Selective Pulmonary Angiography Research Articles

Abstract 15019: Safe Implantation of Remote Pulmonary Artery Pressure Monitoring System (CARDIOMEMS) in a Pregnant Patient With Severe Heart Failure

Introduction: Heart failure (HF) in pregnancy is associated with high maternal and neonatal mortality. Remote pulmonary artery pressure (PAP)-guided management of HF has been shown to reduce hospitalizations and mortality in HF patients. However, PAP monitoring systems (CardioMEMS) have not been implanted during pregnancy. We describe the first case of safe implantation of CarioMEMS in a pregnant patient with HF. Case report: A 38-year-old female with past medical history of non-ischemic cardiomyopathy with an ejection fraction of 15%, left ventricular thrombus, pulmonary hypertension, and atrial fibrillation was found to be 14 weeks pregnant by the obstetrician, and her HF medications were appropriately discontinued. The patient was continued on metoprolol, amlodipine, and enoxaparin and was advised to terminate the pregnancy due to high risk of maternal mortality, however, she decided against it. An interdisciplinary team of obstetricians and cardiologists managed the patient during her pregnancy. As the pregnancy progressed, the patient had multiple hospitalizations due to decompensated HF. To optimize her hemodynamic status and guide diuretic therapy, a decision to implant CardioMEMS was made after a risk-benefit discussion, at 23 weeks of gestation. A long wire and sheath were used from a femoral venous access to limit fluoroscopy. A right heart catheterization was performed, and cardiac filling pressures and output were measured. Minimal contrast (7.5 ml of iodixanol) was used to perform selective pulmonary artery angiography and the sensor was implanted according to manufacturer recommendations. Total fluoroscopic exposure during the procedure was 11.2 minutes (183 Gy-cm2). Patient’s diuresis and afterload reduction was adjusted based on PAP. Conclusion: Remote PAP monitoring system can be safely implanted in pregnant patients using limited contrast and fluoroscopic exposure to proactively manage heart failure.

High incidence of pulmonary artery thrombosis after balloon pulmonary angioplasty in CTEPH patients receiving direct oral anticoagulants

Abstract Background Chronic thromboembolic pulmonary hypertension (CTEPH) requires life-long anticoagulant therapy, whereas limited data exist on the safety and efficacy of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) along with balloon pulmonary angioplasty (BPA). Objectives To evaluate outcomes and complications in CTEPH following BPA for individuals receiving DOACs or VKAs. Methods Consecutive CTEPH patients underwent BPA from September 2014 to August 2021 were included in a retrospective analysis. Complications during BPA, post-BPA hemodynamics and bleeding events were obtained from patient's medical records. Our routine follow-up “selective” pulmonary angiography, to evaluate all segmental pulmonary arteries one by one at six months and every year after final BPA session, was performed to elucidate the incidence of in-situ fresh floating thrombus. Results Of total 250 individuals, 104 were treated with DOACs and 146 with VKAs following BPA. Mean observation period was 905 (SD ± 660) days. Total 1278 BPA sessions were performed among the period in which 409 sessions were treated with DOACs and 869 sessions with VKAs. Significant improvements in hemodynamics and functional status were observed in both groups following BPA. There was no significant difference of hemoptysis during BPA between DOACs and VKAs (7.1% vs 10.1%, P=0.131). Major bleeding events during observation period were equivalent in those treated with DOACs and VKAs. No significant re-elevation of pulmonary artery pressure was observed in both groups after BPA. Follow-up selective pulmonary angiography identified in-situ fresh floating thrombus in pulmonary artery in 22 cases of total 769 follow-up sessions. The occurrence of fresh thrombus was significantly higher in those receiving DOACs than VKAs in therapeutic range of PT-INR >1.8 (3.9% vs 1.2%, P=0.023) whereas no significant difference between DOACs and overall VKAs (3.9% vs 2.4%, P=0.177) Conclusions Post-BPA hemodynamic outcomes and bleeding events appear unaffected by choice of anticoagulant. However, the incidence of in-situ pulmonary thrombosis detected by selective pulmonary angiography was significantly higher in those receiving DOACs than VKAs in therapeutic range, suggesting inadequate anticoagulation under current dose of DOACs. Our study provides a rationale for further examination to evaluate the efficacy of DOACs in CTEPH. Funding Acknowledgement Type of funding sources: None.

Low incidence of restenosis after successful balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension.

