pulmonary angiography presenter: cheng-han li supervisor: yi-hen li grossman’s cardiac...

Pulmonary Angiography

Presenter: Cheng-Han LiSupervisor: Yi-Hen Li

Grossman’s cardiac catheterization, angiography, and intervention

Indicationsthe American Colledge of Radiology and the Society of Cardiovascular and Interventional Radiology 1993

• Suspected pulmonary embolus when pulmonary scintigraphy is unavailable

• High-probability lung scan when there is contraindication to anticoagulation

• Indeterminate lung scan, but suspect pulmonary embolus

• Low-probability lung scan with high clinical suspicion

• Diagnosis and evaluation of suspected chronic pulmonary embolus

• Diagnosis and evaluation of other suspected pulmonary abnormalities such as vasculitis, congenital and acquired anomalies, tumor encasement, and vascular malformation

CT Pulmonary Angiography

• Contrast helical CT for detection central pul. Embolus 90% sensitivity, 96% specificity

• When including subsegmental a., sensitivity63% specificity89%

• Partial volume effects lower contrast evolution in right middle lobe and lingular vessels

• Major limitation failure to detect subsegmental emboli• PIOPED trial, 6% limited to subsegmental emboli• In subgroup of low probability with emboli, 30% limited to su

bsegmental emboli

MR Pulmonary Angiography

• In the past, difficult to detect because of artifacts of motion and air-vessel interface

• Meaney, sensitivity 100%, 87%, and 75% in three readers• MR angiography may surpass CT in the future

Contraindications

• No absolute contraindications• Take care in case of

1. LBBB it may turn into CAVB during right heart catheterization

2. Pulmonary hypertension Pitton found that there were no hemodynamic effects under O2 after bolus of non-ionic contrast

3. Allergy

4. Patients on amiodarone case mortality

Complications

• PIOPED trial (1111 patients) major (1.3%) Death:0.5% respiratory distress(CPR/intubated): 0.4% Renal failure (HD): 0.3% Hematoma (2U transfusion): 0.2% Minor (5.4%) respiratory distress, renal dysfunction, angina,

hypotension, pulmonary congestion, allergy, hematoma, arrhythmia

Procedure

• Venous access right femoral vein right internal jugular vein left internal jugular vein left femoral vein right or left basilic vein

Procedure

• Pulmonary catheterization 6 or 7F pulmonary catheter ( accommodate 20-25m

l/sec flow) 4F nylon catheter ( 20ml/min) is suitable in basilic v

ein

Procedure

• Catheter selection 1. Pigtail should be tight (<1cm) a. safe passage through right heart; b. use of the same catheter to inject contrast in superselective PA c. must be withdraw under floppy-tip guidewire (may hook a papillary m.) 2. Balloon-tipped catheter

Nyman, Grollman, straight pigtail and Berman catheter

Hemodynamic assessment

• All right heart and PA need to be obtained before injection of contrast

• Damping of pressure in main PA indicate massive pulmonary embolism

Contrast Media

• High osmolar or low osmolar iodinated contrast ?• No significant reduction in mortality from contrast reaction• Changes in hemodynamics are not significantly different• A reduction in coughing with low osmolar• Low osmolar increase plasminogen activator I increase thrombin-antithrombin III some suggest add heparin to low osmolar • 40-50ml/min at 20-25ml/min in right or left main PA• Non-dependent parts are obscure PA of middle lobe, lingul

a, and anterior segments of upper lobe

Filming

• Two views frontal and 45 。 Ipsilateral posterior o

blique

Physiology

• Normal main PA pressure 22/8mmHg, mean: 13mmHg

• PA system can accommodate large changes in volume, mostly by recruitment of previously collapsed vessels rather than by distention of open vessels

Anatomy

• Right PA 23.4mm• Left PA 26.4mm• Within the lung, PA branch in either bi

furcational ( similar size of branches) or collateral ( one small branch at 30-80 。 ) fashion

Angiographic findings and interpretation

• PA stenosis 1. Most PA or PV stenoses associate with congenital heart dz ( TOF, truncus arteriosus, PS, PDA, AS and VSD ) 2. May be secondary to rubella, chronic infections (histoplasmosis), or infestation (schistoosomiasis) 3. Measure PG of stenosis

Angiographic findings and interpretation

• Pulmonary AV communications 1. Due to defect in terminal capillary loop 2. Most are asymptomatic, SOB, cyanosis, digital clubbing,and hemoptysis and paradoxical embolism. 3. Simple PAVM supply by 1-3 subsegmental a. & from the same seg. a Complex PAVM supply by 2 or more different seg. a most frequent in right middle or lingula.

