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Acute and Chronic Pulmonary Emboli: Angiography–CT Correlation

¹ All authors: Department of Thoracic Radiology, Massachusetts General Hospital, Founders 202, 55 Fruit St., Boston, MA 02115; and Harvard Medical School, Boston, MA.

View larger version (91K): [in a new window]   Fig. 1A —Acute pulmonary embolism (PE) in 78-year-old woman. Pulmonary angiogram of right pulmonary artery shows complete obstruction of right posterior basal segmental artery. Trailing edge or concave filling defect (arrow) is shown within column of contrast material. Perfusion defect within right posterior basal segment artery (arrowhead) is also detected.

View larger version (10K): [in a new window]   Fig. 1B —Acute pulmonary embolism (PE) in 78-year-old woman. Illustration of complete obstruction due to acute PE as seen on angiography. Trailing edge of thrombus forms concave filling defect within column of contrast material at level of obstruction.

View larger version (61K): [in a new window]   Fig. 1C —Acute pulmonary embolism (PE) in 78-year-old woman. Curved coronal reformatted CT image shows acute thrombus within right posterior basal segment and branch vessels (arrow). Obtained more distal to obstruction, this CT image is able to show expansion of vessel with acute thrombus (arrowheads).

View larger version (27K): [in a new window]   Fig. 1D —Acute pulmonary embolism (PE) in 78-year-old woman. Illustration of coronal reformatted CT image of acute PE shows expansion of diameter of involved vessel distal to point of obstruction (arrow).

View larger version (85K): [in a new window]   Fig. 1E —Acute pulmonary embolism (PE) in 78-year-old woman. Axial CT image shows impacted thrombus distal to point of occlusion (arrow) that expands vessel diameter.

View larger version (127K): [in a new window]   Fig. 2A —Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Figs. 1A, 1B, 1C, 1D, and 1E). Left pulmonary angiogram shows central filling defect (arrow) within posterior segment of left upper lobe. In this patient, all three segmental arteries of left upper lobe arise directly from main pulmonary artery. Nonuniform arterial perfusion (arrowhead) is seen on arteriogram.

View larger version (53K): [in a new window]   Fig. 2B —Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Figs. 1A, 1B, 1C, 1D, and 1E). Curved coronal reformatted CT image shows central nonobstructive filling defect (arrow). CT also shows more proximal nonobstructive thrombus (arrowhead) within main pulmonary artery, more easily seen on CT than on angiogram (A).

View larger version (27K): [in a new window]   Fig. 2C —Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Figs. 1A, 1B, 1C, 1D, and 1E). Illustration shows that eccentric acute thrombus (arrow) makes acute angles with vessel wall.

View larger version (72K): [in a new window]   Fig. 2D —Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Figs. 1A, 1B, 1C, 1D, and 1E). Axial CT image shows central filling defect within posterior segmental artery (arrow) of left upper lobe.

View larger version (17K): [in a new window]   Fig. 2E —Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Figs. 1A, 1B, 1C, 1D, and 1E). Illustration shows acute PE central filling defect on CT image viewed perpendicular to plane of thrombus; well-defined central thrombus is completely surrounded by contrast material.

View larger version (28K): [in a new window]   Fig. 2F —Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Figs. 1A, 1B, 1C, 1D, and 1E). Illustration shows acute PE central filling defect on CT image viewed in long axis of thrombus. Contrast material can be seen on either side of well-defined thrombus forming the "railroad track sign."

View larger version (69K): [in a new window]   Fig. 2G —Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Figs. 1A, 1B, 1C, 1D, and 1E). Axial CT image, obtained more cephalad than D, shows eccentric filling defect within pulmonary artery (arrow).

View larger version (21K): [in a new window]   Fig. 2H —Acute pulmonary embolism (PE) in 78-year-old woman (same patient as shown in Figs. 1A, 1B, 1C, 1D, and 1E). Illustration shows acute PE eccentric filling defect on CT image viewed perpendicular to plane of thrombus; well-defined thrombus (arrow) forms acute angles with vessel wall.

View larger version (124K): [in a new window]   Fig. 3A —Acute pulmonary embolism in 55-year-old man. Right pulmonary artery angiogram shows large filling defect in right pulmonary artery (arrow). Nonuniform arterial perfusion is shown affecting majority of right lung with sparing of anterior segmental artery of right upper lobe. There is reflux of contrast material into left pulmonary artery. Unusual pulmonary artery catheter course due to azygos continuation of anomalous inferior vena cava is also seen.

View larger version (103K): [in a new window]   Fig. 3B —Acute pulmonary embolism in 55-year-old man. CT image obtained distal to large thrombus shows pulmonary arteries to have decreased in vessel diameter (arrows) with respect to adjacent bronchi and contralateral vessels.

View larger version (119K): [in a new window]   Fig. 3C —Acute pulmonary embolism in 55-year-old man. Obtained 3 weeks after embolectomy, CT image shows pulmonary arteries (arrows) have returned to their normal diameter.

View larger version (119K): [in a new window]   Fig. 4A —Chronic pulmonary embolism (PE) in 40-year-old woman. Angiogram shows complete obstruction (arrows) is affecting subsegmental vessels of posterior segment of left upper lobe and anterior and posterior basal segmental arteries. Resultant nonuniform arterial perfusion (arrowheads) is also well shown.