Balloon pulmonary angioplasty (BPA) is now a treatment option for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, the incidence of restenosis and long-term changes in vessel diameters in pulmonary arteries after BPA are unknown. The present study investigated the incidence of restenosis by measuring changes in vessel diameter after BPA. We reviewed 58 patients (168 lesions) with CTEPH who underwent single dilation for the target lesion (type A/B/C lesions) during BPA procedure followed by selective pulmonary angiography more than 6months after the final BPA procedure. The outcomes of BPA were assessed in terms of pulmonary artery diameters. In a median follow-up of 1.9 (1.2-2.7) years, restenosis occurred in only one case with a type C lesion after BPA (0.6%). In type A/B lesions, the minimal lumen diameter was significantly enlarged at follow-up after BPA [3.48 (2.59-4.34) to 4.22 (3.31-4.90) mm]. In type C lesions, the minimal lumen diameter was unchanged at follow-up after BPA [3.15 (1.96-3.64) to 3.28 (2.38-4.61) mm]. The present results revealed that restenosis after BPA rarely occurs in type A/B/C lesions. Minimal lumen diameters for type A/B lesions continually increased and those for type C lesions did not decrease. Stent implantation in type A/B/C lesions would be unnecessary after BPA.

A novel angiographic classification of pseudoaneurysms of the pulmonary chronic inflammatory cavity based on selective angiograms and therapeutic implications.

BackgroundHemoptysis is a common clinical symptom. In the chronic tuberculosis cavity and chronic necrotizing pneumonia cavity, pseudoaneurysms (Pas) easily form and are prone to massive hemoptysis and repeated hemoptysis and can even endanger patient's life. However, it remains to be further analyzed whether Pas of the pulmonary chronic inflammatory cavity selectively affect the peripheral pulmonary branches. This study is based on selective angiography to classify peripheral pulmonary arterial Pas (PAPs) of the pulmonary chronic inflammatory cavity and to determine treatment options for PAPs, thereby guiding individualized clinical treatment.MethodsAngiographic data of 392 noncancer patients undergoing hemoptysis were retrospectively analyzed. All of the patients underwent pulmonary and selective pulmonary angiography and bronchial and nonbronchial systemic collateral arterial angiography. A total of 9 patients had Pas of the pulmonary chronic inflammatory cavity, and a pseudoaneurysm systemic artery collateral (Pasac), inflow and outflow sections of the parent vessels, and direction of blood flow in the parent vessels were clearly observed with digital subtraction angiography (DSA) and/or C-arm cone-beam flat-panel detector computed tomography angiography (CBCTA). Patients with underlying disease had pulmonary tuberculosis (n=8) or lung abscess (n=1). The angiographic types of Pas were analyzed.ResultsEight patients with chronic pulmonary tuberculosis and 1 patient with a necrotizing pneumonia cavity in the convalescent period were included in the study. Pas of the pulmonary chronic inflammatory cavity presented the following types: (I) pulmonary artery pseudoaneurysm (PAPa) (n=2 cases); (II) body arterial Pa (n=3 cases); and (III) systemic-pulmonary anastomosis Pa. Each type could be divided into two subtypes (n=4 cases). In nine cases, embolization and hemostasis were technically and clinically successful.ConclusionsPas of the pulmonary chronic inflammatory cavity are diverse (especially in cases of pulmonary tuberculosis). Angiographic typing plays a guiding role in the selection of an embolization strategy.

Selective Segmental Pulmonary Angiography: Anatomical, Technical and Safety Aspects of a Must-Learn Technique in Times of Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension.

With the advent of balloon pulmonary angioplasty (BPA) for non-surgical chronic thromboembolic pulmonary hypertension (CTEPH) patients, there is renewed interest in the pulmonary angiography technique. This technique is still the standard imaging modality to confirm CTEPH, which, in addition, helps to determine the most appropriate treatment. Furthermore, learning this technique fulfills two main purposes: to identify BPA candidates and to provide the operator with the catheter handling needed to perform BPA. Operators interested in performing BPA must learn not only the pulmonary arteries’ anatomy, but also which are the best angiographic projections and the most suitable catheters to canalize and display each segmental branch. Unfortunately, this information is scarce in the literature. With this goal, learning the diagnostic pulmonary angiography technique can be a first step on the way to perform BPA. Although there are descriptions on how to perform a pulmonary angiography with balloon-tipped catheters and the digital subtraction technique, this technique does not provide operators with the catheter knowledge and manual skill needed to cannulate each segmental branch. In contrast, learning the conventional selective segmental pulmonary angiography (SSPA) technique provides the operator with this knowledge and skills. In this review, based on the experience of the authors, we describe the pulmonary arteries’ anatomy and detail the practical aspects of the SSPA procedure, with the aim of providing operators with the anatomical and technical knowledge needed to perform BPA. We also summarize the contemporary complications of SSPA in CTEPH patients at a reference center.

Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: advances in patient and lesion selection.

Balloon pulmonary angioplasty (BPA) has been performed worldwide for patients who are ineligible for pulmonary endarterectomy (PEA). However, the technical details of BPA have not been standardized, and no international consensus regarding patient and lesion selection for BPA has been reached. Evidence for the combination of BPA with PEA or medical therapy is also lacking. This review highlights recent progress in BPA in terms of patient and lesion selection and the current procedural approach for BPA, including combination treatment. The indications for BPA have expanded with recent reports describing the improved safety and efficacy of BPA. Because lesions are generally present in all segmental and subsegmental pulmonary arteries, it is recommended to treat all the lesions to achieve desirable hemodynamic improvement. Selective pulmonary angiography is the gold standard for lesion selection in modern BPA aimed at total revascularization. Despite the lack of randomized controlled studies, combination treatment with BPA may be well tolerated and effective. BPA, alone or in combination with PEA or medical therapy, may be a treatment option for patients who are not candidates for monotreatment of PEA. However, further investigation is required to standardize patient and lesion selection for BPA.

Pulmonary arteriovenous malformation: Case report

Introduction. Pulmonary arteriovenous malformation (PAVM) is pathological communication between pulmonary artery and pulmonary vein, in way that it shunts normal alveolar capillary membrane resulting in inadequate blood oxygenation in this part of the lung parenchyma Modern therapy of PAVMs includes surgical treatment or endovascular embolization. Case report. A 30-year-old female patient had signs of parestesia and weakness of the extremities on the left side of her body. On physical examination there was only cyanotic discoloration of her lips and clubbing fingers. On the chest x-ray, in the right hemithorax, in the inferior region of the lung, there was relatively homogeneous and well defined shadow, intensity of the soft tissue, which was about 35 mm. A multislice computed tomography pulmonary angiography was performed and showed, in lung parenchyma on both sides, many PAVMs, of which the largest (35 mm) was in inferior right region of the lung on crossing between apical and posterior basal lung segment with 7 mm diameter feeding artery and 9 mm diameter draining vein. The selective pulmonary angiography was per-formed by Seldingers technique. Through sheath, we placed a plug with a diameter of 10 mm. The plug was expanded and a complete occlusion of the final part of the feeding branch of this PAVM was achieved (confirmed by control angiography). In that way, the PAVM was fully shut off from the circulation. In 3 months follow-up, the patient was feeling well, without any recorded complication. Conclusion. Endovascular embolization is recommended as therapy of the first choice for all of PAVMs that have feeding artery greater than 2 mm. Endovascular embolization has high success rate with minimal complications.

Improved hemodynamics and cardiopulmonary function in patients with inoperable chronic thromboembolic pulmonary hypertension after balloon pulmonary angioplasty

BackgroundBalloon pulmonary angioplasty (BPA) has been demonstrated to improve cardiac function and exercise capacity in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH), but its instant impact on cardiopulmonary function has seldom been evaluated. This study aims to determine the safety and efficacy of BPA and its immediate and lasting effects on cardiopulmonary function among CTEPH patients.MethodsFrom May 2018 to January 2019, patients with inoperable CTEPH who underwent BPA sessions were consecutively enrolled. Hemodynamics were measured by right heart catheterization, selective pulmonary angiography and BPA were successively conducted. Hemodynamic variables, WHO functional class (WHO-FC), 6-min walk distance (6MWD) and serum NT-proBNP were evaluated before and after BPA sessions during hospitalization. Pulmonary function testing (PFT) and cardiopulmonary exercise testing (CPET) were performed within 1–3 days pre and post BPA to evaluate the effect of BPA on cardiopulmonary function.ResultsTwenty-five patients with inoperable CTEPH who underwent a total of forty BPA sessions were consecutively enrolled. A total of 183 segmental or subsegmental vessels (4.6 ± 1.9 vessels per session) in 137 segments (3.4 ± 1.6 segments per session) were dilated. No procedure-related complications occurred. Instant hemodynamics, WHO-FC, 6MWD and NT-proBNP were all significantly improved after a single BPA session. Significant improvement in cardiopulmonary function was also evident as assessed by PFT indexes (forced vital capacity, forced expiratory volume in the first second, maximal voluntary ventilation) and CPET parameters (peak work rate, peak VO2, oxygen uptake efficiency slope). Further analysis among ten CTEPH patients receiving multiple BPA sessions (2–4 sessions) indicated BPA resulted in lasting improvements in hemodynamics and cardiopulmonary function.ConclusionsBPA, a safe and effective approach, can bring instant improvements after a single session and lasting benefits after multiple sessions to hemodynamics and cardiopulmonary function for patients with inoperable CTEPH.

