieve the desired prothrombin time ratio. As stable condition, she was discharged after 16 days of hospitalization. Conclusion Pulmonary embolism has been reported in association with dengue fever or severe influenza, particularly influenza A(H1N1). Co-existence of severe dengue, influenza B and acute pulmonary embolism was sparsely reported before. Awareness for these complications should be recommended to all practitioners who treat patients with severe dengue fever, particularly co-infected with influenza.

Clinical significance of peculiarities of the lesions of the vascular bed associated
 with pulmonary thromboembolism

Aim. To study effect of the level of vascular obstruction on the clinical manifestations of pulmonary embolism (PE). Material and methods. 63 patients with PE were included in this study. PE was verified by multidetector computed tomography (MSCT) with pulmonary angiography. 43 patients with high-risk PE survived the first week of the disease. In the remaining 20 patients with community-acquired pneumonia PE was diagnosed using MSCT pulmonary angiography in the first week of illness. Results. Obstruction of the trunk of the pulmonary artery or its lobar branches was detected in 34 (79.1%) patients with a high risk of PE and in only 2 (10%) ones with low-risk PE (p <0,001). The development of pneumonia complicated the course of the disease in 14 (32.6%) patients with a high risk of pulmonary embolism. The clots in the segmental branches of the pulmonary artery were identified in 9 (64.3%) patients with pneumonia. In high-risk patients with PE without pneumonia the lesion of segmental branches was detected only in 1 (3.4%) case (p <0,001). In patients with pneumonia at low risk of PE, the obstruction segmental branches was detected in 17 (85%) cases. Conclusion. The development of obstructive shock in PE is associated with a trunk embolism and/or the main pulmonary artery branches embolism. Infarction pneumonia is associated with the lesions of segmental branches of the pulmonary artery.

Temporary portal vein embolization is as efficient as permanent portal vein embolization in mice

Temporary portal vein embolization may be a safe alternative to permanent portal vein embolization. Such a new approach could be applied in living-related liver transplantation to increase graft volume before procurement. The impact of temporary portal vein embolization on occluded liver after recanalization, however, has never been assessed. Using a mouse model of temporary portal vein embolization, we investigated (1) the efficiency of temporary portal vein embolization in inducing nonoccluded liver hypertrophy and (2) the regeneration potential and functional recovery of embolized liver after recanalization. Selected portal vein branches were occluded using gelfoam powder (temporary portal vein embolization) or embospheres (permanent portal vein embolization), n=5/group. Magnetic resonance volumetry and angiography were used to determine volumes of the liver lobe and portal vein branch recanalization. In order to assess the functional and regenerative capacity of occluded liver lobes, nonoccluded lobes were resected 14days (timespan of complete portal vein recanalization) after temporary portal vein embolization or permanent portal vein embolization. Subsequently, RNA sequencing was performed to compare the signaling pathways of early liver regeneration among the groups. Hypertrophy of nonoccluded lobes 30days after temporary portal vein embolization and permanent portal vein embolization was similar (103 ±26% and 129 ±13%, P=.11). Temporary occluded lobes increased their volumes after nonoccluded lobes resection, reaching similar liver-to-body-weight ratios and similar functional capacity after 7days compared with partial hepatectomy controls (4 ±1% vs 4 ±1%, P=.22). Partial hepatectomy activated similar signaling pathways in temporary occluded and native liver. Temporary portal vein embolization induces hypertrophy of contralateral liver lobes similarly to permanent portal vein embolization in mice. This experimental work suggests that temporary portal vein embolization may be considered as a possibility in living liver donation, because regenerative and functional capacities are preserved in the embolized liver after recanalization in mice.

Surgical Techniques for Repair of Peripheral Pulmonary Artery Stenosis

Peripheral pulmonary artery stenosis is a rare form of congenital heart disease frequently associated with Williams and Alagille syndromes. Patients with this disease typically have systemic level right ventricular pressures secondary to obstruction at the lobar, segmental, and subsegmental branches. The current management of patients with peripheral pulmonary artery stenosis remains somewhat controversial. We have pioneered an entirely surgical approach to the reconstruction of peripheral pulmonary artery stenosis. This approach initially entailed surgical patch augmentation of all major lobar branches and effectively reduced right ventricular pressures by more than half. This was the first report demonstrating an effective approach to the disease. Over the past 5 years, we have gradually evolved the technique to extend the reconstruction's reach to include segmental and subsegmental branch stenoses. An important technical aspect of this approach entails division of the main pulmonary and separation of the branch pulmonary arteries to access the lower lobe branches. Pulmonary artery homograft patches are used to augment hypoplastic pulmonary artery branches. In addition, we perform a Heineke-Mikulicz type ostioplasty for isolated ostial stenoses. The technical details of the surgical approach to peripheral pulmonary artery stenosis are outlined in this article, and can also be used for other complex peripheral pulmonary artery reconstructions.