Pulmonary AV communications

4. 40-65% are associated with Rendu-Osler Weber syndrome5. The entire lung needs to be filmed because small s

ubpleural PAVM may be present6. PAVM can be percutaneously embolized with balloon or coil7. Acquired PAVM trauma, infection ( bronchiectasi

s, invasive aspergillosis, TB and schistosomiasis ) or hepatogenic angiodysplasia

Diffuse or focal attenuation of PA

• PPH dilated proximal PA with smooth, rapid tapering distally

• Pulmonary emphysema narrow peripheral a. and widely spaced; mild to moderate dilated central PA

• Post-OP complications torsion of a lobe after resection fusiform tapering at torsion with slow vascular filling

PPH

Intraluminal AbnormalitiesAcute Pulmonary Thromboembolism

• Primary angiographic evidence persistent central or marginal intraluminal radiolucency

• Secondary signs abrupt cutoff without evidence of an intraluminal defect, oligemic or avascular regions, focal prolonged arterial phase, or abruptly tapered peripheral vessels

• Examination should be done within 24 hrs of the event

Primary evidence of acute PE

Secondary evidence of acute PE

Chronic Pulmonary Thromboembolism

• Angiographic findings 1. Pouching

2. Webs or bands 3. Luminal irregularity 4. Abrupt narrowing of major PA 5. Obstruction of lobar arteries, usually at their origin

Chronic Pulmonary Thromboembolism

• Pulmonary angiography may not adequately assess proximal thromboembolism ( concentric or smooth thrombosis mimic normal-sized vessel)

• Spiral contrast CT can exclude other causes of multiple stenoses such as infection or inflammation, Takayasu’s dz or neoplasm

Pulmonary Vascular Neoplasms

• Leiomyosarcoma of PA 1. typically in main PA 2. entirely intraluminal in half and spread along the lumen 3. It is important to evaluate venous phase

Pulmonary Artery Aneurysms

• Focal increase in diameter by 50% over its initial normal diameter

• Causes Marfan’s syndrome, Tuberculosis (Rasmussen aneurysm), syphilis, septic emboli, Behcet’s dz

• Pseudoaneurysm result from penetrating or catheter trauma

Inflammation

• Infectious and noninfectious inflammatory diseases

• No single finding is diagnostic of a particular dz• Takayasu’s arteritis stenosis, occlusion or dilat

ation• Behcet’s disease 5% will involve PA mainly a

neurysm• Histoplasmosis granuloma in vessels mediastinitis can compress PA or PV which mimicki

ng stenosis

Hemorrhage

• Most life-threatening hemoptysis bronchial artery

• When embolization of bronchial artery can not stop bleeding, rupture of Rasmussen’s aneurysm, Behcet’s disease or Hughes-Stovin syndrome should be considered

Foreign Bodies

• Fractured and embolized medical and non-medical devices

• Hand-injected is helpful to determine to the size and orientation of the vessel

• Nitinol snare retrieve the foreign body

Chapter 31 Profiles in Pulmonary

Embolism

Diagnosis of Pulmonary Embolism

• The most common S/S SOB, chest pain, tachypnea and tachycardia

• Predisposing factors for venous thrombosis

• Clinical acute cor pulmonale• ECG reveals new S1-Q3-T3 or RBBB or

right ischemia

Diagnosis of Pulmonary Embolism

• Chest x-ray Westermark’s sign--oligemia Hampton’s sign--infarction Palla’s sign—enlarged right descending PA• Screening tool D-dimer ELISA(>500ng/ml) TTE or TEE, spiral chest CT, and Pulmonary ventilati

on-perfusion scan• 1/3 PE did not have DVT evidence• Golden diagnostic tool pulmonary angiography

Diagnosis of Pulmonary Embolism

• Echocardiography findings in PE 1. RV dilatation 2. RV hypokinesis 3. Persistent normal motion of RV apex (McConnell’s sign) 4. Bowing of IVS into LV 5. TR 6. Preserved LV function

Diagnosis of Pulmonary Embolism

• Pulmonary angiography1. Before injection of contrast, right heart

catheterization should be done including O2 saturation, pressure measurement

2. In general, if PA systolic pressure> 50mmHg, favor acute or acute on chronic embolism

3. Pressure tracings show damped or wedged in proximal PA, massive PE is suspected

4. It could detect 1-2 mm PA

Contemporary catheter thrombectomy

• Fragmentation A. Pigtail rotation catheter B. Clot Buster• Rheolytic A. AngioJet Rapid Thrombectomy System B. Hydrolyser-Cordis thrombectomy cath• Aspiration thrombectomy A. Meyerovitz technique B. Greenfield embolectomy catheter

Thanks for your attention