Feasibility and efficacy of percutaneous pulmonary vein stenting for the treatment of patients with severe pulmonary vein stenosis due to fibrosing mediastinitis

Objective: To evaluate the feasibility and safety percutaneous pulmonary vein intervention in patients with severe pulmonary vein stenosis (PVS) caused by fibrosing mediastinitis(FM). Methods: This retrospective analysis included 5 FM patients (2 male, 3 female, 54-77 years old) confirmed by clinical presentation and chest computed tomography (CT) scan from January to June 2018 who were from Gansu Provincial Hospital and Shanghai Chest Hospital. CT pulmonary angiography (CTPA) further revealed severe PVS caused by fibrotic tissue compression in mediastinum. After selective pulmonary vein angiography, gradually balloon angioplasty was used to expand the pulmonary vein and then stents were implanted in the pre-dilated stenotic pulmonary veins. Evaluation of therapeutic effect was made at 6 months after the procedure. Results: All of 11 serious compression PVS were treated with stent implantation (diameter: 7-10 mm, length: 17-27 mm). After stenting, degree of pulmonary vein stenosis decreased from (83±16)% to (12±4)% (P<0.01). The minimal diameter of the stenotic pulmonary vein was significantly increased from (0.8±0.5)mm to (7.5±0.8)mm (P<0.01). Trans-stenotic gradient decreased from (27.0±15.1)mmHg (1 mmHg=0.133 kPa) to (2.50±0.58)mmHg (P<0.05). Mean pulmonary pressure measured by cardiac catheter decreased from (45.0±9.0)mmHg to (38.7±8.4)mmHg (P<0.05). One patient experienced cardiac arrest due to vagal nerve reflex during big sizing balloon stent dilation and recovered after cardiopulmonary resuscitation. There were no other serious procedure related complications. During the follow-up, severe stenosis at end of proximal stent was evidenced in 1 patient due to fibrotic compression, and another patient developed in-stent thrombosis due to discontinuation of prescribed anticoagulant. Conclusion: Percutaneous intervention for severe pulmonary vein stenosis caused by FM is feasible and safe, and can improve hemodynamic caused by the compression of mediastinal vascular structures in these carefully selected patients.

Outcomes of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension at a Single Center in Taiwan.

Chronic thromboembolic pulmonary hypertension (CTEPH) is classified as group IV pulmonary hypertension. This study aimed to report our institutional experience in managing CTEPH. We prospectively collected the data of 23 patients diagnosed with CTEPH between August 2001 and August 2017 in Linkou Chang Gung Memorial Hospital. Baseline characteristics including functional class (FC), 6-minute walk distance (6MWD), comorbidities, hematological and biochemical data, echocardiography, cardiac catheterization, and selective pulmonary angiography were recorded at diagnosis. All patients were referred to a cardiac surgeon for pulmonary endarterectomy (PEA) assessment. The mean age at diagnosis was 48.4 ± 16.1 years. Nineteen patients (83%) underwent PEA with mean postoperative follow-up of 37.7 ± 42.8 months. The in-hospital mortality rate of PEA was 11%. The 1-, 2-, 3- and 5-year overall survival rates were 89%, 89%, 81%, and 50%, respectively. After 3 months of PEA, all patients had improvements in FC, 6MWD (from 326 ± 62 to 420 ± 63 m), B-type natriuretic peptide level (from 602 ± 599 to 268 ± 565 pg/mL), and systolic pulmonary artery pressure (from 79 ± 19 to 48 ± 19 mmHg). The patients with proximal disease (Jamieson type 1 or 2) had better survival than those with distal disease (Jamieson type 3 or 4), but there was no significant difference in mortality between FC III and IV. All of the four patients who did not undergo PEA survived for more than 3 years. Significant improvements in symptoms, functional capacity, and hemodynamics were achieved in the CTEPH patients after PEA. However, the overall survival was still unsatisfactory.