Use of Novel Anticoagulation to Treat Pulmonary Thromboembolism in an Ulcerative Colitis Patient with Cytomegalovirus Superinfection

Crohn's disease and ulcerative colitis are the two major types of inflammatory bowel disease, and affect mainly the gastrointestinal tract but also have extraintestinal sequelae, such as arterial and venous thromboembolism. Thromboembolic complications, particularly pulmonary thromboembolism, can be life threatening and require prompt management with anticoagulants. Conventional vitamin K antagonists have been used for the treatment of thromboembolic complications, but the development of novel oral anticoagulants has shifted the paradigm. We report a case of a 42-year-old female with ulcerative colitis with complaints of fever, rectal bleeding, abdominal and chest discomfort of 1-week duration. Initial sigmoidoscopy revealed multiple longitudinal ulcerations with a friable mucosa and easy touch bleeding in all colonic fields. Random biopsies and tissue CMV PCR were performed. The results indicated acute and chronic colitis, together with negative CMV immunohistochemistry, but positive CMV PCR. CMV IgG was positive and CMV real-time PCR using whole blood yielded a viral load of 633 copies/mL (19900 IU/mL). Initial chest dynamic computed tomography (CT) and lower-extremity CT showed diffuse deep vein thrombosis from the left common iliac vein to the calf veins of the lower left leg and filling defects in the lobar and segmental branches of the right lung, suggesting pulmonary thromboembolism. She was treated with oral mesalamine, intravenous steroid and ganciclovir and low-molecular-weight heparin, followed by rivaroxaban, a novel oral anticoagulant. Her symptoms resolved after treatment, and no recurrence was noted during a 6-month post-treatment follow-up.Figure 1Figure 2Figure 3We believe that in the near future, NOACs should replace VKAs for treatment of thrombotic complications in IBD patients.

Surgical Technique for Repair of Peripheral Pulmonary Artery Stenosis and Other Complex Peripheral Reconstructions

Surgical reconstruction of peripheral pulmonary artery stenosis is a technically challenging procedure due to the need to access all lobar and segmental branches. This paper describes our surgical approach that entails division of the main pulmonary and separation of the branch pulmonary arteries. This surgical approach can also be utilized for other complex peripheral pulmonary artery reconstructions.

Intravascular tumour embolism from chondrosarcoma

A 48-year-old woman with a history of sternal chondrosarcoma that had been completely resected 3 years previously presented with a 7-month history of cough and progressive dyspnoea. On admission she had blood oxygen saturation of 88%. Pulmonary CT angiography showed a large tumour embolus in the main pulmonary artery bifurcation that extended into the left pulmonary artery and all the left lobar and segmental arterial branches and caused a large left lower lobe parenchymal consolidation (fi gure). Percutaneous transthoracic biopsy of the consolidation showed metastatic chondrosarcoma. She underwent a left pneumonectomy. Macroscopic examination of the resected lung (fi gure) showed a translucent myxoid tissue fi lling the pulmonary arteries in an arboreous pattern. Microscopic analysis confi rmed that the metastatic chondrosarcoma was confi ned to the vasculature, even inside the parenchymal consolidation. The patient died 4 months later from respiratory insuffi ciency from right-sided pleural and pulmonary infection associated with rapid metastatic spread to the right lung. Pulmonary intravascular tumour embolism is often underdiagnosed at imaging; it is reported in 4–30% of all patients with malignancy on post-mortem examination. It is most common in cancers of the kidney, liver, breast, and lung. Chondrosarcomas are the third most common primary bone malignancy. They often metastasise to the lung parenchyma, but intravascular pulmonary tumour embolism has rarely been reported in chondrosarcoma. Distribution depends on the size of the initial tumour embolus. Small tumour emboli initially lodge distally and propagate towards the centre, gradually aff ecting larger pulmonary vessels, whereas larger tumour aggregates that embolise in more proximal vessels spread both centrally and peripherally. The clinical signs of pulmonary tumour embolism are variable, and often mimic those of acute or chronic pulmonary thromboembolism; unlike thrombo emboli, tumour emboli typically continue to grow despite anticoagulation. Pulmonary tumour embolism can show various patterns on chest CT (fi gure). It can present with a tree-in-bud pattern—a pattern that is more commonly seen in other diseases such as bronchiolar infl ammation or infection— when small tumour emboli cause fi lling and dilatation of the small peripheral centrilobular pulmonary arteries, occasionally leading to a pulmonary infarct. The most characteristic appearance of tumour embolism is enlargement of more central beaded pulmonary arteries, caused by larger tumour emboli. Extensive dissemination can also result in parenchymal consolidation, a cause that should be considered in a patient with a known malignancy.