View larger version (22K): [in a new window]   Fig. 4B —Chronic pulmonary embolism (PE) in 40-year-old woman. Line drawing shows complete obstruction of vessel with convex margin with respect to contrast material. This is the "pouch" defect of chronic PE seen on angiography.

View larger version (119K): [in a new window]   Fig. 4C —Chronic pulmonary embolism (PE) in 40-year-old woman. Curved coronal reformatted CT image viewed on lung windows shows pouch defect of anterior basal segment of right lower lobe (arrow). Contracted artery (arrowheads) is smaller than adjacent bronchus.

View larger version (12K): [in a new window]   Fig. 4D —Chronic pulmonary embolism (PE) in 40-year-old woman. Illustration of reformatted CT image of complete obstruction in chronic PE shows contracted thrombus (arrow) distal to pouch defect.

View larger version (129K): [in a new window]   Fig. 5A —Chronic pulmonary embolism (PE) in 60-year-old man. Right pulmonary angiogram shows multiple intimal irregularities (straight arrows). Poststenotic dilatation (arrowhead) is shown affecting posterior segment of right upper lobe. Also noted within right lower lobe is tortuous vessel (curved arrow).

View larger version (75K): [in a new window]   Fig. 5B —Chronic pulmonary embolism (PE) in 60-year-old man. Coronal reformatted CT image shows organized thrombus (arrows) as cause of intimal irregularities. In addition, poststenotic dilatation (arrowhead) is shown affecting posterior segmental artery. Again shown within right lower lobe is tortuous vessel (curved arrow).

View larger version (19K): [in a new window]   Fig. 5C —Chronic pulmonary embolism (PE) in 60-year-old man. Illustration of intimal irregularity of chronic PE as seen on angiography. This broad-based, smooth, margined abnormality can affect one or both sides of vessel; it forms obtuse angles with vessel wall (arrow).

View larger version (52K): [in a new window]   Fig. 5D —Chronic pulmonary embolism (PE) in 60-year-old man. Axial CT image obtained at level of poststenotic aneurysm shows that posterior segment of right upper lobe (arrow) is affected.

View larger version (73K): [in a new window]   Fig. 5E —Chronic pulmonary embolism (PE) in 60-year-old man. Axial CT image obtained at level of right lower lobe pulmonary artery shows eccentric chronic thrombus (arrow).

View larger version (26K): [in a new window]   Fig. 5F —Chronic pulmonary embolism (PE) in 60-year-old man. Illustration of intimal irregularity of chronic PE viewed in axial plane. This broad-based, smooth, margined, eccentric filling defect forms obtuse angles with vessel wall (arrow).

View larger version (151K): [in a new window]   Fig. 6A —Chronic pulmonary embolism (PE) in 51-year-old man. Oblique view of left-sided pulmonary angiogram shows abrupt vessel narrowing (arrow) and complete obstruction of posterior basal segment of left lower lobe (arrowhead). It was difficult to see vascular band or web in this patient.

View larger version (93K): [in a new window]   Fig. 6B —Chronic pulmonary embolism (PE) in 51-year-old man. Axial CT image obtained near origin or posterior basal segmental artery of left lower lobe shows band or web (arrow).

View larger version (26K): [in a new window]   Fig. 6C —Chronic pulmonary embolism (PE) in 51-year-old man. Illustration of nonobstructive filling defect of chronic PE. Band or web can be identified as thin dark line surrounded by contrast material, often orientated in direction of blood flow.

View larger version (143K): [in a new window]   Fig. 7A —Chronic pulmonary embolism (PE) in 65-year-old man. Abrupt vessel narrowing (arrow) is shown affecting posterior basal subsegmental artery of right lower lobe.

View larger version (63K): [in a new window]   Fig. 7B —Chronic pulmonary embolism (PE) in 65-year-old man. Curved coronal CT image shows similar appearance, with abrupt convergence of contrast material leading to thin column of more distal intravascular contrast material. In addition, organized thrombus (arrows) is identified adjacent to column of contrast material.

View larger version (14K): [in a new window]   Fig. 7C —Chronic pulmonary embolism (PE) in 65-year-old man. Illustration of abrupt vessel narrowing of chronic PE as seen on angiography. This finding is recognized by abrupt convergence of contrast material leading to thin column of intravascular contrast material.

View larger version (132K): [in a new window]   Fig. 8A —Chronic pulmonary embolism in 60-year-old man. Left-sided pulmonary angiogram shows complete occlusion of left lower lobe with nonuniform arterial perfusion and large perfusion defect affecting left lower lobe (arrowheads).

View larger version (117K): [in a new window]   Fig. 8B —Chronic pulmonary embolism in 60-year-old man. Axial CT image viewed on lung window settings shows occluded, contracted left lower lobe pulmonary artery (arrowhead). There is decrease in lung attenuation of left lower and right upper lobes, and more normally perfused lung contributes to mosaic pattern of lung attenuation (arrows). Incidental note is made of centrilobular emphysema.

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