The predictors of complications in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

The aims of this study were to (1) evaluate risk factors of complications of balloon pulmonary angioplasty (BPA) and (2) assess the mechanism of the complications. BPA represents a promising treatment option in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, the complication ratio differs across reports, and the causes remain controversial. All complications found by angiography and non-contrasted computerized tomography (CT) immediately after BPA were recorded. New emergences of a ground-glass pattern or consolidation in CT after BPA that were not recognized on CT images before BPA were counted as pulmonary bleeding. Lesion morphologies were classified into four types (web, ring, abrupt narrowing and occlusive lesions) according to selective pulmonary angiography. Thirty patients consented to analysis of the BPA-related images, and 879 lesions (112 sessions) were evaluated. One hundred and twenty-two (99.2%) of 123 complications were confirmed to be associated with BPA procedures at the local area. In the multivariate analysis, occlusive lesions were the sole independent predictor of procedure-related complications (adjusted odds ratio 5.83, 95%CI [1.94-17.47], p = 0.002). Hemodynamic parameters were not predictors of complications. CT images after BPA presented the predictive value for the occurrence of hemoptysis. Almost all complications were attributed to operators' procedures. Lesion morphology was the sole predictor of BPA-related complications, while hemodynamic parameters were not associated with the frequency of complications. CT scan images after BPA were useful to identify bleeding complications and to predict hemoptysis.

Pulmonary artery pseudoaneurysm causing massive hemoptysis in hyperimmunoglobulin E syndrome: a case report

BackgroundHyperimmunoglobulin E syndrome (HIES) is a rare primary immunodeficiency disorder defined by high serum immunoglobulin E titers that is associated with recurrent respiratory infections, formation of pneumoatoceles, recurrent skin abscesses, and characteristic dental and skeletal abnormalities.Case presentationWe report a case of a 56-year-old male with a history of HIES, cavitary mycetomas, and allergic bronchopulmonary aspergillosis who presented with recurrent massive hemoptysis. Bronchial artery angiography and bronchoscopy failed to identify active hemorrhage, and two embolizations of the bronchial artery did not resolve the bleeding. Subsequently, selective pulmonary artery angiography was conducted that demonstrated a subsegmental pulmonary artery branch pseudoaneurysm with extravasation into an adjacent lung cavity. This was treated successfully with transcatheter embolization.ConclusionsTo our knowledge, this is the first case reported of pulmonary artery pseudoaneurysm in HIES in the medical literature. Pulmonary artery pseudoaneurysm should be considered in the differential diagnosis in patients with HIES and massive hemoptysis.

Balloon pulmonary angioplasty \u2013 efficient therapy of chronic thromboembolic pulmonary hypertension in the patient with advanced sarcoidosis \u2013 a case report

BackgroundApproximately a quarter of patients with advanced sarcoidosis develop pulmonary hypertension (PH), which affects their prognosis. We report unusual case of confirmed chronic thromboembolic pulmonary hypertension (CTEPH) in a patient with stage IV sarcoidosis successfully treated with balloon pulmonary angioplasty (BPA).Case presentationA 65 years old male with a history of colitis ulcerosa, and pulmonary sarcoidosis diagnosed in 10 years before, on long term oral steroids, with a history of deep vein thrombosis and acute pulmonary embolism chronically anticoagulated was referred to our center due to severe dyspnea. On admission he presented WHO functional class IV, mean pulmonary artery pressure (mPAP) in right heart catheterization (RHC) was elevated to 54 mmHg. Diagnosis of CTEPH was definitely confirmed with typical V/Q scan, and with selective pulmonary angiography (PAG) completes by intravascular imagining (intravascular ultrasound, optical coherent tomography). The patient was deemed inoperable by CTEPH team and two sessions of BPA with multimodal approach resulted in significant clinical and haemodynamical improvement to WHO class II and mPAP decrease to 27 mmHg.ConclusionsBalloon pulmonary angioplasty, rapidly developing method of treatment of inoperable CTEPH patients, is also extremely useful therapeutic tool in complex PH patients.