CT-defined phenotype of pulmonary artery stenoses in Alagille syndrome.

Alagille syndrome is a rare disorder commonly associated with pulmonary artery stenosis. Studies exist discussing the cardiovascular sequela but no consistent phenotype, or pattern of pulmonary artery stenosis, has been described. The objective of this study was to characterize the distribution and severity of pulmonary artery stenosis in patients with Alagille syndrome based on computed tomography angiography. A retrospective chart review identified patients with Alagille syndrome who had undergone CT angiography. Pulmonary trunk (MPA), left main pulmonary artery (LPA) and right main pulmonary artery (RPA) diameters in Alagille patients were compared with those from matched control subjects. Stenoses at lobar and segmental pulmonary arteries were categorized as: Grade 1 (<33% stenosis), Grade 2 (33-66% stenosis) or Grade 3 (>66% stenosis). Involvement among the different lung regions was then compared. Fifteen patients ages 6months to 17years were identified; one had surgical augmentation of the central pulmonary arteries and was excluded from the central (main, right and left) pulmonary artery analysis. The proximal LPA and RPA, but not the MPA, were significantly smaller than those of the control subjects (P<0.01). The proximal LPA was significantly smaller than the proximal RPA (P<0.01) in the Alagille group (0.55 LPA:RPA ratio). Within the Alagille group, 75% of the lobar and segmental branches showed mild or no stenoses (Grade 1), 17% showed moderate stenosis (Grade 2) and 8% showed severe stenosis (Grade 3). While not statistically significant, the right lung demonstrated a greater percentage of Grades 2 and 3 stenoses (28%, right vs. 20% left, P=0.1). The right middle and lingula lobes of both lungs showed more Grade 2 and 3 stenoses (33% upper/middle vs. 18% lower, P<0.01). We describe a common pattern pulmonary artery stenosis in Alagille patients consisting of severe proximal LPA stenosis, heavy involvement of the lobar and segmental branches (more often right than left), and a greater involvement of the upper lobes. Knowledge of this phenotypic pattern can help in the diagnosis of Alagille syndrome in patients presenting with pulmonary artery stenosis.

Subclassification of Barcelona Clinic Liver Cancer B and C hepatocellular carcinoma: A cohort study of the multicenter registry database.

We aimed to subclassify hepatocellular carcinoma (HCC) using Barcelona Clinic Liver Cancer intermediate and advanced stages, which include a highly heterogeneous population. From two registries ("random" and "voluntary" cohorts in the Korean Liver Cancer Study Group), patients who were newly diagnosed as HCC with intermediate or advanced stage between 2003 and 2005 were considered eligible. Overall survival (OS) was analyzed using Kaplan-Meier method with comparison by log-rank test. Patients with intermediate-stage HCC (n = 994) were subclassified according to tumor size and Child-Pugh class. Patients with tumor size < 5 cm (B1), those with tumor size ≥ 5 cm and Child-Pugh A (B2), and those with tumor size ≥ 5 cm and Child-Pugh B (B3) had median OS of 30.73, 20.60, and 9.23 months, respectively (P < 0.001 by log-rank test). Among patients with advanced stage HCC (n = 1746), patients were subclassified according to presence of significant portal vein invasion (sPVI; defined as portal vein invasion in lobar, main, or contralateral branch) and extrahepatic spread (EHS). Patients with neither sPVI nor EHS (C1), those with either sPVI or EHS (C2), and those with both sPVI and EHS (C3) had median OS of 8.43, 4.63, and 3.63 months, respectively (P < 0.001 by log-rank test). Subclassification of Barcelona Clinic Liver Cancer intermediate and advanced stages might be useful for determining patient prognosis and guiding treatment strategies for HCC.