Clinical study of optical coherence tomography in the diagnosis of peripheral pulmonary artery thrombus

BackgroundPeripheral pulmonary artery thrombus (PPT) is common in the clinic. However, due to the lack of an ideal diagnostic tool, PPT cannot be quickly diagnosed and effectively treated at present. Optical coherence tomography (OCT) is a new intravascular imaging technique that is characterized by high image resolution. This technique is suitable for small vessel imaging and has the ability to distinguish red and white thrombi. ObjectiveThis study aimed to evaluate the value of OCT in the diagnosis of PPT and in identifying the nature of thrombi by comparing the difference in sensitivity between OCT and selective pulmonary angiography (SPA). MethodsHighly suspected PPT patients were enrolled in this study. Pulmonary ventilation/perfusion (V/Q) mismatch pulmonary segments or peripheral pulmonary arteries were chosen. SPA was performed first, followed by OCT imaging. The diagnostic standard of thrombus with SPA was an intraluminal filling defect. The procedure and criteria for OCT diagnosis of thrombus were previously introduced in intracoronary OCT thrombus images. The diameter of the imaging vessels was measured, and they were grouped according to diameter. The diameter was <2mm in the distal segment group, 2–3mm in the middle segment group, and >3mm in the proximal segment group. The recognition abilities of intravascular thrombus with the different diameters of these two techniques were compared. Patients with obvious clinical symptoms and more red thromboses revealed by OCT were given standardized anticoagulant therapy for half a year. The clinical symptoms, 6-minute walking test and changes in the thrombus in the OCT images of these patients before and after treatment were observed. ResultsA total of 22 patients with highly suspected PPT were suggested to undergo V/Q inspection. Finally, 12 patients were eligible for the study. SPA and OCT were performed in 61 peripheral pulmonary arteries in all 12 patients. The ideal SPA and OCT images obtained from a total of 76 blood vessel segments were suitable for comparative analysis. A total of 62 thrombi were found by SPA. Among these, eight thrombi were in the distal segment, 29 thrombi were in the middle segment, and 25 thrombi were in the proximal segment. A total of 81 thrombi were found by OCT, among which 22 thrombi were in the distal segment, 31 were in the middle segment, and 28 were in the proximal segment. There was a significant difference between two groups in the distal segment group (P=0.013), while there was no significant difference between two groups in the middle segment group or the proximal segment group (P>0.05). In addition to all the thrombi found by SPA, OCT found other thrombi that were missed by SPA. According to previous OCT images for determining the nature of thrombi, OCT revealed 81 thrombi, of which 48 (59%) were red thrombi and 33 (41%) were white thrombi. Then, seven patients who had obvious clinical symptoms and more red thrombi in the peripheral pulmonary artery were given anticoagulant therapy for six months. After treatment, these symptoms were improved, oxygenation indexes increased, and the six-minute walking test was extended in all these patients. After anticoagulation therapy, five patients underwent OCT review. These OCT images were matched and compared before and after anticoagulation therapy. The results revealed that most of the thrombi had disappeared, and a small amount of red thrombi turned white as the volume reduced. The mean lumen area before and after treatment was 2.05±1.03mm2 and 2.86±1.24mm2, respectively, and the difference was statistically significant (P=0.035). ConclusionOCT can clearly show the structure of the lumen and the wall of the peripheral pulmonary artery tube. The sensitivity of the diagnosis of PPT with a diameter of <2mm was higher than that of SPA. Moreover, OCT has the ability to distinguish between red and white thrombi, which is of guiding significance in anticoagulant therapy.

D-dimer test for excluding the diagnosis of pulmonary embolism.