Surgical Techniques for Repair of Peripheral Pulmonary Artery Stenosis

Peripheral pulmonary artery stenosis (PPAS) is a rare form of congenital heart disease that is most frequently associated with Williams and Alagille syndromes. These patients typically have systemic level right ventricular pressures secondary to obstruction at the lobar, segmental, and subsegmental branches. The current management of patients with PPAS remains somewhat controversial. We have pioneered an entirely surgical approach for the reconstruction of PPAS. This approach initially entailed a surgical patch augmentation of all major lobar branches and effectively reduced the right ventricular pressures by more than half. This was the first report demonstrating an effective approach to this disease. Over the past 5 years, we have gradually evolved our technique of reconstruction to include segmental and subsegmental branch stenoses. An important technical aspect of this approach entails the division of the main pulmonary and separation of the branch pulmonary arteries to access the lower lobe branches. Pulmonary artery homograft patches are used to augment hypoplastic pulmonary artery branches. In addition, we perform a Heinecke-Miculicz-type ostioplasty for isolated ostial stenoses. The technical details of the surgical approach to PPAS are outlined in this article and can also be used for other complex peripheral pulmonary artery reconstructions.

A Case of Pseudoaneurysm Due to Fungus Ball within the Progressive Massive Fibrosis in a Patient with Pneumoconiosis: Computed Tomography-Pathologic Correlation

While uncommon, pulmonary artery aneurysms and pseudoaneurysms are associated with high mortality. Overall they are considered rare entities with prevalence rates of around 1 case per 14000 to 100000 autopsies (1, 2). Most pulmonary artery aneurysms and pseudoaneurysms are acquired and associated with cardiovascular disease, infection, iatrogenic causes, trauma, neoplasm, and connective tissue disease. To our knowledge, while there are many cases of Rasmussen aneurysm in patients with cavitary tuberculosis, there have been no reports of pseudoaneurysm due to fungus ball in the progressive massive fibrosis (PMF) of a patient with pneumoconiosis. We described a case of pseudoaneurysm detected by contrast-enhanced chest CT with threedimensional (3D) reconstruction. The pseudoaneurysm arose in the upper lobar branch of the right pulmonary artery and caused by a fungus ball within the PMF in a patient with pneumoconiosis, who underwent transcatheter endovascular embolization of the aneurysm.

A TWO-YEAR FOLLOW-UP OF A FEMALE PATIENT WITH RECURRENT PULMONARY THROMBOEMBOLISM AFTER SUCCESSFUL COMBINED TREATMENT

Objective: to describe a clinical case of recurrent pulmonary thromboembolism (PTE) with developed chronic thromboembolic pulmonary hypertension (CTEPH) and successful stenting of the pulmonary artery branch after ineffective thrombolysis. Patient Ch. born in 1978 was admitted to a cardiology unit with suspected PTE. The patient complained of obvious resting dyspnea increasing with minimal physical exercise. Blood test revealed leukocytosis, D-dimer just above the normal value. Electrocardiography showed sinus rhythm, right axis deviation, and complete right bundle-branch block. EchoCG indicated right hearth dilatation with an increase in systolic pressure gradient across the tricuspid valve up to 60 mm Hg. Lower extremity venous duplex scanning revealed a muscle vein dilated up to 14 mm with echogenic parietal deposits in the muscle thickness at the middle third of the right leg; compression was virtually complete; the valves were incompetent and a muscle vein irregularly dilated up to 7 mm in the middle third of the left leg; the walls were uneven; compression was complete. Angiopulmonography detected occlusion of the lower and middle lobe branches of the right pulmonary artery and the lower lobe branch of the left pulmonary artery. Results. It was decided to perform local thrombolysis in terms of the patient»s young age, obvious clinical symptoms (New-York Heart Association Functional Class (FC) III–IV dyspnea) and the data of earlier studies on the benefit from thrombolysis in intermediate-risk persons and a council of a vascular surgeon, a cardiologist, and an X-ray endovascular diagnosis and treatment physician, and an invasive specialist. The patient underwent local thrombolysis with purolase 6,000,000 IU. Control angiopulmonography revealed no positive changes in the branches of the pulmonary artery. Because of ineffective thrombolysis and the persistence of significant pulmonary hypertension and FC III–IV dyspnea, the patient underwent conduction recanalization of the area of left lower lobe pulmonary artery occlusion, percutaneous transluminal balloon angioplasty, and endoprosthesis replacement with an 8.0–29-mm holometallic peripheral stent. Control angiopulmonography showed that the arterial lumen was completely restored and blood flow was not distally embolized. Conclusion. This clinical case is an example of the delayed diagnosis of recurrent PTE, which was a reason for ineffective thrombolytic therapy that had been performed 11 days after the onset of an episode. In this situation, percutaneous transluminal balloon angioplasty and pulmonary artery branch stenting can improve the status of a patient and reduce the risk of CTEPH in the future. In spite of its apparent ease, angioplasty can cause problems: impossibility and hazard of enhanced contrasting of the pulmonary artery; extensive injury of its branches; arterial cicatricial process associated with multiple episodes of PTE. After angioplasty, patients may develop reperfusion pulmonary edema, the causes of which are fully unclear. However, the successful intervention makes it possible to lower pulmonary artery pressure, pulmonary vascular resistance, and blood NT-proBNP levels and to increase exercise tolerance. At the present time, a number of centers are performing such procedures in patients with CTEPH. This requires 2–3 balloon inflations per session. Holometallic stent placement can decrease the number of necessary inflations and reinterventions in the future. This clinical case demonstrates that pulmonary artery stenting is successful in the patient with recurrent PTE after ineffective thrombolysis.