Pulmonary embolism (PE) can occur when a thrombus (blood clot) travels through the veins and lodges in the arteries of the lungs, producing an obstruction. People who are thought to be at risk include those with cancer, people who have had a recent surgical procedure or have experienced long periods of immobilisation and women who are pregnant. The clinical presentation can vary, but unexplained respiratory symptoms such as difficulty breathing, chest pain and an increased respiratory rate are common.D-dimers are fragments of protein released into the circulation when a blood clot breaks down as a result of normal body processes or with use of prescribed fibrinolytic medication. The D-dimer test is a laboratory assay currently used to rule out the presence of high D-dimer plasma levels and, by association, venous thromboembolism (VTE). D-dimer tests are rapid, simple and inexpensive and can prevent the high costs associated with expensive diagnostic tests. To investigate the ability of the D-dimer test to rule out a diagnosis of acute PE in patients treated in hospital outpatient and accident and emergency (A&E) settings who have had a pre-test probability (PTP) of PE determined according to a clinical prediction rule (CPR), by estimating the accuracy of the test according to estimates of sensitivity and specificity. The review focuses on those patients who are not already established on anticoagulation at the time of study recruitment. We searched 13 databases from conception until December 2013. We cross-checked the reference lists of relevant studies. Two review authors independently applied exclusion criteria to full papers and resolved disagreements by discussion.We included cross-sectional studies of D-dimer in which ventilation/perfusion (V/Q) scintigraphy, computerised tomography pulmonary angiography (CTPA), selective pulmonary angiography and magnetic resonance pulmonary angiography (MRPA) were used as the reference standard.• Adults who were managed in hospital outpatient and A&E settings and were suspected of acute PE were eligible for inclusion in the review if they had received a pre-test probability score based on a CPR.• quantitative, semi quantitative and qualitative D-dimer tests.• Target condition: acute symptomatic PE.• Reference standards: We included studies that used pulmonary angiography, V/Q scintigraphy, CTPA and MRPA as reference standard tests. Two review authors independently extracted data and assessed quality using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). We resolved disagreements by discussion. Review authors extracted patient-level data when available to populate 2 × 2 contingency tables (true-positives (TPs), true-negatives (TNs), false-positives (FPs) and false-negatives (FNs)). We included four studies in the review (n = 1585 patients). None of the studies were at high risk of bias in any of the QUADAS-2 domains, but some uncertainty surrounded the validity of studies in some domains for which the risk of bias was uncertain. D-dimer assays demonstrated high sensitivity in all four studies, but with high levels of false-positive results, especially among those over the age of 65 years. Estimates of sensitivity ranged from 80% to 100%, and estimates of specificity from 23% to 63%. A negative D-dimer test is valuable in ruling out PE in patients who present to the A&E setting with a low PTP. Evidence from one study suggests that this test may have less utility in older populations, but no empirical evidence was available to support an increase in the diagnostic threshold of interpretation of D-dimer results for those over the age of 65 years.

Interventional Therapeutic Strategy for Hemoptysis Originating from Infectious Pulmonary Artery Pseudoaneurysms

This study reports 6 cases of hemoptysis originating from infectious pulmonary artery pseudoaneurysms (PAPs). Selective pulmonary angiography revealed PAPs in 5 cases, and segmental pulmonary artery embolization was performed using coils and gelatin sponge particles. Systemic arterial embolization also was performed in 5 cases because of inadequate initial control or for shunts from systemic to pulmonary arteries. At a median follow-up time of 9 months (range, 25 d to 25 mo), no recurrence occurred, although 2 patients died of respiratory failure. Segmental artery embolization combined with systemic artery embolization may be useful in patients with hemoptysis secondary to PAPs.

Diagnosing chronic thromboembolic pulmonary hypertension: current perspectives

Diagnosing chronic thromboembolic pulmonary hypertension: current perspectives Charaka Hadinnapola, Deepa Gopalan, David P Jenkins Papworth Hospital National Health Service Foundation Trust, Papworth Everard, Cambridge, United Kingdom Abstract: Chronic thromboembolic pulmonary hypertension is a rare and relatively poorly understood disease. It remains underdiagnosed and is often not recognized in primary and secondary care, as its symptoms are nonspecific and there are few clinical signs until late in the disease process. However, pulmonary endarterectomy (PEA) offers a potential cure for patients with this type of pulmonary hypertension; therefore, it is important that they are identified and diagnosed in a timely manner. PEA is associated with a 2.2%&ndash;5% risk of significant morbidity and mortality, even in experienced PEA centers. Therefore, once chronic thromboembolic pulmonary hypertension is diagnosed, further assessment of operability and patient selection is crucial. Assessment of operability involves determining the distribution and burden of chronic thromboembolic disease, assessing pulmonary hemodynamics, and assessing the functional impairment of the patient. Ventilation perfusion scintigraphy is of value in screening for the presence of chronic thromboembolic disease. However, computer tomography pulmonary angiography and magnetic resonance pulmonary angiography are now increasingly used to image the vascular occlusions directly. This allows assessment of the surgically accessible disease burden. Some centers still advocate conventional selective pulmonary angiography for the latter. Right-heart catheterization remains the gold standard for assessing pulmonary hemodynamics. Higher pulmonary vascular resistances are associated with poorer outcomes as well as increased risks at the time of surgery. This is in part because of the presence of more distal chronic thromboembolic material and distal pulmonary artery remodeling. However, in experienced centers, these patients are being operated on safely and with good outcomes. Patients with chronic thromboembolic disease, who have normal pulmonary hemodynamics, require careful functional assessments to determine the benefits of surgery. Keywords: CTEPH, pulmonary endarterectomy, diagnosis