Optimisation of CT pulmonary angiography by applying cardiac CT techniques

Purpose – To reduce effective dose to patients by reducing dose length product (DLP) – To reduce intravenous contrast volume used for computed tomography pulmonary angiography (CTPA) studies – To improve image quality via increased pulmonary arterial enhancement (HU) Methods and materials Twenty-three patients with justified CTPA requests were randomly assigned to study group according to availability of supervising radiologist(s). Twenty-three further consecutive patients who underwent standard protocol CTPA examination were retrospectively assigned to control group during study period. Tube voltage was modified as per body mass index (BMI). Z-axis scan range was limited from lower margin of sternoclavicular joint to upper margin of lowest diaphragm. High flow fixed volume dual pump technique was used with breath hold. Images were acquired using 64 slice Phillips Brilliance CT scanner. Pulmonary arterial opacification was measured at centre of pulmonary trunk and first segmental lower lobar branch. Results All scans were of adequate diagnostic quality. The study group saw reductions in mean DLP of 21% (296.1 milliGray-centimetre [mGy-cm] vs 374.4 mGy-cm), intravenous contrast volume administered of 23% (60 millilitres [mls] vs 78mls). Mean pulmonary arterial opacification was improved by 49% (470 HU vs 316 HU) and mean segmental arterial opacification by 55% (471 HU vs 304 HU) over control group. Conclusion Reduction in CTPA radiation dose and intravenous contrast volume can be achieved by using established cardiac CT techniques while improving image quality at the same time. – To reduce effective dose to patients by reducing dose length product (DLP) – To reduce intravenous contrast volume used for computed tomography pulmonary angiography (CTPA) studies – To improve image quality via increased pulmonary arterial enhancement (HU) Twenty-three patients with justified CTPA requests were randomly assigned to study group according to availability of supervising radiologist(s). Twenty-three further consecutive patients who underwent standard protocol CTPA examination were retrospectively assigned to control group during study period. Tube voltage was modified as per body mass index (BMI). Z-axis scan range was limited from lower margin of sternoclavicular joint to upper margin of lowest diaphragm. High flow fixed volume dual pump technique was used with breath hold. Images were acquired using 64 slice Phillips Brilliance CT scanner. Pulmonary arterial opacification was measured at centre of pulmonary trunk and first segmental lower lobar branch. All scans were of adequate diagnostic quality. The study group saw reductions in mean DLP of 21% (296.1 milliGray-centimetre [mGy-cm] vs 374.4 mGy-cm), intravenous contrast volume administered of 23% (60 millilitres [mls] vs 78mls). Mean pulmonary arterial opacification was improved by 49% (470 HU vs 316 HU) and mean segmental arterial opacification by 55% (471 HU vs 304 HU) over control group. Reduction in CTPA radiation dose and intravenous contrast volume can be achieved by using established cardiac CT techniques while improving image quality at the same time.

Suspected Pulmonary Thromboembolism and Deep Venous Thrombosis: A Comprehensive 64-slice Multidetector Computed Tomography Diagnosis in Gynecologic Patients.

Suspected Pulmonary Thromboembolism and Deep Venous Thrombosis: A Comprehensive 64-slice Multidetector Computed Tomography Diagnosis in Gynecologic Patients.