Primary pulmonary vein stenosis in a premature infant without bronchopulmonary dysplasia: A case report

Primary pulmonary vein stenosis (PVS) presenting in childhood is uncommon and is related to premature with bronchopulmonary dysplasia (BPD). Here we present a premature infant with primary PVS and without BPD. In our case, a 19-month-old girl was diagnosed with PVS, atrial septal defect and patent arterial duct by echocardiography and selective pulmonary artery angiography. Interestingly in the first 2 month after birth, there was no clue of PVS by bed echocardiography in the patient. It is important to focus on the pulmonary vein blood velocity in premature infants and very low birth weight infants even without BPD.

Usefulness of Non-Enhanced 3-Dementional CT with Partial Maximum Intensity Projection for Planning Embolotherapy for Pulmonary Arteriovenous Malformations

Purpose: Computed Tomography (CT) with contrast material is often used for preoperative assessment and planning of embolotherapy in the treatment of Pulmonary Arteriovenous Malformations (PAVMs). However, pulmonary vasculature is well demonstrated in the lung window setting without the need for contrast material; thus, risks of adverse effects of contrast material itself or paradoxical emboli through PAVMs can be avoided. The purpose of this study was to determine the usefulness of non-enhanced 3-Dimentional (3D)-CT angiography for planning of embolotherapy for PAVMs. Materials and methods: Between February 2004 and October 2011, 20 patients (nine males, 11 females) with 41 PAVMs underwent non-contrast CT using a multi-detector-row CT prior to coil embolotherapy. A high-resolution tailored 3D-CT angiogram was reconstructed on a workstation with partial Maximum Intensity Projection (MIP) in the lung-window to assess the angioarchitecture of the lesions for preoperative planning of embolotherapy. For each lesion, location, number, and diameter of feeding arteries and draining veins were measured. It was determined whether there was any side branch close enough to the sac to anchor the first coil to prevent coil migration. The difference between the diameter of the first coil and the feeding artery was measured. Based on findings, diagnostic pulmonary angiography and coil embolotherapy were performed. The depiction of the side branch of the feeding artery close to sac between preoperative partial MIP 3D-CT images and selective pulmonary angiography was evaluated by using the un-weighted κstatistical analysis. Results: A total of 49 feeding arteries were embolized. Mean diameter of the feeding arteries and drainage veins were 3.6 mm and 4.6 mm, respectively. Sixteen and eighteen feeding arteries with a side branch to anchor were depicted on CT and angiography, respectively. In the depiction of the side branch of the feeding artery close to sac between preoperative partial MIP images and selective pulmonary angiography, excellent agreement was obtained (κ=0.91). The mean difference between diameter of the first coil and the feeding artery was 1.5 ± 1.47 mm. All 41 lesions could be identified on angiography, and embolization procedures could be executed as planned based on partial MIP images. Conclusion: Non-enhanced tailored partial MIP 3D-CT in the lung window appears to be a feasible and useful vascular imaging technique for planning coil embolotherapy of PAVMs.

Successful Application of Subcutaneous Adipose Tissue With Fibrin Glue in Conservative Treatment of Tracheobronchial Rupture

An 84-year-old woman underwent aortic and mitral valve replacement. After weaning from cardiopulmonary bypass, hemorrhage was observed in the endobronchial tube. The bleeding bronchus was isolated to protect the airway using the blocker cuff of a Univent tube (Fuji Systems Corp, Tokyo, Japan). Computed tomography showed a pulmonary pseudoaneurysm in the left upper lobe. She underwent selective pulmonary angiography and embolization of the pseudoaneurysm. Bronchoscopy revealed a 5-mm bronchial rupture at the left upper lobe bronchus. The laceration was filled with adipose tissue and fibrin glue. Bronchoscopy showed a completely reepithelialized membrane, and she was discharged 38 days postoperatively.